What other blood pressure (BP) medicines can be taken with losartan (angiotensin II receptor antagonist)?

Blood Pressure Medications That Can Be Combined with Losartan

Calcium channel blockers (like amlodipine) and thiazide diuretics (like chlorthalidone or hydrochlorothiazide) are the most effective blood pressure medications to combine with losartan. 1

Optimal Combination Therapy with Losartan

When blood pressure is not adequately controlled with losartan alone, adding medications from different classes provides complementary mechanisms of action for better blood pressure control.

First-line Combinations:

1. Losartan + Thiazide/Thiazide-like Diuretic

   • Chlorthalidone (12.5-25 mg daily) - preferred due to longer half-life and proven cardiovascular disease reduction 1
   • Hydrochlorothiazide (25-50 mg daily)
   • Indapamide (1.25-2.5 mg daily)

2. Losartan + Calcium Channel Blocker

   • Dihydropyridines:

     • Amlodipine (2.5-10 mg daily) 1
     • Felodipine (2.5-10 mg daily)
     • Nifedipine LA (30-90 mg daily)

   • Non-dihydropyridines:

     • Diltiazem ER (120-360 mg daily)
     • Verapamil SR (120-360 mg daily)

     Note: Use non-dihydropyridines with caution as they may increase risk of bradycardia when combined with beta-blockers 1

Important Considerations

Beneficial Combinations:

• Triple therapy with losartan (ARB) + calcium channel blocker + diuretic is particularly effective for resistant hypertension 2
• For patients with diabetes and hypertension, the combination of losartan with either a calcium channel blocker or diuretic provides superior cardiovascular and renal protection 1

Combinations to Avoid:

• Do not combine losartan with ACE inhibitors or direct renin inhibitors - this increases risk of hyperkalemia without significant additional blood pressure benefit 1, 2
• Avoid combining losartan with potassium-sparing diuretics unless specifically indicated and closely monitored, due to increased risk of hyperkalemia 3

Special Populations:

• In patients with diabetic nephropathy, losartan provides renoprotection and may be combined with diuretics or calcium channel blockers 3
• For patients with isolated systolic hypertension (common in elderly), losartan can be effectively combined with diuretics 4
• In Black patients, diuretics may provide better blood pressure reduction when combined with losartan 1, 5

Dosing Considerations

• Start with low doses of combination medications and titrate gradually
• For stage 2 hypertension (BP ≥140/90 mmHg), initiation with two agents (losartan plus another agent) is recommended 1
• Monitor for:
  • Hyperkalemia, especially in patients with chronic kidney disease
  • Orthostatic hypotension
  • Renal function changes, particularly in elderly patients or those with baseline renal impairment 3

Practical Algorithm for Combining Medications with Losartan:

1. If BP remains >10/5 mmHg above target on maximum losartan dose (100 mg daily):

   • Add amlodipine 5 mg daily (first choice) OR
   • Add chlorthalidone 12.5 mg daily (especially in Black patients or those with volume overload)

2. If BP remains above target on dual therapy:

   • Optimize doses of both medications
   • If still uncontrolled, add the third agent (complete the triad of ARB + CCB + diuretic)

3. If BP remains uncontrolled on triple therapy:

   • Consider adding a fourth agent such as spironolactone (if no hyperkalemia) or a beta-blocker

Remember that the goal of combination therapy is to achieve target blood pressure with minimal side effects, and the specific combination should be tailored based on comorbidities, tolerability, and blood pressure response.