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

Losartan Titration Rate

You can increase losartan every 2 weeks until reaching the target dose, with adjustments made no more frequently than this interval to allow adequate assessment of blood pressure response and tolerability. 1

Standard Titration Protocol

Starting Dose

• Begin with 50 mg once daily for most patients with hypertension 2
• Use 25 mg once daily if the patient has possible intravascular depletion (e.g., on diuretic therapy) or hepatic impairment 2
• For post-myocardial infarction patients, start with 12.5 mg as used in the OPTIMAAL trial 3

Titration Schedule

• Adjust dose every 2 weeks based on blood pressure response and tolerability 1
• The maximum dose for hypertension is 100 mg once daily 2
• For heart failure with reduced ejection fraction, the target dose is 100 mg once daily according to American College of Cardiology guidelines, though some evidence supports 150 mg daily 1

Specific Clinical Scenarios

For Hypertension:

• Week 0: Start 50 mg daily 2
• Week 2-4: Increase to 100 mg daily if blood pressure remains uncontrolled 2
• Consider adding hydrochlorothiazide 12.5-25 mg if 100 mg losartan alone is insufficient 2

For Diabetic Nephropathy:

• Week 0: Start 50 mg once daily 2
• Week 2-4: Increase to 100 mg once daily based on blood pressure response 2

For Heart Failure with Low Blood Pressure:

• Start at the lowest dose and up-titrate slowly with small increments every 1-2 weeks with close observation for symptomatic hypotension 1
• In baseline hypotensive patients, titrate weekly with low increments until reaching target or highest tolerated dose 1

Critical Safety Monitoring

During Titration

• Monitor blood pressure, renal function, and potassium levels within 1-2 weeks after each dose adjustment 1
• Watch for symptomatic hypotension, especially in volume-depleted patients or those with heart failure 1
• Avoid in patients with systolic blood pressure <80 mm Hg or serum creatinine >3 mg/dL without close monitoring 1

Important Contraindications

• Never combine with ACE inhibitors - this increases risk of hyperkalemia and renal dysfunction 1
• Avoid triple therapy with ACE inhibitors and aldosterone antagonists 1

Common Pitfalls to Avoid

Underdosing is widespread - less than 25% of patients are ever titrated to target doses in clinical practice, despite evidence that higher doses provide greater cardiovascular benefits 1. The HEAAL trial demonstrated that 150 mg daily was superior to 50 mg daily with a 10% relative risk reduction in death or heart failure hospitalization 1.

Titrating too quickly - adjusting more frequently than every 2 weeks doesn't allow adequate time to assess the full antihypertensive effect and may lead to unnecessary dose escalations or adverse effects 1.