What is the recommended dosage and treatment plan for losartan (Losartan) in patients with hypertension?

Losartan Dosing for Hypertension

For hypertension, start losartan at 50 mg once daily and titrate to 100 mg once daily based on blood pressure response to achieve optimal cardiovascular outcomes. 1

Initial Dosing Strategy

• Standard starting dose: 50 mg once daily for most patients with hypertension 1
• Reduced starting dose: 25 mg once daily for patients with possible intravascular depletion (e.g., those on diuretic therapy) or mild-to-moderate hepatic impairment 1
• The usual starting dose provides effective blood pressure reduction with placebo-adjusted reductions of approximately 15.5/9.2 mmHg when combined with hydrochlorothiazide 12.5 mg 1

Dose Titration and Target Dosing

The maximum and often optimal dose is 100 mg once daily, though evidence supports even higher dosing in specific contexts 1:

• In the HEAAL trial, losartan 150 mg daily was superior to 50 mg daily, showing a 10% relative risk reduction in death or heart failure hospitalization over 4.7 years 2
• This dose-response relationship mirrors findings with ACE inhibitors, emphasizing that higher doses of renin-angiotensin system blockers provide greater benefit 2
• The FDA-approved maximum dose remains 100 mg daily, though ACC/AHA guidelines acknowledge 150 mg as a target dose in heart failure contexts 2, 1

Treatment Algorithm by Clinical Context

Uncomplicated Hypertension

• Start 50 mg once daily 1
• If blood pressure goal (<140/90 mmHg) not achieved after 2-4 weeks, increase to 100 mg once daily 1
• Consider adding hydrochlorothiazide 12.5 mg if monotherapy insufficient 1

Hypertension with Left Ventricular Hypertrophy

• Start 50 mg once daily 1
• Add hydrochlorothiazide 12.5 mg daily and/or increase losartan to 100 mg once daily based on blood pressure response 1
• Subsequently increase hydrochlorothiazide to 25 mg once daily if needed 1

Hypertension with Type 2 Diabetes and Nephropathy

• Start 50 mg once daily 1
• Increase to 100 mg once daily based on blood pressure response 1

Combination Therapy Considerations

Combination therapy with a diuretic is recommended for most patients as initial therapy when blood pressure is ≥140/90 mmHg 2:

• Preferred combination: losartan with hydrochlorothiazide (thiazide/thiazide-like diuretic) 2
• Fixed-dose single-pill combinations are recommended to improve adherence 2
• Do not combine losartan with an ACE inhibitor—this combination increases adverse events without improving survival 2

Blood Pressure Targets

Target systolic blood pressure of 120-129 mmHg in most adults with hypertension, provided treatment is well tolerated 2:

• This represents the most recent (2024) ESC guideline recommendation prioritizing cardiovascular risk reduction 2
• In cases of poor tolerability, target "as low as reasonably achievable" (ALARA principle) 2
• For patients at increased cardiovascular risk (stage A heart failure), target <130/80 mmHg 2

Special Populations

Pediatric Patients (6-16 years)

• Starting dose: 0.7 mg/kg once daily (up to 50 mg total) 1
• Maximum dose: 1.4 mg/kg daily (not to exceed 100 mg) 1
• Not recommended in children <6 years or with eGFR <30 mL/min/1.73 m² 1

Elderly Patients

• No dosage adjustment required 3
• Losartan shows similar efficacy to other antihypertensives in elderly populations 3
• Consider starting at 25 mg if concerns about volume status 1

Hepatic Impairment

• Start at 25 mg once daily in mild-to-moderate hepatic impairment 1
• Not studied in severe hepatic impairment 1

Renal Impairment

• No dosage adjustment needed for mild-to-moderate renal dysfunction 3

Timing of Administration

Take losartan at the most convenient time of day to establish a habitual pattern and improve adherence 2:

• Once-daily dosing provides sustained 24-hour blood pressure control 4, 5
• No evidence supports preferential morning versus evening dosing for cardiovascular outcomes 2

Common Pitfalls and Caveats

Underdosing

• The ELITE II trial showed losartan 50 mg once daily failed to demonstrate non-inferiority to captopril, likely due to inadequate dosing 2
• Many patients remain on suboptimal doses—actively titrate to 100 mg daily unless contraindicated 2

Race-Based Response

• Losartan may be somewhat less effective in Black patients (typically a low-renin population) 1
• Consider combination therapy earlier in this population 1

Postoperative Management

• Resume losartan as soon as patient can take oral medications after surgery 6
• Delaying resumption of ARBs has been associated with increased 30-day mortality risk 6
• Avoid abrupt withdrawal to prevent rebound hypertension 6

Volume Status

• Assess for volume depletion before initiating therapy, particularly in patients on diuretics 1
• Risk of first-dose hypotension is low but consider 25 mg starting dose if concerned 1, 3

Safety and Tolerability

Losartan demonstrates excellent tolerability with adverse event rates similar to placebo 1, 7, 5:

• Dizziness is the only adverse event occurring >1% more frequently than placebo 7
• Cough incidence (3.1%) is similar to placebo (2.6%), making it an excellent alternative for patients with ACE inhibitor-induced cough 7, 5
• No clinically relevant metabolic effects or laboratory abnormalities documented 5
• Long-term safety data (up to 6 months in large observational studies) confirm excellent tolerability with adverse effects in only 0.2% of patients 8

Monitoring

• Check blood pressure response 2-4 weeks after initiation or dose adjustment 1
• Monitor serum potassium and creatinine, particularly when combined with other RAAS blockers or in patients with renal impairment 1
• Assess for volume status if hypotension occurs 6