What is the maximum recommended dose of Candesartan (Angiotensin II receptor antagonist) for an adult patient with hypertension or heart failure?

Maximum Recommended Dose of Candesartan

The maximum recommended dose of candesartan is 32 mg once daily for both hypertension and heart failure, as doses larger than 32 mg do not appear to provide greater blood pressure lowering effect. 1

Dosing by Indication

Hypertension

• Starting dose: 16 mg once daily for patients who are not volume depleted 1
• Dose range: 8-32 mg once daily, administered as a single dose or divided into twice daily dosing 1
• Maximum dose: 32 mg daily 2, 1
• Patients requiring further blood pressure reduction should be titrated to 32 mg, though doses exceeding this amount do not demonstrate additional antihypertensive benefit 1

Heart Failure

• Starting dose: 4 mg once daily 3
• Target dose: 32 mg once daily 3
• Titration schedule: Gradual dose escalation from 4 mg → 8 mg → 16 mg → 32 mg daily, with adjustments made no more frequently than every 2 weeks 3
• The 32 mg daily dose has documented positive effects on mortality and morbidity in heart failure patients 2, 3
• Higher doses provide greater clinical benefits than lower doses in heart failure management 3

Critical Monitoring Requirements

Before Initiating Therapy

• Check serum potassium (must be <5.0 mmol/L) and creatinine (<250 mmol/L) 2
• Assess volume status and blood pressure 3

During Dose Titration

• Recheck potassium and creatinine 4-6 days after starting or increasing dose 2, 3
• Monitor for hypotension, renal impairment, and hyperkalemia 3

Dose Adjustment for Hyperkalemia

• If potassium 5.0-5.5 mmol/L: Reduce dose by 50% 2
• If potassium >5.5 mmol/L: Discontinue candesartan 2

Special Populations

Renal Impairment

• Severe renal dysfunction (CrCl <30 mL/min): Maximum dose should be limited to 8 mg daily due to accumulation risk 4
• Dosing recommendations for candesartan with hydrochlorothiazide cannot be provided for creatinine clearance <30 mL/min 1
• No dose adjustment necessary for mild to moderate renal impairment 5

Hepatic Impairment

• Moderate to severe hepatic impairment: Not recommended for initiation because the appropriate starting dose of 8 mg cannot be given with combination products 1
• No dose adjustment needed for mild to moderate hepatic impairment at doses up to 12 mg/day 4, 5

Elderly Patients

• No dose adjustment required based on age alone 5, 6
• Pharmacokinetic properties are not significantly different from younger individuals 5

Important Clinical Considerations

Combination Therapy Contraindications

• Do not combine candesartan with ACE inhibitors routinely, as this increases risks of renal dysfunction and hyperkalemia 3
• The triple combination of ACE inhibitor + ARB + aldosterone antagonist is specifically contraindicated 3

Time to Maximal Effect

• The maximal antihypertensive effect of any dose can be expected within 4 weeks of initiating that dose 1

Comparative Efficacy

• Candesartan provides better antihypertensive efficacy than losartan and is at least as effective as telmisartan and valsartan 7
• Clinical trials demonstrate candesartan is highly selective with high potency, long duration of action, and tolerability similar to placebo 7