What is the recommended starting dose of losartan (angiotensin II receptor antagonist) for a patient with chronic kidney disease (CKD) stage 3a?

Losartan Dosing for Chronic Kidney Disease Stage 3a

For patients with chronic kidney disease (CKD) stage 3a, the recommended starting dose of losartan is 50 mg once daily or divided into twice daily dosing. 1

Dosing Considerations

• The usual dose range for losartan in hypertensive patients with CKD is 50-100 mg daily, which can be administered once daily or divided into twice daily dosing 1
• No specific dose adjustment is required for CKD stage 3a (eGFR 45-59 mL/min/1.73m²) as losartan does not require dose adjustment for mild to moderate renal impairment 1
• Losartan can be titrated up to 100 mg daily if needed for blood pressure control or optimal antiproteinuric effect 1, 2
• The medication can be administered without regard to food 3

Monitoring Recommendations

• Check serum creatinine and potassium levels within 2-4 weeks of initiation or dose increase of losartan 1
• Monitor for hyperkalemia, especially in patients with CKD or those on potassium supplements or potassium-sparing drugs 1
• Continue losartan therapy unless serum creatinine rises by more than 30% within 4 weeks following initiation or dose increase 1
• A temporary increase in serum creatinine up to 30% is expected and not a reason to discontinue therapy 1

Clinical Benefits in CKD

• Losartan is recommended for patients with CKD and albuminuria (moderately or severely increased) to slow CKD progression 1
• Losartan should be administered using the highest approved dose that is tolerated to achieve maximum renoprotective benefits 1
• Studies show losartan reduces proteinuria by approximately 24% in patients with CKD and hypertension, independent of its blood pressure-lowering effects 4
• Losartan has been shown to retard the progression of renal insufficiency in patients with advanced kidney disease 5

Special Considerations

• Consider reducing the dose or discontinuing losartan in cases of:
  • Symptomatic hypotension 1
  • Uncontrolled hyperkalemia despite medical treatment 1
  • Serum creatinine rise >30% within 4 weeks of initiation 1
• Avoid combination with ACE inhibitors or direct renin inhibitors as this increases risk of adverse effects without additional benefit 1
• Losartan is contraindicated in pregnancy 1

Optimal Antiproteinuric Dosing

• Research suggests that 100 mg of losartan provides optimal antiproteinuric effect in patients with nephrotic range proteinuria 2
• The 50 mg dose showed less antiproteinuric effect, while increasing to 150 mg did not provide additional benefit 2

By starting with 50 mg daily and monitoring renal function and potassium levels, the dose can be safely titrated up to 100 mg daily if needed for optimal blood pressure control and renoprotection in patients with CKD stage 3a.