Should a patient with uncontrolled hypertension (elevated blood pressure) on losartan (angiotensin II receptor antagonist) 50 mg daily with a current blood pressure reading of 145/68 mmHg be considered for a medication adjustment?

From the Guidelines

The patient's medication regimen should be adjusted to achieve better blood pressure control, considering the current reading of 145/68 mmHg is above the recommended target. The current blood pressure reading indicates that the systolic pressure remains above the generally recommended target of less than 140 mmHg, though the diastolic pressure is well-controlled 1. Options for adjustment include increasing the losartan dose to 100 mg daily (the maximum recommended dose) or adding a second antihypertensive medication such as a thiazide diuretic like hydrochlorothiazide 12.5-25 mg daily. Before making changes, it would be important to:

• Confirm the elevated readings with multiple measurements
• Assess medication adherence
• Counsel the patient on lifestyle modifications including:
  • Sodium restriction
  • Regular exercise
  • Weight management
  • Limiting alcohol consumption Losartan works by blocking angiotensin II receptors, reducing vasoconstriction and sodium retention, but some patients require higher doses or combination therapy to achieve target blood pressure goals 1. Any medication adjustment should be followed by blood pressure monitoring within 2-4 weeks to assess effectiveness and potential side effects. According to the 2024 ESC guidelines for the management of elevated blood pressure and hypertension, reinforcement of lifestyle measures and addition of low-dose spironolactone to existing treatment are recommended for resistant hypertension 1. However, since this patient is not yet considered to have resistant hypertension, the first step would be to optimize the current regimen and lifestyle modifications before considering additional therapies.

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)]. The antihypertensive effects of losartan were demonstrated principally in 4 placebo-controlled, 6- to 12-week trials of dosages from 10 to 150 mg per day in patients with baseline diastolic blood pressures of 95 to 115 Doses of 50 mg, 100 mg and 150 mg once daily gave statistically significant systolic/diastolic mean decreases in blood pressure, compared to placebo in the range of 5.5 to 10.5/3.5 to 7. 5 mmHg, with the 150-mg dose giving no greater effect than 50 mg to 100 mg.

The patient's current blood pressure is 145/68 mmHg, which is not controlled.

• Current Medication: Losartan 50 mg daily
• Blood Pressure Goal: <140/90 mmHg
• Consideration for Medication Adjustment: The patient's blood pressure is not controlled, and the current dose of losartan is 50 mg daily. The dosage of losartan can be increased to a maximum dose of 100 mg once daily as needed to control blood pressure 2. Therefore, the patient should be considered for a medication adjustment, and increasing the dose of losartan to 100 mg daily could be an option.

From the Research

Patient Assessment

• The patient's current blood pressure reading is 145/68 mmHg, which indicates uncontrolled hypertension.
• The patient is currently taking losartan 50 mg daily, an angiotensin II receptor antagonist.
• The patient's heart rate is 82 beats per minute.

Medication Adjustment Considerations

• According to the study 3, losartan potassium is effective as a once-daily antihypertensive agent, but its efficacy may be limited in some patients.
• The study 4 suggests that combining losartan with a low-dose diuretic, such as hydrochlorothiazide, may offer an additive antihypertensive effect with fewer adverse experiences.
• The study 5 demonstrates that losartan potassium significantly reduces mean 24-h ambulatory blood pressure and trough clinic sitting blood pressure, and is well tolerated.
• The study 6 supports the use of triple fixed-dose combination therapy with an angiotensin II receptor blocker, a calcium channel blocker, and a thiazide diuretic to improve blood pressure control.

Potential Next Steps

• Consider increasing the dose of losartan or adding a low-dose diuretic, such as hydrochlorothiazide, to enhance the antihypertensive effect 4.
• Alternatively, consider switching to a different antihypertensive agent or adding a calcium channel blocker to the patient's regimen 6.
• Monitor the patient's blood pressure and adjust the medication regimen as needed to achieve optimal blood pressure control.