What is the maximum recommended dose of losartan (angiotensin II receptor antagonist)?

Maximum Dose of Losartan

The maximum recommended dose of losartan is 100 mg once daily for hypertension, as established by the FDA label. 1

Dosing Guidelines for Different Indications

Hypertension

• Starting dose: 50 mg once daily
• Maximum dose: 100 mg once daily
• Special populations:
  • Patients with possible intravascular depletion (e.g., on diuretic therapy): Start with 25 mg once daily
  • Mild-to-moderate hepatic impairment: Start with 25 mg once daily 1

Hypertensive Patients with Left Ventricular Hypertrophy

• Starting dose: 50 mg once daily
• Maximum dose: 100 mg once daily
• Hydrochlorothiazide 12.5 mg daily can be added and/or losartan dose increased based on blood pressure response 1

Nephropathy in Type 2 Diabetic Patients

• Starting dose: 50 mg once daily
• Maximum dose: 100 mg once daily 1

Special Considerations

Hepatic Impairment

• Patients with mild-to-moderate hepatic impairment should start with 25 mg once daily
• Losartan has not been studied in patients with severe hepatic impairment 1

Renal Function

• No dosage adjustment is necessary for various degrees of renal insufficiency
• Losartan is not removed during hemodialysis 2

Pediatric Patients

• Starting dose: 0.7 mg/kg once daily (up to 50 mg total)
• Maximum dose: 1.4 mg/kg daily (not to exceed 100 mg)
• Not recommended in pediatric patients less than 6 years of age or with eGFR < 30 mL/min/1.73 m² 1

Pharmacokinetics and Administration

• Losartan is rapidly absorbed, reaching maximum concentrations 1-2 hours after administration
• Approximately 14% of losartan is converted to its active metabolite E3174, which is 10-40 times more potent
• The half-life of the active metabolite ranges from 6-9 hours
• Can be administered without regard to food 2

Clinical Efficacy Considerations

While the FDA-approved maximum dose is 100 mg daily, some research suggests potential benefits of higher doses in specific conditions:

• In type 1 diabetic patients with nephropathy, 100 mg daily was found to be more effective than 50 mg for renoprotection and blood pressure reduction, with no additional benefit at 150 mg 3
• For nondiabetic patients with nephrotic range proteinuria, 100 mg provided optimal antiproteinuric effects compared to 50 mg and 150 mg 4

Important Contraindications

• Losartan is contraindicated in pregnancy 5
• Should be used with caution in patients with severe bilateral renal artery stenosis 5

Common Pitfalls to Avoid

1. Underdosing: Starting at 50 mg and not titrating to the maximum 100 mg dose when needed for optimal blood pressure control or renoprotection
2. Pregnancy exposure: Losartan should be avoided in pregnancy due to potential fetal toxicity
3. Combination therapy risks: Avoid routine combined use of an ACE inhibitor, ARB, and aldosterone antagonist as this combination is potentially harmful 5

Remember that while some research suggests potential benefits of doses higher than 100 mg in specific conditions 6, the FDA-approved maximum dose remains 100 mg daily for all approved indications.