What adjustments should be made to an elderly patient's hypertension (HTN) medication regimen, currently on losartan, with an office blood pressure reading of hypertension?

Adjust Losartan Dose Now—Do Not Wait

For this elderly male with BP 156/104 on losartan, increase the losartan dose from 50mg to 100mg once daily immediately rather than waiting 2 more weeks. 1 This represents standard dose optimization before adding a second agent, and delaying treatment intensification in stage 2 hypertension (>150/100 mmHg) increases cardiovascular risk unnecessarily. 2

Rationale for Immediate Dose Escalation

• The FDA label for losartan specifies that the usual starting dose is 50mg once daily, with dosage increased to a maximum of 100mg once daily as needed to control blood pressure. 1
• Maximizing the current medication dose before adding a new agent is the guideline-recommended approach, particularly in elderly patients where polypharmacy carries additional risks. 2, 3
• Recent evidence demonstrates that maximizing dose provides similar blood pressure reductions to adding a new medication (-1.1 mmHg difference at 12 months), with better treatment sustainability in older adults. 4

Why Not Wait 2 More Weeks

• This patient has stage 2 hypertension (BP >150/100 mmHg), which warrants immediate treatment intensification rather than observation. 2
• Delaying action for patients with stage 2 hypertension increases cardiovascular risk, and prompt dose adjustment is required. 2
• The current BP of 156/104 is >30 mmHg above target (<140/90 mmHg for elderly patients), indicating inadequate control that requires action now. 3

Specific Treatment Algorithm

Step 1: Increase losartan to 100mg once daily immediately 1

• Start with this dose optimization rather than adding a second drug class, as this follows the stepwise approach recommended for elderly patients. 3
• For elderly patients, aim for BP goal of <140/90 mmHg if tolerated, though <130/80 mmHg is acceptable if well-tolerated without orthostatic symptoms. 3

Step 2: Recheck BP in 2-4 weeks after dose increase 2, 3

• Monitor for orthostatic hypotension by checking BP in both sitting and standing positions, as elderly patients are at higher risk. 3
• Check serum potassium and creatinine 2-4 weeks after uptitrating losartan, especially at higher doses. 2

Step 3: If BP remains ≥140/90 mmHg on losartan 100mg, add a second agent 2, 3

• Add amlodipine 2.5-5mg daily (start low in elderly) as the preferred second agent, providing complementary vasodilation through calcium channel blockade. 3
• Alternative: Add chlorthalidone 12.5mg daily (NOT 25mg in elderly due to 3-fold higher hypokalemia risk). 3
• Do not use chlorthalidone >12.5mg in elderly patients, as doses above this significantly increase hypokalemia risk without substantial additional BP benefit. 3

Step 4: If BP remains uncontrolled on dual therapy at optimal doses, add a third agent 2

• Add the remaining drug class (thiazide diuretic if on losartan + amlodipine, or amlodipine if on losartan + thiazide) to achieve guideline-recommended triple therapy. 2

Critical Monitoring Points for Elderly Patients

• Check for orthostatic hypotension at every visit, as elderly patients are at higher risk for falls with BP lowering. 3
• Monitor serum potassium closely when using losartan, especially if adding a thiazide diuretic later (hyperkalemia risk with ARB, hypokalemia risk with thiazide). 2
• Assess medication adherence before assuming treatment failure—non-adherence is the most common cause of apparent treatment resistance. 2, 5
• Consider home BP monitoring to confirm sustained hypertension and rule out white-coat effect (home BP ≥135/85 mmHg confirms true hypertension). 2

Common Pitfalls to Avoid

• Do not add a second medication before maximizing losartan to 100mg daily—this violates the stepwise approach and exposes patients to unnecessary polypharmacy. 2, 4
• Do not delay treatment intensification for 2 more weeks when BP is >150/100 mmHg—this is stage 2 hypertension requiring immediate action. 2
• Do not use chlorthalidone >12.5mg in elderly patients due to excessive hypokalemia risk (3-fold higher than lower doses). 3
• Do not withhold appropriate treatment intensification solely based on age—individualize BP targets based on frailty and tolerability, not age alone. 2, 6

Target Timeline

• Achieve target BP (<140/90 mmHg) within 3 months of initiating or modifying therapy. 2, 3
• Reassess within 2-4 weeks after each medication adjustment to evaluate response and side effects. 2, 3

2, 3, 1, 4