Switching from Losartan to Nifedipine for Uncontrolled Hypertension
No, you should not switch from losartan 100 mg to nifedipine 60 mg ER—instead, add nifedipine to the losartan or add a thiazide diuretic to the losartan. Switching monotherapy to another monotherapy is less effective than combination therapy for uncontrolled hypertension.
Why Combination Therapy is Preferred
The most effective approach for uncontrolled hypertension on a single agent is to add a second drug from a different class, not to switch drugs. 1
In most trials, combination of two or more drugs has been the most widely used treatment regimen to reduce blood pressure, with approximately 9 out of 10 high-risk hypertensive patients requiring two or more antihypertensive drugs to achieve blood pressure <140/90 mmHg 1
The ability of any single agent to achieve target blood pressure values (<140/90 mmHg) does not exceed 20-30% of the overall hypertensive population except in subjects with grade 1 hypertension 1
Sequential monotherapy (switching from one drug to another) is laborious, frustrating for both doctors and patients, leads to low compliance, and unduly delays urgent control of blood pressure in high-risk hypertensives 1
Recommended Treatment Options
Option 1: Add a Thiazide Diuretic to Losartan (Preferred)
The combination of an angiotensin receptor blocker (ARB) like losartan with a thiazide diuretic is a well-established, evidence-based approach. 1
Patients with hypertension and chronic stable angina should be treated with a regimen that includes an ACE inhibitor or ARB and a thiazide diuretic 1
The addition of hydrochlorothiazide to losartan therapy provides greater antihypertensive efficacy, equivalent to that seen with captopril plus hydrochlorothiazide 2
Losartan can be titrated to losartan/HCTZ 50 mg/12.5 mg after 4 weeks, followed by losartan/HCTZ 50 mg/25 mg if necessary 3
Option 2: Add Nifedipine to Losartan
If a thiazide is contraindicated or not tolerated, adding a long-acting dihydropyridine calcium channel blocker like nifedipine ER to losartan is an appropriate alternative. 1
If either angina or hypertension remains uncontrolled, a long-acting dihydropyridine CCB can be added to the basic regimen of β-blocker, ACE inhibitor/ARB, and thiazide diuretic 1
Nifedipine in combination therapy has been shown effective for resistant hypertension, with adequate control achieved and maintained in 60% of patients when added to existing therapy 4
Why Not Switch to Nifedipine Alone?
Comparative studies show that losartan and nifedipine GITS provide comparable efficacy, with trough sitting diastolic blood pressure reductions of -12.7 mm Hg for losartan versus -11.1 mm Hg for nifedipine GITS at 12 weeks 3
Since both drugs have similar efficacy, switching from one to the other is unlikely to provide better blood pressure control than simply adding a second agent 3
Losartan has superior tolerability compared to nifedipine GITS with respect to edema (4% vs 15%), less bother to patients, and fewer therapy dropouts 3
Important Safety Considerations
Avoid rapid-release, short-acting nifedipine formulations entirely. 1
Nifedipine in capsule form should no longer be prescribed 1
Rapid-release, short-acting dihydropyridines (e.g., nifedipine) must be avoided in the absence of adequate concurrent β-blockade in acute coronary syndromes, because controlled trials suggest increased adverse outcomes 1
Practical Implementation
Start with losartan 100 mg plus hydrochlorothiazide 12.5-25 mg daily, or add nifedipine ER 30 mg daily to the existing losartan 100 mg. 3, 5
If using nifedipine ER, start at 30 mg once daily and titrate to 60 mg after 4 weeks if needed, with a maximum of 90 mg daily 6, 3
Allow at least 4 weeks to observe the full response before further titration 1
Monitor for edema, which occurs more frequently with nifedipine (15% vs 4% with losartan) 3
When nifedipine extended-release tablets are taken after a fatty meal, there is an average increase of 60% in peak plasma nifedipine concentration, so advise consistent timing with respect to meals 6