What is the recommended rate of titration for losartan (angiotensin II receptor antagonist) dose increases?

Losartan Titration Rate

Losartan should be titrated no more frequently than every 2 weeks when increasing doses toward the target of 100 mg daily for most indications. 1

Standard Titration Protocol

Starting Dose

• Begin with 50 mg once daily for most hypertensive patients 2
• Use 25 mg once daily in patients with possible intravascular depletion (e.g., those on diuretics) or hepatic impairment 2

Titration Schedule

• Increase doses every 2 weeks to target doses or maximally tolerated doses 1
• The FDA-approved dosing allows increases from 50 mg to 100 mg once daily as needed for blood pressure control 2
• For heart failure patients with low blood pressure, use small increments every 1-2 weeks, titrating one drug at a time with close observation 3

Target Doses by Indication

Hypertension:

• Target: 100 mg once daily 2
• Maximum: 100 mg once daily 2

Heart Failure with Reduced Ejection Fraction:

• Target: 100 mg once daily (ACC/AHA guidelines) 1
• Alternative target: 150 mg once daily (European Society of Cardiology guidelines, based on HEAAL trial showing 10% relative risk reduction versus 50 mg) 1

Diabetic Nephropathy:

• Start: 50 mg once daily 2
• Target: 100 mg once daily 2, 4

Special Considerations for Titration Speed

Patients with Low Blood Pressure

• In heart failure patients with baseline low blood pressure, start at the lowest dose and up-titrate slowly with small increments 3
• Monitor closely for symptomatic hypotension, though mild dizziness upon standing can often be managed through patient education without dose reduction 3
• Titrate weekly with low increments until reaching target or highest tolerated dose 3

Renal Impairment

• Losartan can be used without dose adjustment in patients with various degrees of renal insufficiency (eGFR >30 mL/min/1.73 m²) 1, 5
• The standard 2-week titration interval applies 1
• Monitor electrolytes and serum creatinine within 1-2 weeks after initiating treatment 1

Critical Pitfalls to Avoid

Underdosing is widespread: Less than 25% of patients are ever titrated to target doses in clinical practice 1. Higher doses provide greater cardiovascular benefits than lower doses, with little evidence that medium-range doses approximate the benefits of target doses 1.

Do not titrate faster than every 2 weeks in stable outpatients, as this is the guideline-recommended interval to assess response and tolerability 1. The only exception is heart failure patients with low blood pressure who may require weekly titration with very small increments 3.

Avoid simultaneous use with ACE inhibitors: This combination increases the risk of hyperkalemia and renal dysfunction 1.

Monitor for hyperkalemia: Especially important when using higher doses or in patients with renal impairment 1.