Can You Increase Losartan When Amlodipine is Not Tolerated?
Yes, you should increase losartan to its maximum effective dose of 100 mg daily when amlodipine cannot be tolerated, as this is the FDA-approved dose escalation strategy for blood pressure control. 1
Dose Escalation Algorithm
When amlodipine is discontinued due to intolerance, immediately increase losartan from 50 mg to 100 mg once daily. 2, 1 The FDA label explicitly states that losartan can be increased to a maximum of 100 mg once daily as needed to control blood pressure. 1
Next Steps if Blood Pressure Remains Uncontrolled
- Add hydrochlorothiazide 12.5 mg daily if blood pressure remains above goal after 2-4 weeks on losartan 100 mg. 2
- Preferentially use chlorthalidone 12.5-25 mg daily instead of hydrochlorothiazide, as it has a longer half-life and proven cardiovascular disease reduction in trials. 3, 2
- Reassess blood pressure within 2-4 weeks after each dose adjustment. 2
Why This Approach Works
The 2017 ACC/AHA guidelines list losartan with a usual dose range of 50-100 mg given 1-2 times daily, confirming that dose escalation is standard practice. 3 Clinical trials demonstrate that higher doses of losartan (100 mg) provide better cardiovascular outcomes than lower doses. 2
Common Pitfall to Avoid
Clinicians frequently fail to titrate ARBs like losartan to their target doses that have been proven to reduce morbidity and mortality. 2 Don't leave patients on subtherapeutic doses—push to 100 mg before adding additional agents unless contraindicated.
Monitoring Requirements
- Monitor serum potassium and creatinine after dose increase, especially in patients with chronic kidney disease or those on potassium supplements or potassium-sparing drugs. 3, 2
- Avoid combining losartan with ACE inhibitors or direct renin inhibitors, as this increases risk of hyperkalemia and renal dysfunction. 3, 2
- Confirm the patient is not pregnant, as losartan is contraindicated in pregnancy. 3, 2
Special Consideration for Hepatic Impairment
If the patient has mild-to-moderate hepatic impairment, start with losartan 25 mg daily and titrate more cautiously. 1 Losartan has not been studied in severe hepatic impairment. 1