Alternative Medications for Losartan and Amlodipine
For patients requiring alternatives to losartan and amlodipine, switch to other ARBs (valsartan 80-320mg daily, telmisartan 20-80mg daily, or irbesartan 150-300mg daily) and other dihydropyridine calcium channel blockers (felodipine 2.5-10mg daily or nifedipine LA 30-90mg daily), as these are guideline-recommended first-line agents with equivalent efficacy for blood pressure control and cardiovascular protection. 1
Within-Class ARB Alternatives to Losartan
Telmisartan is the preferred ARB alternative, offering once-daily dosing at 20-80mg with cardiovascular protective effects demonstrated in the ONTARGET trial showing non-inferiority to ACE inhibitors for major cardiovascular outcomes. 1, 2
Valsartan 80-320mg once daily provides robust blood pressure lowering without the need for twice-daily dosing that losartan sometimes requires. 1
Irbesartan 150-300mg once daily offers consistent 24-hour blood pressure control with a favorable side effect profile. 1
Candesartan 8-32mg once daily is another effective option, though requires monitoring for hyperkalemia particularly in patients with chronic kidney disease. 1
All ARBs share the same contraindications: avoid in pregnancy, do not combine with ACE inhibitors or aliskiren, monitor for hyperkalemia especially with CKD or potassium supplements, and assess for bilateral renal artery stenosis risk. 1, 2
Within-Class Calcium Channel Blocker Alternatives to Amlodipine
Felodipine 2.5-10mg once daily is the most comparable dihydropyridine alternative, with similar efficacy and the advantage of being acceptable even in heart failure with reduced ejection fraction when required. 1
Nifedipine LA 30-90mg once daily provides potent blood pressure reduction with proven cardiovascular outcomes data. 1
Nisoldipine 17-34mg once daily offers once-daily dosing with similar efficacy to amlodipine. 1
All dihydropyridine calcium channel blockers cause dose-related pedal edema (more common in women), should be avoided in heart failure with reduced ejection fraction (except amlodipine or felodipine if required), and do not cause the bradycardia or heart block seen with non-dihydropyridines. 1
Alternative Drug Classes if Within-Class Substitution Fails
ACE inhibitors are the primary alternative class if ARBs are not tolerated. Lisinopril 10-40mg once daily or ramipril 2.5-20mg once or twice daily are preferred options, but cannot be used if the patient had angioedema with losartan (must wait 6 weeks after ARB discontinuation before starting an ACE inhibitor). 1
Thiazide diuretics serve as excellent alternatives or additions. Chlorthalidone 12.5-25mg once daily is preferred over hydrochlorothiazide due to its prolonged half-life and proven cardiovascular disease reduction in trials. 1
Non-dihydropyridine calcium channel blockers (diltiazem ER 120-360mg once daily or verapamil SR 120-360mg once or twice daily) can replace amlodipine but must not be used in heart failure with reduced ejection fraction and should not be routinely combined with beta blockers due to bradycardia and heart block risk. 1
Critical Pitfalls to Avoid
Do not underdose ARB alternatives: If switching from losartan 100mg, use equivalent doses (telmisartan 80mg, valsartan 320mg, irbesartan 300mg) rather than starting at minimum doses, as subtherapeutic dosing leaves patients inadequately treated. 2, 3
Do not combine ARBs with ACE inhibitors or aliskiren: This combination increases adverse events including hyperkalemia and acute kidney injury without providing additional cardiovascular benefit. 1, 2
Monitor for peripheral edema with all dihydropyridine calcium channel blockers: This is a dose-related class effect occurring more frequently in women, not a sign of heart failure, and may require dose reduction or drug discontinuation. 1
Assess renal function and potassium levels: All ARBs increase hyperkalemia risk, particularly in patients with GFR <45 mL/min or those on potassium supplements or potassium-sparing diuretics. 1