For a smoker with uncontrolled hypertension already taking amlodipine 5 mg and no renal impairment, should losartan be started at 25 mg?

Starting Dose of Losartan in Uncontrolled Hypertension

For a smoker with uncontrolled hypertension already taking amlodipine 5 mg and no renal impairment, losartan should be started at 50 mg once daily, not 25 mg. 1

FDA-Approved Starting Dose

• The FDA label specifies that the usual starting dose of losartan for adult hypertension is 50 mg once daily, with the option to increase to a maximum of 100 mg once daily as needed for blood pressure control 1
• A starting dose of 25 mg is recommended only for patients with possible intravascular depletion (e.g., those already on diuretic therapy) 1

Why 50 mg Is the Appropriate Starting Dose

• Your patient does not meet criteria for the lower 25 mg starting dose because:

  • No diuretic therapy is mentioned
  • No renal impairment is present
  • No hepatic impairment is described
  • No evidence of volume depletion 1

• The 25 mg dose is reserved for patients with mild-to-moderate hepatic impairment or those at risk of intravascular volume depletion 1

Target Dosing for Optimal Outcomes

• The target dose of losartan for hypertension is 100 mg once daily, as this provides superior cardiovascular outcomes compared to lower doses 2
• Clinical evidence demonstrates that 50 mg daily appears inferior to ACE inhibitors for mortality reduction, and higher doses (100-150 mg) provide greater benefits 2
• The HEAAL trial showed that 150 mg daily was superior to 50 mg daily, with a 10% relative risk reduction in death or heart failure hospitalization 2

Practical Titration Strategy

• Start losartan at 50 mg once daily 1
• Reassess blood pressure within 2-4 weeks after initiation 2
• If blood pressure remains ≥140/90 mmHg, increase to 100 mg once daily 1
• The combination of amlodipine + losartan provides complementary mechanisms (vasodilation through calcium channel blockade and renin-angiotensin system inhibition) 3

If Blood Pressure Remains Uncontrolled

• After optimizing losartan to 100 mg daily, add hydrochlorothiazide 12.5-25 mg daily as the third agent to achieve guideline-recommended triple therapy 2, 3
• Target blood pressure is <130/80 mmHg for most adults, with a minimum acceptable goal of <140/90 mmHg 2

Critical Safety Monitoring

• Check serum creatinine/eGFR and potassium within 1-2 weeks after initiating losartan, especially given the patient's smoking status and cardiovascular risk 2
• Monitor blood pressure in both sitting and standing positions to detect orthostatic hypotension 2

Common Pitfall to Avoid

• Do not start at 25 mg unless the patient has hepatic impairment or is volume-depleted on diuretics—this underdoses the medication and delays achieving blood pressure control 1, 4
• Underdosing is widespread in clinical practice, with less than 25% of patients ever titrated to target doses of 100 mg 2