Can losartan 50 mg twice daily be increased to 100 mg twice daily?

Can Losartan 50 mg BID Be Increased to 100 mg BID?

No, losartan should not be increased to 100 mg twice daily (200 mg total daily dose) because the FDA-approved maximum daily dose is 100 mg, and exceeding this dose is not supported by regulatory approval or clinical guidelines. 1

FDA-Approved Maximum Dosing

• The FDA label explicitly states that the maximum dose of losartan for hypertension is 100 mg once daily, with no provision for higher total daily doses. 1
• The American College of Cardiology/American Heart Association guidelines confirm that losartan's usual dose range is 50-100 mg/day administered in "1 or 2" divided doses, meaning the total daily dose should not exceed 100 mg. 2

Appropriate Dosing Strategies

If Currently on 50 mg BID (100 mg Total Daily)

• This regimen is already at the maximum approved dose. The current prescription of 50 mg twice daily delivers 100 mg total per day, which is guideline-concordant and provides acceptable 24-hour blood pressure coverage. 2, 3
• Twice-daily dosing of 50 mg may offer more consistent blood pressure control throughout the day compared to 100 mg once daily, particularly in patients who experience end-of-dose blood pressure elevation. 2

If Currently on 50 mg Once Daily

• Increase to 100 mg once daily (not 100 mg BID) if blood pressure remains ≥140/90 mmHg after 2-4 weeks. 1, 2
• Alternatively, split the 100 mg total daily dose into 50 mg twice daily for more uniform 24-hour coverage. 2, 3

Next Steps When Blood Pressure Remains Uncontrolled

If blood pressure stays elevated on losartan 100 mg daily (whether given once or twice daily):

• Add hydrochlorothiazide 12.5-25 mg once daily as the preferred second agent; this combination provides additive blood pressure lowering of approximately 15.5/9.2 mmHg. 2
• Consider a dihydropyridine calcium channel blocker (e.g., amlodipine 5-10 mg daily) as an alternative second agent. 2
• Use a single-pill fixed-dose combination (losartan + hydrochlorothiazide) to markedly improve medication adherence. 2

Special Considerations for Heart Failure

• For heart failure with reduced ejection fraction, the target dose is 100-150 mg once daily, with the HEAAL trial demonstrating that 150 mg was superior to 50 mg (10% relative risk reduction in death or hospitalization, P=0.027). 2
• The 150 mg daily dose for heart failure is off-label in the United States but supported by European Society of Cardiology guidelines and clinical trial evidence. 2
• Even in heart failure, the dose should be given once daily, not divided into twice-daily administration at supramaximal doses. 2

Critical Safety Monitoring

• Check serum creatinine and potassium within 1-2 weeks after any dose increase, especially in patients with chronic kidney disease, diabetes, or those receiving potassium-sparing agents. 2
• Reassess blood pressure every 2-4 weeks during titration, aiming for a target of <130/80 mmHg within 3 months. 2

Common Pitfall to Avoid

• Do not exceed 100 mg total daily dose for hypertension by prescribing 100 mg BID; this doubles the FDA-approved maximum and lacks safety or efficacy data. 1, 2
• Do not combine losartan with an ACE inhibitor or aliskiren; dual RAAS blockade increases hyperkalemia, syncope, and acute kidney injury by 2-3-fold without cardiovascular benefit. 2