Can telmisartan be given in a twice daily (bid) dose?

Telmisartan Should Be Administered Once Daily, Not Twice Daily (BID)

Telmisartan should only be administered once daily, not as a twice daily (BID) dose, as consistently recommended by all major clinical guidelines. 1

Evidence Supporting Once-Daily Dosing

• The American College of Cardiology/American Heart Association guidelines specifically designate telmisartan as a once-daily medication with a target dose of 80 mg daily for hypertension and heart failure management 2, 1
• All major hypertension and heart failure guidelines consistently recommend telmisartan as a once-daily medication, with no support for twice-daily dosing 1
• The 2018 ACC/AHA hypertension guidelines specifically list telmisartan with a usual dose range of 20-80 mg/day with daily (not twice daily) frequency 1

Pharmacokinetic Properties Supporting Once-Daily Dosing

• Telmisartan has a long terminal elimination half-life of >20 hours in both healthy subjects and hypertensive patients, making it suitable for once-daily dosing 3
• The drug demonstrates a smooth, consistent blood pressure-lowering effect throughout the 24-hour dosing interval at 40-80 mg doses, with high trough-peak ratios 4
• Steady-state plasma concentrations are achieved after 5-7 days of once-daily administration, with no clinically relevant accumulation even after 28 days of treatment 3

Clinical Efficacy of Once-Daily Dosing

• Telmisartan at 80 mg once daily provides effective blood pressure control throughout the entire 24-hour dosing interval, including the challenging last 6 hours before the next dose (2:00 a.m. to 8:00 a.m.) 5
• Once-daily telmisartan has demonstrated superior antihypertensive effect toward the end of the dosing interval compared with amlodipine and losartan 4
• Maximum blood pressure reduction occurs with a once-daily dosage of 40 to 80 mg, with no evidence suggesting improved efficacy with divided dosing 6

Dosing Recommendations

• The recommended starting dose is 40 mg once daily, which can be titrated up to the target dose of 80 mg once daily for hypertension and heart failure 2
• Therapy should be adjusted no more frequently than every 2 weeks to allow for full effect assessment and tolerability 2
• At least 50% of the target dose (40 mg daily) should be achieved to obtain significant clinical benefits in heart failure patients 2

Cautions and Contraindications

• Telmisartan should not be used in combination with ACE inhibitors or direct renin inhibitors due to increased risk of adverse effects 2
• Monitor for hyperkalemia, especially in patients with chronic kidney disease or those on potassium supplements or potassium-sparing drugs 2
• There is a risk of acute renal failure in patients with severe bilateral renal artery stenosis 2
• Telmisartan is contraindicated during pregnancy 2

Conclusion

Dividing telmisartan into twice-daily dosing would deviate from established guidelines and could potentially reduce medication adherence without providing additional clinical benefit 1. The pharmacokinetic profile and clinical evidence strongly support once-daily administration as the optimal dosing regimen for telmisartan.