What are the next steps for a 2-year-old female patient with stage 2 hypertension who remains hypertensive on Losartan (losartan) 25mg daily monotherapy?

From the Guidelines

For a 2-year-old female patient with persistent stage 2 hypertension on losartan 25mg daily monotherapy, I strongly recommend consulting with a pediatric nephrologist or cardiologist immediately to reassess and adjust the treatment plan. The current treatment approach with losartan, an ACE inhibitor, may not be the most appropriate first-line therapy for a child of this age, as suggested by the clinical practice guideline for screening and management of high blood pressure in children and adolescents 1. Given the patient's age and the rarity of essential hypertension in toddlers, a comprehensive evaluation for secondary causes of hypertension is crucial, including renal ultrasound, echocardiogram, and laboratory studies to assess renal function and rule out conditions like renal artery stenosis, coarctation of the aorta, or renal parenchymal disease 1. Lifestyle modifications, such as sodium restriction and increased physical activity, should also be implemented alongside pharmacological treatment, as recommended for children and adolescents with hypertension 1. Regular blood pressure monitoring with age-appropriate equipment and techniques is vital for ongoing management, and the use of ambulatory blood pressure monitoring (ABPM) may be considered for confirmation of hypertension and assessment of treatment effectiveness, as per the guideline 1. Considering the guideline's recommendations for stage 2 hypertension, if the BP reading is still at the stage 2 HTN level when repeated, diagnostic evaluation, including ABPM, should be conducted, and treatment should be initiated or the patient referred to subspecialty care 1. A potential alternative pharmacological approach could involve switching to a calcium channel blocker such as amlodipine or a diuretic like hydrochlorothiazide, as these may be more suitable for young children, but this decision should be made under the guidance of a specialist. The primary goal is to reduce the risk of target organ damage and improve the patient's quality of life by achieving adequate blood pressure control, which may involve a combination of lifestyle modifications and pharmacological interventions tailored to the patient's specific needs and underlying condition.

From the FDA Drug Label

Pediatric Hypertension The usual recommended starting dose is 0.7 mg per kg once daily (up to 50 mg total) administered as a tablet or a suspension [see DOSAGE AND ADMINISTRATION (2.5)]. Dosage should be adjusted according to blood pressure response. Doses above 1. 4 mg per kg (or in excess of 100 mg) daily have not been studied in pediatric patients Losartan is not recommended in pediatric patients less than 6 years of age or in pediatric patients with estimated glomerular filtration rate less than 30 mL/min/1.73 m2

The patient is 2 years old and still hypertensive on losartan 25mg daily monotherapy. Dosage adjustment may be considered, but since the patient is less than 6 years old, losartan is not recommended. Considering the patient's age, an alternative treatment should be explored. 2

From the Research

Potential Strategies to Improve Hypertension Management

• Increase the dose of losartan: According to 3, losartan potassium 50 to 100mg once daily as monotherapy lowers blood pressure to a similar degree to enalapril, atenolol and felodipine extended release (ER). The current dose of 25mg daily may not be sufficient to achieve optimal blood pressure control.
• Add a diuretic: The study 4 found that adding hydrochlorothiazide, 12.5 mg/d, to losartan monotherapy produced additional and clinically meaningful blood pressure decrements. This suggests that combining losartan with a diuretic may be an effective strategy to improve blood pressure control.
• Combine losartan with a calcium channel blocker: The study 5 found that combining losartan with amlodipine reduced blood pressure more effectively than maximal doses of losartan or amlodipine with hydrochlorothiazide in stage 2 hypertensive patients. Similarly, the study 6 found that combination amlodipine/losartan therapy provided an effective and generally well-tolerated first line therapy for reducing blood pressure in stage 2 hypertensive patients.

Considerations for Combination Therapy

• The study 7 found that losartan/hydrochlorothiazide combination therapy was effective and safe in reducing blood pressure, and had fewer adverse effects on uric acid and other metabolic parameters compared to diuretic monotherapy.
• The study 5 found that the combination of losartan and amlodipine was more effective in reducing blood pressure than the combination of losartan and hydrochlorothiazide.
• The choice of combination therapy should be individualized based on the patient's specific needs and medical history, and should take into account factors such as potential side effects, drug interactions, and cost-effectiveness.