What is the effective dose of Losartan (angiotensin II receptor blocker) for treating hypertension?

Effective Dose of Losartan

For hypertension, start losartan at 50 mg once daily and titrate to a maximum of 100 mg once daily as needed for blood pressure control; for heart failure with reduced ejection fraction, the target dose is 150 mg daily, which has been proven superior to lower doses in reducing mortality and hospitalization. 1, 2, 3

Hypertension Dosing

Standard Dosing Protocol

• Initial dose: 50 mg once daily is the FDA-approved starting dose for most adults with hypertension 1
• Maximum dose: 100 mg once daily can be used if blood pressure remains uncontrolled 1
• Patients with possible intravascular depletion (e.g., on diuretics) should start at 25 mg once daily 1

Evidence for Hypertension

• Doses of 50-100 mg once daily produce statistically significant blood pressure reductions of 5.5-10.5/3.5-7.5 mmHg compared to placebo 1
• The 150 mg dose provides no greater antihypertensive effect than 50-100 mg for hypertension alone 1
• Twice-daily dosing at 50-100 mg/day gives consistently larger trough responses than once-daily dosing at the same total dose 1

Combination Therapy

• Adding hydrochlorothiazide 12.5 mg to losartan 50 mg once daily produces blood pressure reductions of 15.5/9.2 mmHg 1
• Combination therapy is preferred by the European Society of Cardiology for most adults with confirmed hypertension 4

Heart Failure Dosing

Target Dosing for Optimal Outcomes

• Target dose: 150 mg daily for heart failure with reduced ejection fraction, based on the HEAAL trial 2, 3
• The HEAAL trial demonstrated that 150 mg daily of losartan was superior to 50 mg daily, with a 10% relative risk reduction in death or heart failure hospitalization over 4.7 years (P=0.027) 2
• The commonly prescribed 50 mg daily dose appears inferior to ACE inhibitors for mortality reduction 2

Alternative Target Recommendations

• The American College of Cardiology/American Heart Association guidelines recommend 100 mg once daily as the target dose for heart failure 3, 5
• A threshold of 50% of target dose (50 mg daily) is considered the minimum for meaningful benefit 3

Titration Strategy

• Start at 50 mg once daily and titrate gradually 3
• Adjust therapy no more frequently than every 2 weeks to target doses or maximally tolerated doses 3, 5
• Monitor renal function and potassium levels within 1-2 weeks after initiation, especially in patients with systolic blood pressure <80 mmHg or creatinine >3 mg/dL 3

Critical Dosing Considerations

Why Higher Doses Matter

• The ELITE II trial failed to show that losartan 50 mg daily was as effective as captopril for heart failure 2
• Higher doses provide greater benefits than lower doses, with little evidence that medium-range doses approximate the benefits of target doses 2
• The most dramatic blood pressure decreases occur with the starting dose; subsequent increments produce comparatively smaller changes 2

Common Pitfalls

• Underdosing is widespread in clinical practice: <25% of patients are ever titrated to target doses 2
• Many physicians are unfamiliar with the higher target doses needed for heart failure (150 mg) compared to hypertension dosing 2
• The dose of losartan for hypertension (50-100 mg) is lower than the optimal dose for heart failure (150 mg) 2

Special Populations

Hepatic Impairment

• Start at 25 mg once daily in patients with mild-to-moderate hepatic impairment 1
• Losartan has not been studied in severe hepatic impairment 1

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

Renal Impairment

• No dosage adjustment necessary for various degrees of renal insufficiency 6
• Losartan 50-100 mg once daily is effective and well-tolerated in patients with chronic renal disease, including those on hemodialysis 7

Contraindications

Combination Therapy to Avoid

• Do not combine losartan with ACE inhibitors, as this increases risk of hyperkalemia and renal dysfunction 3
• The VALIANT trial showed that combining valsartan with captopril increased adverse events without improving survival 2
• Avoid triple therapy with ACE inhibitors and aldosterone antagonists 3