What can be done to improve stage 1 hypertension in a 72-year-old female patient on Losartan (losartan) 25mg daily monotherapy?

From the Guidelines

For a 72-year-old female patient with persistent stage 1 hypertension on losartan 25mg daily, I recommend increasing the losartan dose to 50mg daily as the first step, as this is a common and effective strategy for optimizing blood pressure control 1. If this is insufficient after 2-4 weeks, adding a thiazide diuretic like hydrochlorothiazide 12.5mg daily would be appropriate, as combination therapy with an angiotensin receptor blocker and a diuretic is a well-established and effective approach for managing hypertension 1. Alternatively, a calcium channel blocker such as amlodipine 5mg daily could be added or substituted if there are concerns about electrolyte disturbances with diuretics, as these agents have complementary mechanisms of action and can provide additional blood pressure lowering effects 1. Blood pressure should be monitored regularly, aiming for a target below 130/80 mmHg in this age group, and lifestyle modifications should also be emphasized, including sodium restriction, regular physical activity, weight management, limiting alcohol consumption, and following a DASH diet rich in fruits, vegetables, and low-fat dairy. Key considerations in managing hypertension in this patient include:

• Optimizing the dose of the current medication, losartan, to ensure maximum benefit before adding additional agents 1
• Selecting combination therapy that targets different blood pressure regulation mechanisms to minimize side effects and maximize efficacy 1
• Monitoring blood pressure regularly and adjusting the treatment plan as needed to achieve and maintain target blood pressure levels
• Emphasizing lifestyle modifications as an essential component of hypertension management, as these can have a significant impact on blood pressure control and overall cardiovascular health.

From the FDA Drug Label

The usual starting dose of losartan is 50 mg once daily. The dosage can be increased to a maximum dose of 100 mg once daily as needed to control blood pressure [see CLINICAL STUDIES (14.1)]. A starting dose of 25 mg is recommended for patients with possible intravascular depletion (e.g., on diuretic therapy).

The patient is currently taking 25mg daily of losartan, which is below the recommended starting dose of 50mg daily for adult hypertension. To improve the patient's condition, the dosage of losartan can be increased to 50mg daily or up to a maximum dose of 100mg daily as needed to control blood pressure 2.

From the Research

Treatment Options for Stage 1 Hypertension

To improve the condition of a 72-year-old female patient with stage 1 hypertension who is currently on losartan 25mg daily monotherapy, several options can be considered:

• Adding a low-dose diuretic to the existing losartan therapy, as studied in 3, which showed that the combination of losartan and hydrochlorothiazide (HCTZ) was effective in reducing blood pressure and had fewer adverse effects on metabolic parameters.
• Switching to a combination therapy of an angiotensin-receptor blocker (ARB) and a calcium channel blocker (CCB), as investigated in 4, which found that both losartan/HCTZ and amlodipine/ARB combinations improved left ventricular relaxation in hypertensive patients.
• Considering the patient's age and potential comorbidities, the management of stage 1 hypertension should take into account the patient's overall cardiovascular risk, as discussed in 5, which provides guidance on the management of stage 1 hypertension in adults with a low 10-year risk for cardiovascular disease.

Combination Therapies

Combination therapies involving losartan and other antihypertensive agents have been studied:

• The combination of losartan and HCTZ was found to be effective in reducing blood pressure and improving left ventricular relaxation, as shown in 3 and 4.
• The combination of amlodipine and an ARB was also found to be effective in improving left ventricular relaxation, as shown in 4.
• The effects of various antihypertensive drugs, including ARBs and CCBs, on central aortic pressure and biomarkers of vascular function were reviewed in 6, which highlighted the potential benefits of these therapies beyond blood pressure control.

Patient-Specific Considerations

When selecting a treatment option, the patient's individual characteristics, such as age, comorbidities, and potential drug interactions, should be taken into account:

• The efficacy and safety of amlodipine in patients with hypertension and concomitant diabetes mellitus and/or renal dysfunction were reviewed in 7, which found that amlodipine was at least as efficacious as other classes of antihypertensive agents in reducing blood pressure.
• The potential benefits and risks of each treatment option should be carefully weighed, considering the patient's overall health status and cardiovascular risk profile, as discussed in 5.