What is the recommended dosage and treatment guidelines for losartan (angiotensin II receptor blocker) in patients with hypertension?

Losartan Dosage and Treatment Guidelines for Hypertension

The standard dosing regimen for losartan in hypertension is to start at 50 mg once daily, with titration to a maximum of 100 mg once daily as needed to control blood pressure. 1

Initial Dosing

• Standard starting dose: 50 mg once daily 1
• Lower starting dose (25 mg) recommended for:
  • Patients with possible intravascular depletion (e.g., on diuretic therapy) 1
  • Patients with mild-to-moderate hepatic impairment 1
• Maximum dose: 100 mg once daily 1

Dose Titration

• Titrate based on blood pressure response
• Optimal dose for most patients is 100 mg daily, which provides greater clinical benefit than 50 mg 2, 3
• Allow at least 2 weeks between dose adjustments 2
• Monitor blood pressure regularly to assess response

Special Populations

Patients with Left Ventricular Hypertrophy

• Start with 50 mg once daily
• Consider adding hydrochlorothiazide 12.5 mg daily and/or increasing losartan to 100 mg once daily based on blood pressure response 1
• Losartan has shown superior outcomes compared to beta-blockers in reducing stroke risk in hypertensive patients with LVH 4, 5

Patients with Diabetic Nephropathy

• Start with 50 mg once daily
• Increase to 100 mg once daily based on blood pressure response 1, 3
• 100 mg daily is more effective than 50 mg daily for renoprotection in diabetic nephropathy 3

Hepatic Impairment

• Start with 25 mg once daily in mild-to-moderate hepatic impairment 1
• Not studied in severe hepatic impairment 1

Renal Impairment

• No initial dosage adjustment necessary for various degrees of renal insufficiency 1, 6
• Not removed during hemodialysis 6

Combination Therapy

• For uncontrolled hypertension on losartan monotherapy, add:
  • Calcium channel blocker (preferred) 2
  • Thiazide-like diuretic 2
• For resistant hypertension, consider adding:
  • Spironolactone 25 mg daily (if serum potassium <4.5 mmol/L) 7, 2
  • Alternatives if spironolactone is not tolerated: eplerenone, amiloride, beta-blocker, or alpha-blocker 7, 2

Monitoring

• Check blood pressure within 1 month of starting therapy for stage 2 hypertension 2
• Monitor renal function and potassium levels, especially in patients with:
  • Chronic kidney disease
  • Bilateral renal artery stenosis
  • Concomitant potassium-sparing diuretics 2
• Target blood pressure: <140/90 mmHg 7, 2
  • Consider lower targets (<130/80 mmHg) for specific populations (e.g., those with diabetes, chronic kidney disease) 7

Practical Considerations

• Can be administered without regard to food 6
• Once-daily dosing improves adherence 2
• Generally well-tolerated with minimal adverse effects 6, 8
• Contraindicated in pregnancy 6

Losartan has demonstrated favorable outcomes not only in blood pressure reduction but also in end-organ protection, particularly in patients with left ventricular hypertrophy and diabetic nephropathy 4, 5.