What is the highest recommended dose of losartan (angiotensin II receptor antagonist) for treating hypertension?

Highest Recommended Dose of Losartan for Hypertension

The highest recommended dose of losartan for treating hypertension is 100 mg once daily, as indicated in the FDA-approved labeling. 1

Dosing Guidelines for Losartan

Standard Dosing

• Initial starting dose: 50 mg once daily
• Maximum dose: 100 mg once daily
• For patients with possible intravascular depletion (e.g., on diuretic therapy): 25 mg starting dose

Special Populations

• Patients with mild-to-moderate hepatic impairment: 25 mg starting dose
• Losartan has not been studied in patients with severe hepatic impairment

Evidence Supporting Maximum Dosing

The 2020 ACC/AHA clinical performance and quality measures for heart failure clearly identifies 100 mg once daily as the target dose for losartan 2. While earlier ACC/AHA guidelines from 2013 had recommended losartan 150 mg as the target dose, the current guidelines specifically note that "because current FDA-approved labeling has 100 mg as the maximal dose, the 100-mg dose is used in the performance measure" 2.

This is further supported by the 2017 ACC/AHA/HFSA focused update, which maintains 100 mg once daily as the target dose for losartan 2.

Dose-Response Relationship

It's important to note that achieving target doses of angiotensin receptor blockers (ARBs) like losartan is associated with improved clinical outcomes:

• Studies have supported a dose-response relationship of these therapies with improved outcomes 2
• Treating at less than target doses may result in worse clinical outcomes in patients who could tolerate higher doses 2
• In clinical trials, higher doses have provided greater benefits than lower doses 2

Clinical Applications Beyond Hypertension

The maximum dose of 100 mg daily is also recommended for:

• Hypertensive patients with left ventricular hypertrophy 1
• Nephropathy in Type 2 diabetic patients 1

Common Pitfalls in Losartan Dosing

1. Underdosing: Many physicians initiate treatment at low doses but fail to uptitrate to target doses. This is particularly concerning since the optimal dose for losartan in heart failure (100 mg daily) is higher than commonly prescribed doses for hypertension alone 2.

2. Assuming medium-range doses provide most benefits: There is little evidence that subtarget doses yield survival benefits that approximate those produced by target doses 2.

3. Permanent dose reductions: In clinical practice, dose reductions are often permanent, leading to indefinite treatment with subtarget doses, which may compromise efficacy 2.

4. Failure to recognize the importance of target dosing: The 2020 ACC/AHA guidelines emphasize that "to achieve the maximal benefits of guideline-directed medical therapy in patients with chronic HFrEF, therapies must be initiated and titrated to maximally tolerated doses" 2.

In conclusion, while losartan can be initiated at lower doses (25-50 mg daily), the evidence clearly supports uptitration to the maximum FDA-approved dose of 100 mg daily in patients who can tolerate it to achieve optimal therapeutic benefits for hypertension management.