What is the next best step for a 64-year-old female with hypertension (HTN) on losartan (angiotensin II receptor antagonist) 50mg daily with persistent elevated blood pressure?

Management of Hypertension in a 64-Year-Old Female on Losartan 50mg Daily

The next best step for this patient with persistent elevated blood pressure (133/95 mmHg) on losartan 50mg daily is to increase the losartan dose to 100mg once daily. 1, 2

Assessment of Current Blood Pressure Control

• The patient's current BP of 133/95 mmHg indicates inadequate control despite treatment with losartan 50mg daily 2
• The diastolic BP of 95 mmHg is particularly concerning as it remains in the hypertensive range (≥90 mmHg) 2
• At 64 years old, this patient falls into the 50-80 year age group, which is considered a higher risk category requiring more aggressive BP management 2

Treatment Algorithm for Non-Black Patients

Step 1: Dose Optimization

• For non-black patients with inadequate BP control on low-dose ARB therapy, the next step is to increase to the full dose of the ARB before adding another agent 2
• Losartan can be safely increased from 50mg to 100mg once daily, which is the maximum FDA-approved dose 1
• The FDA label specifically states: "The dosage can be increased to a maximum dose of 100 mg once daily as needed to control blood pressure" 1

Step 2: If Inadequate Response After Dose Increase

• If BP remains uncontrolled after 2-4 weeks on losartan 100mg daily, add a thiazide/thiazide-like diuretic 2
• Hydrochlorothiazide 12.5mg or indapamide 2.5mg would be appropriate additions 2

Evidence Supporting Dose Increase

• The FDA-approved dosing for losartan indicates that 100mg is the maximum effective dose for hypertension management 1
• Clinical studies show that increasing losartan from 50mg to 100mg provides additional BP-lowering effects 3
• Losartan has a favorable safety profile even at the maximum dose, with dizziness being the only adverse effect reported more frequently than placebo 4

Rationale for Choosing Dose Increase Over Adding a Second Agent

• Maximizing the first-line agent before adding a second medication is the recommended approach according to the 2020 International Society of Hypertension guidelines 2
• Simplifying the regimen with once-daily dosing of a single agent improves adherence 2
• Losartan at higher doses has shown better cardiovascular outcomes in clinical trials 5

Monitoring Recommendations

• Reassess BP in 2-4 weeks after increasing the dose 2
• Target BP should be <130/80 mmHg according to current guidelines 2
• If BP remains uncontrolled after dose optimization, proceed to add a thiazide diuretic as the next step 2

Potential Pitfalls and Considerations

• Check medication adherence before increasing the dose, as non-adherence is a common cause of treatment failure 2
• Monitor renal function and serum potassium after dose increase, especially if the patient has any degree of renal impairment 6
• If the patient experiences intolerable side effects with the increased dose, consider adding a dihydropyridine calcium channel blocker instead of increasing the losartan dose 2