Increase Losartan to 50 mg Daily as the First Step
For an elderly patient on losartan 25 mg daily with persistent hypertension, the most appropriate initial action is to increase the losartan dose to 50 mg once daily, as this is the standard starting dose for hypertension and the current dose is subtherapeutic. 1
Rationale for Dose Escalation
- The FDA-approved usual starting dose of losartan for adult hypertension is 50 mg once daily, with the option to increase to a maximum of 100 mg daily as needed for blood pressure control 1
- The current dose of 25 mg daily is specifically reserved for patients with possible intravascular depletion (e.g., those already on diuretic therapy), which does not apply to this patient 1
- Evidence from the HEAAL trial demonstrated that losartan 150 mg daily was superior to 50 mg daily, with a 10% relative risk reduction in death or heart failure hospitalization, underscoring that higher doses of renin-angiotensin system blockers provide greater benefit 2
Stepwise Treatment Algorithm
Step 1: Titrate losartan to 50 mg daily
- Reassess blood pressure within 2-4 weeks 3
- If blood pressure remains uncontrolled, increase to 100 mg daily 1
Step 2: If blood pressure remains elevated on losartan 100 mg daily, add amlodipine 2.5-5 mg daily
- Dihydropyridine calcium channel blockers are well-tolerated in elderly patients and do not cause bradycardia 3
- Start with low dose (2.5 mg) and titrate gradually to minimize vasodilatory side effects 3
- Amlodipine demonstrated superior blood pressure reduction compared to losartan monotherapy in head-to-head trials (mean reduction -12.6 vs -10.3 mm Hg diastolic; p=0.002) 4
Step 3: If blood pressure remains uncontrolled on losartan + amlodipine, add a thiazide-like diuretic
- Hydrochlorothiazide 12.5 mg daily should be added based on blood pressure response 1
- The combination of losartan plus hydrochlorothiazide provides greater antihypertensive efficacy than either agent alone 5, 6
- Losartan may minimize the metabolic consequences of diuretic therapy (hypokalemia, hyperuricemia) compared to other antihypertensive combinations 7
Critical Monitoring Parameters for Elderly Patients
- Recheck blood pressure within 4 weeks of any medication adjustment 3
- Target blood pressure goal of <140/90 mm Hg if tolerated in elderly patients 3
- Monitor for orthostatic hypotension by checking blood pressure in both sitting and standing positions 3
- Achieve target blood pressure control within 3 months of initiating treatment adjustments 3
- Monitor serum potassium and creatinine, especially when adding diuretics or increasing ARB doses 8
Common Pitfalls to Avoid
- Do not skip dose optimization: The patient is on a subtherapeutic dose; jumping to combination therapy without first optimizing the current medication wastes an opportunity for simpler management 1
- Avoid beta-blockers in elderly patients when alternatives exist: They are associated with higher withdrawal rates due to adverse events compared to ARBs in this population 5
- Start low and go slow with calcium channel blockers: Begin amlodipine at 2.5 mg in elderly patients to minimize peripheral edema and other vasodilatory effects 3