What is the recommended dosage of telmisartan (angiotensin II receptor antagonist) for adults with hypertension?

Telmisartan Dosing for Adults with Hypertension

The recommended dosage of telmisartan for adults with hypertension is 40 mg once daily as the starting dose, with a dose range of 20-80 mg once daily based on blood pressure response. 1

Initial Dosing

• The usual starting dose is 40 mg once daily 1
• Lower starting dose of 20 mg may be considered for patients with volume depletion, those on hemodialysis, or those taking diuretics 1
• No initial dosage adjustment is necessary for elderly patients or those with renal impairment 1

Dose Titration

• Blood pressure response is dose-related over the range of 20 to 80 mg 1
• Most of the antihypertensive effect is apparent within 2 weeks of starting therapy 1
• Maximal blood pressure reduction is generally attained after 4 weeks of treatment 1
• Dose adjustments should be made no more frequently than every 1-2 weeks, based on blood pressure response 2

Target Dosing

• Maximum effective dose is typically 80 mg once daily 1, 2
• For cardiovascular risk reduction, 80 mg once daily is the recommended dose 1
• Doses higher than 80 mg daily have not shown additional benefit in clinical trials 2, 3

Administration Considerations

• Telmisartan may be administered with or without food 1
• Can be administered with other antihypertensive agents when combination therapy is needed 1
• For stage 2 hypertension (BP ≥140/90 mmHg with BP more than 20/10 mmHg above target), initiation with combination therapy including telmisartan is recommended 4

Monitoring Parameters

• Blood pressure should be monitored regularly during dose titration 4
• Follow-up evaluation of adherence and response to treatment should occur at monthly intervals until control is achieved 4
• Monitor renal function and serum potassium, especially in patients with renal impairment 5

Special Considerations

• Telmisartan is contraindicated in patients with known hypersensitivity to the medication 1
• Do not co-administer with aliskiren in patients with diabetes 1
• Avoid use during pregnancy due to risk of fetal harm 1
• Patients on dialysis may develop orthostatic hypotension; blood pressure should be closely monitored 1

Common Pitfalls

• Underdosing: Many patients remain on suboptimal doses, which may result in inadequate blood pressure control 3
• Failure to recognize the full antihypertensive effect may take up to 4 weeks 1, 3
• Inappropriate discontinuation due to minor increases in creatinine, which may be expected and often not clinically significant 5, 6
• Combining telmisartan with ACE inhibitors is not recommended due to increased risk of adverse effects 1

Treatment Algorithm

1. Start with telmisartan 40 mg once daily for most patients 1
2. If blood pressure goal is not achieved after 2-4 weeks, increase to 80 mg once daily 1, 3
3. If blood pressure remains uncontrolled on maximum dose, add a second antihypertensive agent from a different class (preferably a thiazide diuretic or calcium channel blocker) 4
4. For stage 2 hypertension, consider initial combination therapy with telmisartan plus another agent 4