What are the recommended starting doses and titration guidelines for valsartan in adults with hypertension or heart failure, and how should the dose be modified in patients with chronic kidney disease (estimated glomerular filtration rate <30 mL/min/1.73 m²), elderly or frail individuals?

Valsartan Dosing Recommendations

For hypertension, start valsartan at 80–160 mg once daily and titrate to a maximum of 320 mg daily; for heart failure with reduced ejection fraction, target 160 mg twice daily (320 mg total daily dose), with at least 160 mg daily as the minimum effective dose. 1

Hypertension Dosing

Standard Adult Dosing

• Initiate therapy at 80 mg once daily for most patients with mild-to-moderate hypertension 2, 3
• Titrate to 160 mg once daily if blood pressure remains ≥140/90 mmHg after 2–4 weeks; this dose provides optimal efficacy-to-tolerability ratio 3
• Maximum dose is 320 mg once daily for resistant hypertension; doses up to 640 mg/day have been studied and found safe, though 160 mg represents the optimal balance 4, 3
• Target blood pressure <130/80 mmHg for most adults to reduce cardiovascular risk 5

Combination Therapy Strategy

• Add hydrochlorothiazide 12.5–25 mg daily if blood pressure remains uncontrolled on valsartan 160 mg monotherapy; fixed-dose combinations improve adherence 5, 4
• Escalate to triple therapy (valsartan + calcium-channel blocker + thiazide diuretic) if dual therapy fails to achieve target 5

Administration Timing

• Take once daily at the most convenient time to establish a habitual pattern and maximize adherence 5
• Morning dosing is traditional, but evening dosing is equally acceptable; consistency matters more than timing 5

Heart Failure Dosing

Target Dosing for HFrEF

• Target dose is 160 mg twice daily (320 mg total daily) based on major clinical trials demonstrating mortality and morbidity benefits 1
• Minimum effective dose is 160 mg daily (at least 50% of target dose); lower doses may not provide optimal cardiovascular protection 1
• Titrate no more frequently than every 2 weeks to target or maximally tolerated doses 1

Titration Approach

• Many physicians underdose valsartan in heart failure; aggressive titration to target doses is essential to achieve maximal benefit 1
• Higher doses provide greater benefits than lower doses, with sustained AT1-receptor blockade over 24 hours achieved at 160 mg 1
• Temporary dose reductions may be necessary for hypotension or renal impairment, but efforts should be made to return to target doses when clinically stable 1

Special Populations

Chronic Kidney Disease (eGFR <30 mL/min/1.73 m²)

• Starting dose for sacubitril-valsartan is 24/26 mg twice daily in patients with CrCl <30 mL/min or moderate hepatic impairment 6
• For valsartan monotherapy, initiate conservatively and monitor closely; no absolute contraindication exists, but caution is warranted 6
• Monitor serum creatinine and potassium within 1–2 weeks after initiation or dose increases 1, 5
• An increase in creatinine up to 50% above baseline or to 3 mg/dL is acceptable; seek specialist advice if creatinine rises by 100% or exceeds 4 mg/dL 1

Elderly and Frail Patients

• Increase doses more gradually (every 2–4 weeks rather than weekly) in patients ≥85 years or those who are frail 6
• Measure blood pressure in both sitting and standing positions at 1 minute and 3 minutes after standing to detect orthostatic hypotension 6
• Elderly patients may require lower maintenance doses due to increased risk of symptomatic hypotension 6

Hepatic Impairment

• Maximum dose should not exceed 80 mg daily in patients with hepatic dysfunction 2
• Valsartan is not recommended for patients with severe hepatic dysfunction or biliary cirrhosis 2

Critical Safety Monitoring

Renal Function and Electrolytes

• Check serum creatinine/eGFR and potassium within 1–2 weeks after starting therapy or increasing doses, particularly in patients with diabetes, CKD, or baseline renal impairment 1, 5
• Monitor at least annually during maintenance therapy 1
• Avoid potassium supplements and potassium-sparing diuretics unless specifically indicated; monitor for hyperkalemia (K+ >5.0 mmol/L) 1

Blood Pressure Monitoring

• Reassess blood pressure every 2–4 weeks during titration, aiming to reach target within 3 months 5
• Asymptomatic hypotension does not require treatment changes 1
• For symptomatic hypotension, reconsider need for nitrates, calcium-channel blockers, and other vasodilators; reduce or stop if possible 1

Contraindicated Combinations

• Never combine valsartan with ACE inhibitors; this dual RAAS blockade increases risk of hyperkalemia, syncope, and acute kidney injury by 2–3-fold without added cardiovascular benefit 1, 5
• Avoid NSAIDs unless essential; they may attenuate diuretic effects, cause renal impairment, and worsen blood pressure control 1
• Do not use the triple combination of valsartan + ACE inhibitor + mineralocorticoid receptor antagonist 1

Common Pitfalls to Avoid

• Underdosing is widespread: Less than 25% of heart failure patients are titrated to target doses in clinical practice; aggressive titration is necessary 1
• Do not delay treatment for extensive testing: Laboratory screening should not postpone antihypertensive therapy initiation 5
• Do not assume medication discontinuation was due to side effects: Assess adherence directly, as cost, access issues, or misunderstanding are common causes 7
• Valsartan is absolutely contraindicated in pregnancy: Discontinue immediately upon pregnancy detection due to serious fetal toxicity (renal dysfunction, oligohydramnios, skull hypoplasia, fetal death) 7