From the Guidelines
To improve blood pressure control in this 72-year-old female patient with stage 2 hypertension, I recommend optimizing her current medication regimen by increasing the losartan dose and changing the propranolol dosing frequency, as well as considering the addition of a diuretic, based on the most recent guidelines from the 2020 International Society of Hypertension global hypertension practice guidelines 1.
Current Medication Regimen
The patient is currently on losartan 25mg daily and propranolol 20mg twice weekly.
- Losartan is an angiotensin II receptor antagonist, which is effective in lowering blood pressure by blocking the action of angiotensin II on its receptor, thereby reducing vasoconstriction and aldosterone-mediated volume expansion.
- Propranolol is a beta-blocker that reduces blood pressure by decreasing cardiac output, reducing renin release, and decreasing sympathetic outflow.
Optimizing the Medication Regimen
- Increase the losartan dose from 25mg to 50mg daily, as the current dose is at the lower end of the therapeutic range, to achieve better blood pressure control, as suggested by the 2020 guidelines 1.
- Change propranolol from twice weekly to a daily regimen of 20mg twice daily, as the irregular twice-weekly dosing is inadequate for consistent blood pressure control, given propranolol's short half-life requiring regular administration.
- Consider adding a thiazide diuretic, such as hydrochlorothiazide 12.5mg daily, if blood pressure remains uncontrolled after optimizing the current medications, as combination therapy with different mechanisms of action is often effective in elderly patients, in line with recommendations from the American Heart Association 1.
Lifestyle Interventions
In addition to medication adjustments, lifestyle interventions should be maximized, including:
- Ensuring a low sodium diet (<2400 mg/d) 1
- Encouraging weight loss, exercise, and an overall healthy dietary pattern
- Ensuring adherence to medication regimens and monitoring for potential secondary causes of hypertension
Monitoring and Follow-Up
Regular blood pressure monitoring is essential during medication adjustments, ideally checking at home twice daily for two weeks after any change. Kidney function should be assessed before and after dose increases, particularly with losartan, as angiotensin receptor blockers can affect renal function in older adults 1. These changes should provide more consistent 24-hour blood pressure control by addressing both the renin-angiotensin system and sympathetic nervous system activity more effectively.
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)]. Doses of 50 mg, 100 mg and 150 mg once daily gave statistically significant systolic/diastolic mean decreases in blood pressure, compared to placebo in the range of 5.5 to 10.5/3.5 to 7. 5 mmHg, with the 150-mg dose giving no greater effect than 50 mg to 100 mg.
The patient is currently taking losartan 25mg daily, which is below the recommended starting dose of 50mg once daily. To improve blood pressure control, the dosage of losartan can be increased to 50mg once daily or up to 100mg once daily as needed. Additionally, the patient is taking propranolol 20mg twice weekly, which may not be sufficient for blood pressure control. The frequency or dose of propranolol may need to be adjusted, but this is not directly addressed in the provided drug labels 2 2.
- Increase losartan dose to 50mg once daily or up to 100mg once daily as needed to control blood pressure.
- Consider adjusting the dose or frequency of propranolol.
From the Research
Potential Strategies to Improve Hypertension Management
The patient is currently taking losartan 25mg daily and propranolol 20mg twice weekly, but remains stage 2 hypertensive. To improve this, several strategies can be considered:
- Increasing the dose of losartan: Studies have shown that higher doses of losartan can be more effective in lowering blood pressure 3, 4.
- Adding hydrochlorothiazide (HCTZ) to the treatment regimen: The combination of losartan and HCTZ has been shown to be effective in lowering blood pressure and is a recommended treatment option for patients who require combination therapy 5, 3, 4.
- Switching to a different antihypertensive medication: Amlodipine has been shown to be effective in lowering blood pressure and may be a suitable alternative for some patients 3, 6.
- Optimizing the dosing regimen: The current dosing regimen of propranolol 20mg twice weekly may not be optimal, and increasing the frequency or dose of propranolol may be necessary to achieve better blood pressure control.
Considerations for Losartan Therapy
Losartan has been shown to be effective in lowering blood pressure in elderly patients with hypertension, and its efficacy is comparable to other antihypertensive agents 7. However, the addition of HCTZ to losartan therapy can provide greater antihypertensive efficacy 5, 7, 3, 4. Losartan is generally well tolerated, but its efficacy and tolerability may vary depending on the individual patient and the specific treatment regimen.
Comparison with Other Antihypertensive Agents
Amlodipine has been shown to be effective in lowering blood pressure and may be a suitable alternative for some patients 3, 6. However, the choice of antihypertensive agent will depend on individual patient factors, such as comorbidities and concomitant medications. The efficacy and safety of losartan compared to other antihypertensive agents, including amlodipine, should be considered when making treatment decisions 7, 3, 6.