What is the next best step in managing a patient with hypertension who is currently on losartan (angiotensin II receptor antagonist) 25 mg twice daily (bid) and metoprolol (beta blocker) 25 mg daily?

From the Guidelines

The next best step in managing a patient with hypertension currently on losartan 25 mg twice daily and metoprolol 25 mg daily would be to optimize the losartan dosing to 50-100 mg once daily and consider adding a thiazide diuretic. This recommendation is based on the most recent and highest quality study, which suggests that a combination of a β-blocker, an ACE inhibitor or ARB, and a thiazide or thiazide-like diuretic should be considered in the absence of a prior MI, LV systolic dysfunction, diabetes mellitus, or proteinuric CKD 1. Some key points to consider when managing hypertension include:

• Optimizing the current treatment regimen, including health behavior change and diuretic-based treatment 1
• Ensuring adherence to antihypertensive agents of different classes at maximum or maximally tolerated doses 1
• Considering lifestyle modifications, such as weight reduction, adopting a DASH eating plan, reducing dietary sodium intake, and engaging in regular aerobic physical activity 1 Before making any medication changes, it's essential to confirm the patient's adherence to the current regimen, verify proper blood pressure measurement technique, and rule out white coat hypertension with home blood pressure monitoring. Additionally, the patient's blood pressure targets should be considered, with a goal of <140/90 mm Hg for most patients, and <130/80 mm Hg for those with certain comorbidities or risk factors 1. The rationale for these changes is to simplify the medication regimen while maximizing the antihypertensive effect through complementary mechanisms of action targeting different pathways of blood pressure regulation.

From the FDA Drug Label

The usual starting dose of losartan is 50 mg once daily. The dosage can be increased to a maximum dose of 100 mg once daily as needed to control blood pressure [see CLINICAL STUDIES (14.1)]. A starting dose of 25 mg is recommended for patients with possible intravascular depletion (e.g., on diuretic therapy).

The next best step in managing a patient with hypertension who is currently on losartan 25 mg twice daily and metoprolol 25 mg daily would be to consider increasing the dose of losartan to 50 mg once daily or 50 mg twice daily, as the patient is currently on a lower dose. However, the decision to increase the dose should be based on the patient's blood pressure response and clinical judgment.

• The patient's current dose of losartan is 25 mg bid, which is lower than the recommended maximum dose of 100 mg once daily.
• Increasing the dose of losartan may help to better control the patient's blood pressure.
• It is also important to monitor the patient's blood pressure and adjust the dose as needed to achieve optimal blood pressure control 2.

From the Research

Next Best Step in Management of Hypertension

The patient is currently on losartan 25 mg twice daily (bid) and metoprolol 25 mg daily. To determine the next best step in management, we need to consider the current treatment regimen and the patient's response to it.

• The patient is already on a relatively low dose of losartan, which is an angiotensin II receptor antagonist 3, 4.
• Losartan has been shown to be effective in reducing blood pressure when used as monotherapy or in combination with other antihypertensive agents 3, 4, 5.
• The current dose of losartan is 25 mg bid, which is lower than the recommended dose of 50-100 mg once daily 3, 4.
• Increasing the dose of losartan to 50-100 mg once daily may be considered to achieve better blood pressure control 3, 4.
• However, a study comparing twice-daily versus once-daily losartan found no significant difference in blood pressure reduction between the two regimens 6.
• Another study found that twice-daily administration of losartan was more effective in eliminating the non-dipper phenomenon compared to once-daily evening administration 7.

Considerations for Next Steps

Based on the available evidence, the next best step in management of hypertension for this patient could be:

• Increasing the dose of losartan to 50-100 mg once daily to achieve better blood pressure control 3, 4.
• Considering twice-daily administration of losartan to eliminate the non-dipper phenomenon 7.
• Adding a diuretic, such as hydrochlorothiazide, to the treatment regimen to further reduce blood pressure 5.
• Monitoring the patient's blood pressure and adjusting the treatment regimen as needed to achieve optimal blood pressure control.