What is the recommended dose of Telmisartan (angiotensin II receptor antagonist) for adults with hypertension?

Telmisartan Dosing for Hypertension in Adults

For adults with hypertension, start telmisartan at 40 mg once daily, with a dose-related blood pressure response across the range of 20-80 mg, and titrate to 80 mg once daily if blood pressure remains uncontrolled after 2-4 weeks. 1

Initial Dosing

• The usual starting dose is 40 mg once daily, which can be administered with or without food 1
• Blood pressure response is dose-related over the range of 20-80 mg, with most antihypertensive effect apparent within 2 weeks and maximal reduction generally attained after 4 weeks 1
• No initial dosage adjustment is necessary for elderly patients or those with renal impairment, including patients on hemodialysis 1

Dose Titration Strategy

• If blood pressure remains uncontrolled on 40 mg once daily, increase to 80 mg once daily (the FDA-approved maximum dose) 2, 1
• Blood pressure should be monitored regularly during dose titration, with follow-up evaluation at monthly intervals until control is achieved 3, 4
• Maximum blood pressure reduction occurs with dosages of 40-80 mg/day 5

Target Blood Pressure Goals

• Target blood pressure of <140/90 mmHg for all patients with hypertension without comorbidities 6
• Target systolic blood pressure of <130 mmHg for patients with known cardiovascular disease (strong recommendation) or high-risk patients with diabetes mellitus or chronic kidney disease (conditional recommendation) 6

Combination Therapy Considerations

• For stage 2 hypertension (BP ≥140/90 mmHg with BP more than 20/10 mmHg above target), consider initiating combination therapy with telmisartan plus another agent 3
• If blood pressure remains uncontrolled on telmisartan 80 mg daily, add a second antihypertensive agent from a different class, preferably a thiazide diuretic (such as hydrochlorothiazide) or calcium channel blocker 3, 4
• Combination therapy, preferably with a single pill combination, improves adherence and persistence 6
• For resistant hypertension on maximum dose telmisartan plus other agents, adding an aldosterone antagonist like spironolactone should be considered 4

Special Populations

• Patients on dialysis may develop orthostatic hypotension and require close blood pressure monitoring 1
• In patients with volume or salt depletion (e.g., those on high-dose diuretics), symptomatic hypotension may occur after initiation; either correct this condition prior to starting telmisartan or begin treatment under close supervision with a reduced dose 1

Common Pitfalls to Avoid

• Do not exceed 80 mg once daily for hypertension, as this is the maximum FDA-approved dose and doses above this range have not been shown to provide additional benefit 1
• Avoid undertreating by remaining at 40 mg when blood pressure is not controlled—uptitration to 80 mg should be attempted unless contraindicated 2
• Do not use telmisartan with an ACE inhibitor, as this combination is not recommended 1
• Do not co-administer with aliskiren in patients with diabetes 1