What is the recommended dose of Losartan (angiotensin II receptor antagonist) for adults with hypertension?

Losartan Dosing for Adults with Hypertension

The recommended starting dose of losartan for adults with hypertension is 50 mg once daily, with titration to a maximum dose of 100 mg once daily as needed to control blood pressure. 1

Initial Dosing Considerations

• Standard starting dose: 50 mg once daily 1
• Lower starting dose: 25 mg once daily is recommended for patients with possible intravascular depletion (e.g., those on diuretic therapy) 1
• Administration: Can be taken with or without food 2

Dose Titration

• Titration schedule: Dose can be increased to 100 mg once daily based on blood pressure response 1
• Monitoring: Blood pressure should be checked every 2-4 weeks during dose adjustments 3
• Target blood pressure: <140/90 mmHg within 3 months 3
• Follow-up timing:
  • Stage 1 hypertension with 10-year ASCVD risk ≥10%: Recheck BP in 1 month 3
  • Stage 2 hypertension: Evaluation within 1 month of diagnosis 4, 3

Special Populations

Hepatic Impairment

• Mild to moderate impairment: Starting dose should be reduced to 25 mg once daily 1
• Severe hepatic impairment: Losartan has not been studied in this population 1

Renal Impairment

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

Clinical Efficacy Considerations

• Maximum clinical benefit: Higher doses (100 mg) provide greater clinical benefit than lower doses 3
• The HEAAL trial demonstrated that 150 mg daily of losartan was superior to 50 mg daily, supporting the use of higher doses when tolerated 4
• Blood pressure response: The most dramatic decreases in blood pressure typically occur with the initial dose; subsequent changes with each dosing increment are comparatively smaller 3

Combination Therapy

For patients with uncontrolled hypertension on losartan monotherapy:

1. First step: Increase losartan to maximum dose (100 mg daily) 3
2. Second step: Add a calcium channel blocker (e.g., amlodipine 5 mg daily) or a thiazide-like diuretic (e.g., hydrochlorothiazide 12.5-25 mg) 4, 3
3. For stage 2 hypertension (≥160/100 mmHg): Consider initiating treatment with 2 antihypertensive agents of different classes 4

Safety and Monitoring

• Most common side effect: Dizziness (reported more frequently than placebo) 5
• First-dose hypotension: Uncommon but more likely in volume-depleted patients 5
• Monitoring: Renal function and potassium levels should be monitored, especially in patients with chronic kidney disease, bilateral renal artery stenosis, or those on potassium-sparing diuretics 3
• Contraindications: Pregnancy (should be avoided in second and third trimesters due to risk of fetal toxicity) 2

Specific Indications Beyond Hypertension

• Hypertensive patients with left ventricular hypertrophy: Starting dose 50 mg once daily, with addition of hydrochlorothiazide 12.5 mg daily and/or increase to 100 mg once daily based on blood pressure response 1
• Nephropathy in Type 2 diabetic patients: Starting dose 50 mg once daily, with increase to 100 mg once daily based on blood pressure response 1, 4

Losartan's favorable tolerability profile makes it an excellent choice for hypertension management, with minimal drug interactions and a side effect profile similar to placebo in clinical trials 2, 5.