Olmesartan Dosing and Treatment Strategy for Hypertension
Initial Dosing
Start olmesartan at 20 mg once daily for most adults with hypertension, which is the optimal dose that produces approximately 10/6 mmHg blood pressure reduction over placebo. 1
- For patients with possible intravascular volume depletion (e.g., those on diuretics or with impaired renal function), consider starting with a lower dose under close medical supervision 1
- The 20 mg dose represents the recommended starting point that balances efficacy and tolerability 1, 2
Dose Titration Strategy
If blood pressure remains uncontrolled after 2 weeks on olmesartan 20 mg, increase to 40 mg once daily, which provides approximately 12/7 mmHg reduction over placebo. 1
- Doses above 40 mg do not provide additional benefit and should not be used 1
- Twice-daily dosing offers no advantage over once-daily administration 1
- The antihypertensive effect begins within 1 week and is largely established by 2 weeks 1
Blood Pressure Targets
Target blood pressure to 120-129/<80 mmHg in most adults, provided treatment is well tolerated, with an initial goal of <140/90 mmHg in all patients. 3
- For patients ≥65 years, target systolic BP to 130-139 mmHg 3
- For patients ≥85 years or those with symptomatic orthostatic hypotension, consider more lenient targets (e.g., <140 mmHg) 3
- Diastolic BP should be targeted to <80 mmHg in all hypertensive patients 3
Combination Therapy Algorithm
If blood pressure is not controlled on olmesartan 40 mg monotherapy after 2-4 weeks, add hydrochlorothiazide (thiazide diuretic) or a calcium channel blocker as second-line therapy. 3, 4
- For Stage 2 hypertension (BP ≥140/90 mmHg with BP more than 20/10 mmHg above target), initiate combination therapy from the start 4
- Olmesartan plus hydrochlorothiazide provides greater antihypertensive efficacy than either component alone 5, 2
Resistant Hypertension Management
If BP remains uncontrolled on a three-drug combination (olmesartan + thiazide + calcium channel blocker), add spironolactone as the fourth agent. 3
- If spironolactone is not tolerated, use eplerenone instead 3
- Subsequent options include beta-blockers (if not already indicated), centrally acting agents, alpha-blockers, hydralazine, or potassium-sparing diuretics 3
Monitoring Schedule
Monitor blood pressure at monthly intervals until control is achieved, then continue regular monitoring to maintain target BP. 4, 6
- Assess treatment adherence and response at each follow-up visit 4
- BP control should be achieved within 3 months of initiating therapy 6
- The antihypertensive effect is maintained throughout the 24-hour dosing interval with trough-to-peak ratios of 60-80% 1
Pediatric Dosing (≥6 Years)
For children 20 to <35 kg who can swallow tablets, start olmesartan 10 mg once daily; for children ≥35 kg, start 20 mg once daily. 1
- Maximum dose is 20 mg daily for children <35 kg or 40 mg daily for children ≥35 kg 1
- Titrate after 2 weeks if further BP reduction is needed 1
- Do not use olmesartan in children <1 year of age 1
Special Populations
In patients with severe renal insufficiency (CrCl <20 mL/min) or moderate hepatic insufficiency (Child-Pugh score 7-9), do not exceed 20 mg daily. 7
Long-Term Considerations
Olmesartan maintains its antihypertensive effect during long-term treatment (up to 1 year) without tachyphylaxis or rebound effect upon withdrawal. 1
- The drug is well tolerated with an adverse event profile similar to placebo 8, 2
- Dizziness is the most common adverse effect, occurring in approximately 3% of patients 7
- Minimal clinically significant drug interactions occur due to lack of cytochrome P450 interaction 7, 8
Important Caveats
The antihypertensive effect is smaller in Black patients (a typically low-renin population), similar to other ARBs and ACE inhibitors. 1