What is the recommended dosing of Valsartan (Angiotensin II receptor antagonist) for an adult patient with primary hypertension (HTN)?

Valsartan Dosing for Hypertension in Adults

For adult patients with primary hypertension, start valsartan at 80 mg or 160 mg once daily, with the higher starting dose (160 mg) preferred for patients requiring greater blood pressure reduction; titrate up to a maximum of 320 mg once daily if needed, though most benefit occurs at 80-160 mg. 1

Initial Dosing Strategy

• Start with 80 mg once daily for most patients with stage 1 hypertension who are not volume-depleted 1
• Start with 160 mg once daily for patients requiring greater initial blood pressure reduction or those with stage 2 hypertension 1
• The antihypertensive effect becomes substantially present within 2 weeks, with maximal reduction generally achieved after 4 weeks 1

Dose Titration and Maximum Dosing

• Titrate up to 320 mg once daily if additional blood pressure reduction is needed beyond the starting dose 1
• The dose range of 80-160 mg once daily represents the optimal balance between efficacy and tolerability based on dose-finding studies 2, 3
• Doses beyond 80 mg provide incremental benefit, but adding a diuretic produces greater blood pressure reduction than dose escalation alone 1

Blood Pressure Targets

• Target blood pressure <130/80 mm Hg for patients with known cardiovascular disease or 10-year ASCVD risk ≥10% 4
• For patients without additional cardiovascular risk markers, a target of <130/80 mm Hg may be reasonable 4
• The European Society of Cardiology recommends targeting systolic blood pressure to 120-129 mm Hg in most adults to reduce cardiovascular risk 5

Combination Therapy Approach

• Initiate two-drug combination therapy (either as separate agents or fixed-dose combination) for patients with stage 2 hypertension or blood pressure >20/10 mm Hg above target 4
• Combine valsartan with a dihydropyridine calcium channel blocker or thiazide diuretic as first-line therapy 5
• Fixed-dose single-pill combinations are preferred to improve adherence 5
• If blood pressure remains uncontrolled on two drugs, escalate to three-drug therapy with valsartan, a calcium channel blocker, and a thiazide/thiazide-like diuretic 5

Administration and Monitoring

• Administer once daily at the most convenient time (typically upon awakening) to establish a habitual pattern and improve adherence 5, 6
• Follow up monthly after initiation or dose adjustments until blood pressure target is achieved 4, 5
• Monitor serum potassium and creatinine within 1-2 weeks after initiating or increasing doses, particularly in patients with baseline renal impairment 5

Critical Safety Considerations

• Never combine valsartan with an ACE inhibitor, as this increases the risk of hyperkalemia and renal dysfunction 5
• If symptomatic hypotension or renal dysfunction occurs, consider dose reduction 1
• Valsartan has a tolerability profile comparable to placebo, with significantly lower incidence of cough compared to ACE inhibitors 6, 7

Common Pitfalls to Avoid

• Do not delay treatment for extensive laboratory testing; screening for comorbidities should not delay initiation of therapy 5
• Do not underdose: while 80 mg is effective, many patients benefit from 160 mg, and the tolerability remains excellent at this dose 2, 3
• Do not double the dose to make up for a missed dose 1
• Valsartan tablets and oral suspension are not interchangeable on a milligram-per-milligram basis (suspension has 60% higher systemic exposure) 1