What is the maximum recommended dose of losartan (angiotensin II receptor antagonist) that can be taken?

Maximum Dose of Losartan

The maximum recommended dose of losartan is 100 mg once daily for hypertension according to FDA labeling, though doses up to 150 mg daily have been studied and recommended by the European Society of Cardiology specifically for heart failure with reduced ejection fraction. 1, 2

Standard Maximum Dosing by Indication

Hypertension

• The FDA-approved maximum dose is 100 mg once daily 1
• The American College of Cardiology/American Heart Association guidelines confirm this 100 mg daily maximum for hypertension, which can be administered as a single dose or split into two 50 mg doses 2, 3
• Doses above 100 mg daily have not been adequately studied for hypertension alone 1

Heart Failure with Reduced Ejection Fraction

• The European Society of Cardiology recommends a target dose of 150 mg daily for heart failure, which is higher than the standard hypertension maximum 2
• The HEAAL trial demonstrated that 150 mg daily was superior to 50 mg daily, showing a 10% relative risk reduction in death or heart failure hospitalization (P=0.027) 2
• The American College of Cardiology acknowledges that 150 mg daily may be considered in heart failure patients not achieving adequate control with 50-100 mg 2

Nephropathy in Type 2 Diabetes

• The FDA label recommends starting at 50 mg once daily and increasing to 100 mg once daily based on blood pressure response 1
• Clinical evidence supports that 100 mg significantly reduced albumin-to-creatinine ratio and risks of chronic kidney disease progression 3

Important Dosing Considerations

Titration Strategy

• Start at 50 mg once daily for most patients 1
• Use 25 mg once daily as starting dose in patients with possible intravascular depletion (e.g., on diuretic therapy) or mild-to-moderate hepatic impairment 1
• Adjust therapy no more frequently than every 2 weeks when titrating to target doses 2

Special Populations

• Pediatric patients: Maximum dose is 1.4 mg/kg daily (not to exceed 100 mg daily); doses above this have not been studied 1
• Hepatic impairment: Start at 25 mg once daily in mild-to-moderate impairment; losartan has not been studied in severe hepatic impairment 1
• Renal impairment: No dosage adjustment necessary for various degrees of renal insufficiency, including patients on hemodialysis 1, 4

Critical Safety Warnings

• Monitor renal function and potassium levels within 1-2 weeks after initiating treatment, especially in patients with systolic blood pressure <80 mm Hg or serum creatinine >3 mg/dL 2
• Never combine losartan with ACE inhibitors, as this increases risk of hyperkalemia and renal dysfunction (demonstrated in the VALIANT trial) 2, 3
• Avoid combination with direct renin inhibitors for the same reasons 3

When Maximum Dose is Insufficient

If blood pressure remains uncontrolled on losartan 100 mg daily:

• Add hydrochlorothiazide 12.5-25 mg daily, which provides additive blood pressure-lowering effects 2, 1
• Consider alternative antihypertensive agents from different classes 2
• The combination of losartan 100 mg with low-dose hydrochlorothiazide 12.5 mg has been shown more effective than losartan 100 mg alone for both blood pressure reduction and proteinuria amelioration 5

Common Pitfall to Avoid

Underdosing is widespread in clinical practice, with less than 25% of patients ever titrated to target doses 2. Higher doses provide greater cardiovascular benefits than lower doses, with little evidence that medium-range doses approximate the benefits of target doses 2. For heart failure patients specifically, the 50 mg daily dose appears inferior to ACE inhibitors for mortality reduction, supporting the use of higher doses when tolerated 2.