Losartan Dosing Recommendations for Hypertension and Diabetic Nephropathy
The recommended starting dose of losartan for hypertension is 50 mg once daily, with titration to a maximum dose of 100 mg once daily as needed for blood pressure control. For diabetic nephropathy, start with 50 mg once daily and increase to 100 mg once daily based on blood pressure response. 1
Dosing for Hypertension
Adult Hypertension
- Starting dose: 50 mg once daily 1
- Maximum dose: 100 mg once daily 1
- For patients with possible intravascular depletion (e.g., those on diuretic therapy): Start with 25 mg once daily 1
- Losartan can be administered without regard to food 2
Special Populations
- Patients with mild-to-moderate hepatic impairment: Starting dose of 25 mg once daily 1
- Losartan has not been studied in patients with severe hepatic impairment 1
- No dosage adjustment is necessary for patients with various degrees of renal insufficiency 2
- Losartan is not removed during hemodialysis 2
Dosing for Diabetic Nephropathy
- Starting dose: 50 mg once daily 1
- Target dose: 100 mg once daily based on blood pressure response 1
- Evidence suggests that 100 mg daily is the optimal dose for renoprotection in diabetic nephropathy 3
- In the RENAAL study, losartan at doses up to 100 mg daily significantly reduced the incidence of end-stage renal disease by 28% compared to placebo 4
Efficacy Considerations
- Losartan 100 mg daily has been shown to be significantly more effective than 50 mg daily in reducing albuminuria (48% vs 30% reduction) in patients with diabetic nephropathy 3
- Losartan 100 mg daily was also more effective than 50 mg daily in reducing systolic, diastolic, and mean arterial blood pressure 3
- No significant additional benefit was observed when increasing the dose from 100 mg to 150 mg daily for either renoprotection or blood pressure reduction 3
Clinical Pearls and Caveats
- The optimal dose of losartan for heart failure (150 mg daily) is higher than that commonly prescribed (50 mg daily) and higher than doses approved for other cardiovascular indications in the US 5
- The commonly prescribed dose of 50 mg daily appears to be inferior to ACE inhibitors with respect to mortality reduction in heart failure 5
- For patients with hypertension and type 2 diabetes who are allergic to ACE inhibitors, ARBs like losartan are recommended as first-line treatment 6
- Blood pressure target for most patients with diabetes and hypertension should be <130/80 mmHg 6
- Never combine an ARB like losartan with an ACE inhibitor or direct renin inhibitor due to increased risk of adverse effects without added benefit 6
- Monitor for hyperkalemia, especially if adding a mineralocorticoid receptor antagonist to losartan 6
Monitoring Recommendations
- Monitor serum creatinine/eGFR and potassium levels at least annually 6
- For patients with diabetic nephropathy, determine baseline blood pressure and level of albuminuria before starting therapy 6
- Counsel patients to temporarily hold losartan when at risk for volume depletion (e.g., during acute illness with vomiting or diarrhea) 5
By following these evidence-based dosing recommendations, you can optimize the benefits of losartan therapy for patients with hypertension and diabetic nephropathy while minimizing potential adverse effects.