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

Recommended Dosing of Telmisartan for Adults with Hypertension

The usual starting dose of telmisartan for adults with hypertension is 40 mg once daily, with a target dose of 80 mg once daily for optimal blood pressure control. 1, 2

Dosing Guidelines

• The initial dose of telmisartan is typically 40 mg once daily, with most of the antihypertensive effect becoming apparent within 2 weeks and maximal reduction generally attained after 4 weeks 2
• Blood pressure response is dose-related over the range of 20 to 80 mg, with 40-80 mg/day considered the maximum effective dosage range 2, 3
• For patients with stage 1 hypertension and 10-year ASCVD risk ≥10%, initiation with telmisartan as a single antihypertensive drug is reasonable 1
• For patients with stage 2 hypertension (BP ≥140/90 mmHg with BP more than 20/10 mmHg above target), initiation with combination therapy including telmisartan is recommended 1, 4

Special Population Considerations

• No initial dosage adjustment is necessary for elderly patients or patients with renal impairment, including those on hemodialysis 2
• Patients on dialysis may develop orthostatic hypotension and should have their blood pressure closely monitored 2
• Telmisartan can be administered with or without food 2

Monitoring and Follow-up

• 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 for hyperkalemia, especially in patients with chronic kidney disease or those on potassium supplements or potassium-sparing drugs 1

Treatment Algorithm

1. Initial therapy:

   • Start with telmisartan 40 mg once daily for most patients 2, 3
   • For stage 2 hypertension (BP >20/10 mmHg above target), consider initial combination therapy 1, 4

2. Dose titration:

   • If blood pressure remains uncontrolled after 2-4 weeks, increase to 80 mg once daily 2, 3
   • Maximum antihypertensive effect is generally achieved with 40-80 mg dosages 2, 3

3. Combination therapy:

   • If blood pressure remains uncontrolled on maximum dose of telmisartan, add a second antihypertensive agent from a different class 4
   • Preferred combinations include telmisartan with either:
     • Dihydropyridine calcium channel blockers (e.g., amlodipine) 1, 5
     • Thiazide diuretics 1, 6

Important Precautions

• Telmisartan is contraindicated in patients with known hypersensitivity to the drug 2
• Do not co-administer aliskiren with telmisartan in patients with diabetes 2
• The American College of Cardiology advises against combining telmisartan with ACE inhibitors or other ARBs, as this combination is potentially harmful 1
• In patients with an activated renin-angiotensin system (e.g., volume- or salt-depleted patients), symptomatic hypotension may occur after initiation of therapy 2
• Telmisartan is contraindicated during pregnancy, especially in the second and third trimesters 2

Clinical Efficacy

• At doses of ≥40 mg, telmisartan produces statistically significant reductions in blood pressure 3
• Telmisartan 40 to 80 mg/day has shown similar efficacy to amlodipine 5 to 10 mg/day, atenolol 50 to 100 mg/day, and ACE inhibitors like enalapril 5 to 20 mg/day 7
• Long-term studies have demonstrated that telmisartan maintains its efficacy over extended treatment periods of up to 4 years 6