Is a regimen of losartan (angiotensin II receptor antagonist) 50mg twice daily (bid), metoprolol (beta blocker) 50mg twice daily, and amlodipine (calcium channel blocker) 5mg daily excessive?

From the Guidelines

The regimen of losartan 50mg twice daily, metoprolol 50mg twice daily, and amlodipine 5mg daily may be considered excessive for some individuals, particularly if they are prone to hypotension or have certain comorbidities, as it combines three different types of blood pressure medications that can potentially cause additive hypotensive effects. According to the 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure 1, the recommended initial daily dose of metoprolol succinate extended release is 12.5-25 mg QD, with a maximum dose of 200 mg QD, suggesting that the prescribed dose of 50mg twice daily may be higher than necessary for some patients. Additionally, the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults recommends careful consideration of the potential risks and benefits of combination therapy, particularly in patients with certain comorbidities or those who are prone to hypotension 1.

Some key points to consider when evaluating the appropriateness of this regimen include:

• The patient's specific medical condition and health history
• The presence of any comorbidities that may increase the risk of hypotension or other adverse effects
• The patient's blood pressure goals and current blood pressure readings
• The potential for additive hypotensive effects when combining multiple blood pressure medications
• The need for regular monitoring of blood pressure and adjustment of the medication regimen as needed to minimize the risk of adverse effects.

It is essential to consult with a healthcare provider to determine the best course of treatment and to monitor for any potential side effects or adverse reactions. Regular blood pressure monitoring at home would be helpful to ensure that the patient's blood pressure is within the target range and not too low. If the patient is experiencing side effects like dizziness, lightheadedness, unusual fatigue, or other concerns, they should contact their doctor immediately for evaluation.

From the Research

Dosage Comparison

• The provided studies do not directly address the specific regimen of losartan 50mg twice daily, metoprolol 50mg twice daily, and amlodipine 5mg daily.
• However, study 2 compared the efficacy and tolerability of a fixed-dose combination of metoprolol extended release/amlodipine with losartan plus amlodipine in patients with mild-to-moderate hypertension.
• Study 3 evaluated the effectiveness and safety of losartan and its combination with amlodipine in therapy of arterial hypertension, with losartan used at a dose of 50-100 mg/24 h.
• Study 4 assessed the efficacy and tolerability of a triple combination of amlodipine/losartan/rosuvastatin in patients with hypertension and hypercholesterolemia, with losartan potassium 100mg once daily.
• Study 5 compared the efficacy and safety of combined therapy with losartan, amlodipine, and hydrochlorothiazide in the management of stage 2 hypertension, with losartan/amlodipine 50/10mg.
• Study 6 compared the efficacy and safety of amlodipine and losartan potassium in essential hypertension, with amlodipine 5mg daily and losartan potassium 50mg daily.

Efficacy and Safety

• The studies suggest that the combination of losartan, amlodipine, and other antihypertensive agents can be effective in reducing blood pressure and managing hypertension 2, 3, 4, 5.
• The safety profiles of these combinations were generally positive, with few adverse events reported 2, 3, 4, 5.
• However, the specific regimen of losartan 50mg twice daily, metoprolol 50mg twice daily, and amlodipine 5mg daily was not directly evaluated in these studies.

Regimen Evaluation

• Based on the available evidence, it is difficult to determine whether the specified regimen is excessive, as the studies did not directly assess this specific combination and dosage.
• However, the individual components of the regimen have been shown to be effective and generally well-tolerated in various studies 2, 3, 4, 5, 6.