What are the recommended dosages for losartan (angiotensin II receptor antagonist) and lisinopril (angiotensin-converting enzyme inhibitor) for hypertension management?

Recommended Dosages for Losartan and Lisinopril in Hypertension Management

For hypertension management, losartan should be started at 50 mg once daily with titration to a maximum of 100 mg once daily, while lisinopril should be initiated at 2.5-5 mg once daily with titration to 20-40 mg once daily. 1, 2

Losartan Dosing

Initial Dosing

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

Titration and Maximum Dosing

• Can be titrated to maximum dose of 100 mg once daily as needed for blood pressure control 1
• Dose adjustments should be made based on blood pressure response 1
• No dosage adjustment needed for patients with renal insufficiency 3

Special Considerations for Losartan

• Can be administered without regard to food 3
• Has a favorable drug-drug interaction profile 3
• Pharmacokinetics are linear and dose-proportional 3
• Terminal half-life of active metabolite (E3174) ranges from 6-9 hours 3
• Contraindicated in pregnancy and history of angioedema with ARBs 2

Lisinopril Dosing

Initial Dosing

• Standard starting dose: 2.5-5 mg once daily 2
• Lower starting dose recommended for patients with renal impairment (GFR < 30 mL/min) 2

Titration and Maximum Dosing

• Target dose: 20-40 mg once daily 2
• Dose should be increased gradually every 1-2 weeks as tolerated 2
• High-dose lisinopril (32.5-35 mg daily) has shown significant benefits over low-dose (2.5-5 mg daily) with a 12% reduction in death or hospitalization 2

Monitoring and Follow-up

• Follow-up evaluation of adherence and response to treatment should occur at monthly intervals until blood pressure control is achieved 2
• Blood pressure, renal function, and electrolytes should be monitored 1-2 weeks after starting treatment and after each dose increase 2
• After blood pressure control is achieved, monitoring can be reduced to every 3 months and then every 6 months 2

Efficacy Considerations

• Both losartan and lisinopril effectively lower blood pressure and reduce cardiovascular events 4
• In clinical trials, losartan 50 mg once daily produced mean reductions in systolic/diastolic BP of approximately 9-10 mmHg 5, 6
• Losartan 100 mg daily (alone or with hydrochlorothiazide) has been shown to reduce systolic/diastolic BP by 24/12 mmHg in high-risk patients 7

Treatment Algorithm

1. Initial Selection:

   • For patients with uncomplicated hypertension: Start with either losartan 50 mg once daily or lisinopril 2.5-5 mg once daily
   • For patients with diabetes, chronic kidney disease, or heart failure: Consider lisinopril as first choice unless contraindicated (e.g., history of ACE inhibitor-induced cough)
   • For patients with history of ACE inhibitor-induced cough: Use losartan

2. Dose Titration:

   • Assess blood pressure response after 2-4 weeks
   • If target BP not achieved, increase losartan to 100 mg daily or lisinopril to 10-20 mg daily
   • Continue titration at 2-4 week intervals until target BP achieved or maximum dose reached

3. If Monotherapy Insufficient:

   • Add a calcium channel blocker or thiazide diuretic 4
   • Consider fixed-dose combinations for improved adherence 4

Common Pitfalls and Caveats

• Avoid combining ACE inhibitors (like lisinopril) with ARBs (like losartan) as this combination increases adverse effects without additional benefit 4
• Monitor renal function and potassium levels within 1-2 weeks after starting treatment, particularly in patients with diabetes, renal impairment, or those taking potassium supplements 2
• Be aware that ACE inhibitors like lisinopril commonly cause dry cough (up to 20% of patients), while losartan rarely causes cough 2
• Losartan has the unique property of reducing serum uric acid levels, which may be beneficial in patients with hyperuricemia 6
• Both medications should be avoided during pregnancy 2

The 2024 ESC guidelines recommend that for most patients with confirmed hypertension (BP ≥140/90 mmHg), combination BP-lowering treatment is recommended as initial therapy, preferably with a RAS blocker (either an ACE inhibitor or an ARB) with a dihydropyridine CCB or diuretic 4.