What are the guidelines for titrating blood pressure in patients on losartan (angiotensin II receptor antagonist)?

From the Guidelines

When titrating blood pressure in patients on losartan, the most effective approach is to follow a stepped-care strategy, starting with a single agent and sequentially titrating the dose and adding other agents as needed, as recommended by the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1.

Key Considerations

• The target blood pressure is typically <130/80 mmHg for most patients, though this may be individualized based on comorbidities and age 1.
• Blood pressure should be measured at consistent times of day, preferably in the morning before medication intake and in the evening.
• For patients with blood pressure >20/10 mm Hg above their target, initiation of antihypertensive therapy with 2 agents may be recommended, with careful monitoring of blood pressure to avoid hypotension or orthostatic hypotension 1.

Titration Strategy

• Start with 50 mg of losartan once daily for most adults and monitor blood pressure response after 2-4 weeks.
• If needed, increase to the maximum dose of 100 mg once daily.
• For elderly patients or those with hepatic or renal impairment, begin with 25 mg daily.

Monitoring and Adjustments

• Monitor for side effects including dizziness, hyperkalemia, and changes in renal function, particularly during dose adjustments.
• Serum potassium and creatinine should be checked within 1-2 weeks of initiation or dose changes.
• The full antihypertensive effect of losartan may take 3-6 weeks to develop, so avoid frequent dose adjustments before this timeframe.

Additional Therapy

• If blood pressure remains uncontrolled at maximum losartan dose, consider adding a thiazide diuretic or calcium channel blocker rather than further increasing losartan beyond recommended doses.

From the FDA Drug Label

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)]. Dosage should be adjusted according to blood pressure response. The dose should be increased to 100 mg once daily based on blood pressure response [see CLINICAL STUDIES (14.3)].

The guidelines for titrating blood pressure in patients on losartan are to:

• Start with a dose of 50 mg once daily
• Increase the dose to a maximum of 100 mg once daily as needed to control blood pressure
• Adjust the dosage according to blood pressure response
• Increase the dose to 100 mg once daily based on blood pressure response in patients with nephropathy in type 2 diabetes 2
• Use a starting dose of 25 mg in patients with possible intravascular depletion, and adjust as needed 2 Key considerations include:
• Dose adjustment: based on blood pressure response
• Maximum dose: 100 mg once daily
• Starting dose: 50 mg once daily, or 25 mg in patients with possible intravascular depletion
• Special populations: adjust dose according to specific population needs, such as in patients with hepatic impairment or pediatric patients 2

From the Research

Guidelines for Titrating Blood Pressure while on Losartan

• The optimal dose of losartan for renoprotection and blood pressure reduction in patients with diabetic nephropathy is 100 mg daily 3.
• Losartan can be administered once daily at doses of 25 to 100 mg/day, with a significant reduction in 24-h urinary protein excretion observed at doses of 50 mg and above 4.
• In patients with mild renal insufficiency, the daily dose of 50 mg can be increased to 100 mg after 4 weeks if sitting diastolic blood pressure remains ≥ 90 mm Hg or is reduced by < 5 mm Hg 5.
• Losartan dose titration to 100 mg can be an effective strategy for reducing blood pressure and albuminuria in type 2 diabetic patients who do not attain target blood pressure with an initial dose of 50 mg 6.
• The addition of a diuretic, such as hydrochlorothiazide, can also be considered as an alternative strategy for further reducing blood pressure and albuminuria in patients who do not respond to losartan dose titration 6.

Blood Pressure Reduction with Losartan

• Losartan has been shown to significantly reduce mean 24-h ambulatory blood pressure and trough clinic sitting blood pressure in patients with hypertension 7.
• The blood pressure-lowering effect of losartan is sustained over a 24-hour period, with a smooth and consistent reduction in blood pressure observed throughout the day 7.
• Losartan has been shown to reduce systolic and diastolic blood pressure in patients with diabetic nephropathy, with a significant reduction in albuminuria also observed 3.

Renoprotective Effects of Losartan

• Losartan has been shown to have renoprotective effects in patients with chronic kidney disease and hypertension, with a significant reduction in urinary protein excretion observed 4.
• The renoprotective effects of losartan are thought to be independent of its blood pressure-lowering effects, with losartan reducing proteinuria by approximately 24% in patients with proteinuric chronic kidney disease 4.