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. 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[see USE IN SPECIFIC POPULATIONS (8. 4), CLINICAL PHARMACOLOGY (12.3), and CLINICAL STUDIES (14)].
The patient is currently taking 25mg of losartan daily, which is lower than the recommended dose for a pediatric patient. However, since the patient is only 2 years old, losartan is not recommended due to age restrictions.
- The patient's current dosage is not appropriate due to her age.
- Consider alternative treatments for hypertension in pediatric patients under 6 years old.
- Bradycardia in the high 40s to low 50s should also be taken into account when adjusting or changing medications 1.
From the Research
For a 2-year-old female with persistent stage 2 hypertension despite losartan 25mg daily and propranolol 20mg twice weekly, I strongly recommend consulting pediatric nephrology urgently and modifying the current regimen due to the bradycardia, likely related to the propranolol. The patient's current presentation is unusual and concerning, requiring specialist evaluation. Considering the bradycardia (heart rate 40s-50s), which is likely related to the propranolol, it is essential to modify the current regimen. The most recent and highest quality study, 2, suggests that amlodipine/losartan-based single-pill combination therapy is effective and safe in patients with hypertension. Given this, discontinuing propranolol and adding a calcium channel blocker such as amlodipine starting at 0.1mg/kg/day could be a viable option. Losartan could be increased if needed, but only under specialist guidance. A comprehensive workup for secondary causes of hypertension is essential, including:
- Renal ultrasound
- Echocardiogram
- Plasma renin activity
- Aldosterone levels
- Screening for pheochromocytoma Hypertension in toddlers is rarely primary and commonly indicates underlying renal, cardiovascular, or endocrine pathology. The bradycardia further complicates management as it limits beta-blocker use. Regular blood pressure monitoring, preferably with 24-hour ambulatory measurement, and assessment of end-organ damage should be performed. Proper cuff size and measurement technique are crucial for accurate readings in young children. Additionally, the study 3 suggests that amlodipine may be better than losartan in lowering blood pressure variability in essential hypertensive patients, which could be beneficial in this case. However, the study 4 provides evidence that losartan/hydrochlorothiazide combination is effective and safe in hypertensive patients, which could also be considered as an alternative option. But based on the most recent study 2, amlodipine/losartan-based single-pill combination therapy seems to be a more suitable option. It is crucial to prioritize the patient's morbidity, mortality, and quality of life when making treatment decisions. Therefore, consulting pediatric nephrology urgently and modifying the current regimen is the best course of action.