What is the recommended treatment and dosage for high blood pressure using Olmesartan (Benicar)?

Olmesartan for Hypertension: Treatment and Dosing

Start olmesartan at 20 mg once daily for most adults with hypertension, increasing to 40 mg once daily after 2 weeks if blood pressure remains uncontrolled; doses above 40 mg provide no additional benefit. 1

Initial Dosing Strategy

Standard Adult Dosing

• Begin with 20 mg once daily as monotherapy in patients who are not volume-depleted 1
• After 2 weeks, if blood pressure reduction is insufficient, increase to 40 mg once daily 1
• Doses exceeding 40 mg do not provide greater antihypertensive effect 1
• Twice-daily dosing offers no advantage over once-daily administration 1

Volume-Depleted Patients

• Use a lower starting dose (consider 10 mg) in patients with possible intravascular volume depletion 1
• This includes patients on diuretics or those with impaired renal function 1
• Initiate under close medical supervision in these cases 1

Blood Pressure Targets

General Adult Population

• Initial target: <140/90 mmHg for all patients 2
• Optimal target: 120-129 mmHg systolic and <80 mmHg diastolic if treatment is well tolerated 2
• This more intensive target reduces cardiovascular disease risk in most adults 2

Special Populations Requiring Modified Targets

• Patients ≥65 years: 130-139 mmHg systolic 2
• Patients ≥85 years or with symptomatic orthostatic hypotension: <140 mmHg systolic (more lenient) 2
• Frail patients or limited life expectancy (<3 years): <140/90 mmHg (more lenient) 2

Treatment Algorithm

Monotherapy Approach

Olmesartan is indicated as first-line therapy as an ARB, which has demonstrated effective reduction of blood pressure and cardiovascular events in randomized controlled trials 2

Step 1: Olmesartan 20 mg once daily 1 Step 2: If uncontrolled after 2 weeks, increase to olmesartan 40 mg once daily 1

Combination Therapy

If blood pressure remains uncontrolled on olmesartan 40 mg:

• Add a thiazide/thiazide-like diuretic (preferred second agent) 2
• Alternatively, add a calcium channel blocker 2
• For stage 2 hypertension (BP ≥160/100 mmHg or >20/10 mmHg above target), consider starting with combination therapy immediately 2

Resistant Hypertension (Uncontrolled on 3 Drugs)

If blood pressure remains uncontrolled on olmesartan + diuretic + calcium channel blocker:

• Add spironolactone (preferred fourth agent) 2
• If spironolactone not tolerated: eplerenone, amiloride, doxazosin, beta-blocker, or clonidine 2

Expected Blood Pressure Reduction

Efficacy Data

• Olmesartan 20 mg once daily: Reduces blood pressure by approximately 10/6 mmHg (systolic/diastolic) compared to placebo 1
• Olmesartan 40 mg once daily: Reduces blood pressure by approximately 12/7 mmHg compared to placebo 1
• Onset of effect occurs within 1 week, with maximal effect by 2 weeks 1
• Trough-to-peak ratios of 60-80% demonstrate sustained 24-hour blood pressure control 1

Comparative Effectiveness

At recommended starting doses, olmesartan 20 mg was more effective than losartan 50 mg, valsartan 80 mg, or irbesartan 150 mg in reducing blood pressure 3

Monitoring and Follow-Up

Timeline

• Reassess blood pressure after 2 weeks to determine if dose escalation is needed 1
• Achieve target blood pressure within 3 months of initiating therapy 2
• Monthly follow-up until blood pressure is controlled 2

Long-Term Considerations

• Blood pressure lowering effect is maintained throughout 24 hours with once-daily dosing 1
• No evidence of tachyphylaxis during long-term treatment up to 1 year 1
• No rebound effect following abrupt withdrawal after 1 year of treatment 1

Pediatric Dosing (6 Years and Older)

Weight-Based Dosing

• Patients 20 to <35 kg: Start 10 mg once daily, may increase to maximum 20 mg once daily 1
• Patients ≥35 kg: Start 20 mg once daily, may increase to maximum 40 mg once daily 1
• Reassess after 2 weeks and increase dose if needed 1
• Not recommended for children <1 year of age 1

Safety Profile

Tolerability

• Adverse event frequency similar to placebo 1, 4, 5
• No dose-related increase in adverse events 1, 5
• Well tolerated for up to 2 years of continuous treatment 1, 5
• Minimal drug-drug interactions (not metabolized by cytochrome P-450) 3, 4

Common Pitfalls to Avoid

• Do not exceed 40 mg once daily as higher doses provide no additional benefit 1
• Do not use twice-daily dosing as it offers no advantage over once-daily administration 1
• Screen for volume depletion before initiating standard doses in patients on diuretics 1
• Do not target blood pressure <120/70 mmHg as this may increase risk without additional benefit 2
• Adjust targets for elderly patients to avoid excessive blood pressure lowering 2