- ACRONYMS AND DEFINITIONS
- ARB - Angiotensin II receptor blocker
- CrCl - Creatinine clearance
- HCTZ - Hydrochlorothiazide
- ANGIOTENSIN II RECEPTOR BLOCKERS (ARBs)
Azilsartan (Edarbi®)
Dosage forms
Tablet
- 40 mg
- 80 mg
Dosing
Hypertension
- Starting: 80 mg once daily
- Maintenance: 40 - 80 mg once daily
- Max: 80 mg once daily
- May take without regard to food
Generic / Price
- NO/$$$$Other
- Consider starting dose of 40 mg a day if on high doses of diuretics
Candesartan (Atacand®)
Dosage forms
Tablet
- 4 mg
- 8 mg
- 16 mg
- 32 mg
Dosing - Adults
Hypertension
- Starting: 16 mg once daily
- Maintenance: 8 - 32 mg/day
- Max: 32 mg/day
- May be given in one or two divided doses
- May take without regard to food
Heart failure
- Starting: 4 mg once daily
- Target dose: 32 mg once daily
- Max: 32 once daily
- Dose may be doubled every 2 weeks as tolerated
- May take without regard to food
Dosing - Pediatric
Hypertension (1 to 5 years)
- Starting: 0.20 mg/kg/day
- Maintenance: 0.05 to 0.4 mg/kg/day
- May be given in one or two divided doses
- See Atacand PI [sec 2.2] for instructions on compounding a 1 mg/ml suspension
- May take without regard to food
Hypertension (6 to 16 years)
- Starting (< 50 kg): 4 - 8 mg/day
- Starting (≥ 50 kg): 8 - 16 mg/day
- Maintenance (< 50 kg): 2 - 16 mg/day
- Maintenance (≥ 50 kg): 4 - 32 mg/day
- May be given in one or two divided doses
- May take without regard to food
Generic / Price
- YES/$Other
- In moderate liver disease, starting dose is 8 mg for hypertension
- Lower starting dose may be appropriate in patients taking diuretics
- Most of the blood pressure effect is seen within 2 weeks
- Maximum blood pressure effect is seen within 4 - 6 weeks
- See Atacand PI [sec 2.2] for instructions on compounding a 1 mg/ml suspension
Eprosartan (Teveten®)
Dosage forms
Tablet
- 400 mg
- 600 mg
Dosing
Hypertension
- Starting: 600 mg once daily
- Maintenance: 400 - 800 mg/day
- Max: 800 mg/day
- May be given in one or two divided doses
- May take without regard to food
Generic / Price
- YES/$$Other
- Moderate-to-severe kidney disease - dose should not exceed 600 mg a day
- Lower starting dose may be appropriate in patients taking diuretics
- Maximum blood pressure effect is seen within 2 - 3 weeks
Irbesartan (Avapro®)
Dosage forms
Tablet
- 75 mg
- 150 mg
- 300 mg
Dosing - Adults
Hypertension
- Starting: 150 mg once daily
- Maintenance: 150 - 300 mg once daily
- Max: 300 mg once daily
- May take without regard to food
Diabetic nephropathy
- Target dose: 300 mg once daily
- May take without regard to food
Dosing - Pediatric
Hypertension (6 - 12 years)
- Starting: 75 mg once daily
- Max: 150 mg once daily
- May take without regard to food
- AAP recommended dosing [2]
Hypertension (≥ 13 years)
- Starting: 150 mg once daily
- Max: 300 mg once daily
- May take without regard to food
- AAP recommended dosing [2]
Generic / Price
- YES/$Other
- Lower starting dose may be appropriate in patients taking diuretics
Losartan (Cozaar®)
Dosage forms
Tablet
- 25 mg
- 50 mg
- 100 mg
Dosing - Adults
Hypertension
- Starting: 50 mg once daily
- Maintenance: 25 - 100 mg once daily
- Max: 100 mg once daily
- May take without regard to food
Diabetic nephropathy
- Starting: 50 mg once daily
- Maintenance: 50 - 100 mg once daily
- Max: 100 mg once daily
- May take without regard to food
Hypertension with Left Ventricular Hypertrophy
- Starting: 50 mg once daily
- Maintenance: 50 - 100 mg once daily
- Max: 100 mg once daily
- May take without regard to food
Dosing - Pediatric
Hypertension (≥ 6 years)
- Starting: 0.7 mg/kg (max 50 mg) once daily
- Max: 1.4 mg/kg (max 100 mg) once daily
- See Cozaar PI [sec 2.5] for instructions on compounding a 2.5 mg/ml suspension
- May take without regard to food
Generic / Price
- YES/$Other
- Lower starting dose may be appropriate in patients taking diuretics
- Liver disease - starting dose should be 25 mg
- May take 3 - 6 weeks for maximum effect
- See Cozaar PI [sec 2.5] for instructions on compounding a 2.5 mg/ml suspension
Olmesartan (Benicar®)
Dosage forms
Tablet
- 5 mg
- 20 mg
- 40 mg
Dosing - Adults
Hypertension
- Starting: 20 mg once daily
- Maintenance: 20 - 40 mg once daily
- Max: 40 mg once daily
- May take without regard to food
Dosing - Pediatric
Hypertension (6 - 16 years)
- Starting (20 to <35 kg): 10 mg once daily
- Starting (≥ 35 kg): 20 mg once daily
- Max (< 35 kg): 20 mg once daily
- Max (≥ 35 kg): 40 mg once daily
- Increase dose at intervals of 2 weeks
- See Benicar PI [sec 2.2] for instructions on compounding a 2 mg/ml suspension
- May take without regard to food
Generic / Price
- YES/$-$$Other
- Lower starting dose may be appropriate in patients taking diuretics
- See Benicar PI [sec 2.2] for instructions on compounding a 2 mg/ml suspension
Telmisartan (Micardis®)
Dosage forms
Tablet
- 20 mg
- 40 mg
- 80 mg
Dosing
Hypertension
- Starting: 40 mg once daily
- Maintenance: 20 - 80 mg once daily
- Max: 80 mg once daily
- May take without regard to food
Cardiovascular risk reduction
- Target: 80 mg once daily
- Max: 80 mg once daily
- May take without regard to food
Generic / Price
- YES/$Other
- Lower starting dose may be appropriate in patients taking diuretics
- Maximum blood pressure effect seen within 4 weeks
Valsartan (Diovan®)
Dosage forms
Tablet
- 40 mg
- 80 mg
- 160 mg
- 320 mg
Dosing - Adults
Hypertension
- Starting: 80 - 160 mg once daily
- Maintenance: 80 - 320 mg once daily
- Max: 320 mg once daily
- May take without regard to food
Heart failure
- Starting: 40 mg twice daily
- Maintenance: 80 - 160 mg twice daily
- Max: 160 mg twice daily
- May take without regard to food
Post-Myocardial infarction
- Starting: 20 mg twice daily
- Maintenance: 40 - 160 mg twice daily
- Max: 160 mg twice daily
- May take without regard to food
Dosing - Pediatric
Hypertension (6 - 16 years)
- Starting: 1.3 mg/kg (max 40 mg) once daily
- Max: 2.7 mg/kg (max 160 mg) once daily
- See Diovan PI [sec 2.2] for instructions on compounding a 4 mg/ml suspension
- May take without regard to food
Generic / Price
- YES/$Other
- Lower starting dose may be appropriate in patients taking diuretics
- Maximum blood pressure effect seen within 4 weeks
- When the suspension is replaced by a tablet, the dose of valsartan may have to be increased. The exposure to valsartan with the suspension is 1.6 times greater than with the tablet.
- See Diovan PI [sec 2.2] for instructions on compounding a 4 mg/ml suspension
- THIAZIDE + ARB
Atacand HCT® (candesartan + HCTZ)
Dosage forms
Tablet
- Candesartan - HCTZ
- 16 mg - 12.5 mg
- 32 mg - 12.5 mg
- 32 mg - 25 mg
Dosing
Hypertension
- Dosing: HCTZ 12.5 - 50 mg/day | Candesartan 8 - 32 mg/day
- May be given once daily or divided into two doses
- May take without regard to food
Generic / Price
- YES/$-$$Other
- Maximal effect seen within 4 weeks
Avalide® (irbesartan + HCTZ)
Dosage forms
Tablet
- Irbesartan - HCTZ
- 150 mg - 12.5 mg
- 300 mg - 12.5 mg
Dosing
Hypertension
- Starting: 150/12.5 mg once daily
- Max: 300/25 mg once daily
- Titrate dose at intervals of 1 - 2 weeks
- May take without regard to food
Generic / Price
- YES/$Benicar HCT® (olmesartan + HCTZ)
Dosage forms
Tablet
- Olmesartan - HCTZ
- 20 mg - 12.5 mg
- 40 mg - 12.5 mg
- 40 mg - 25 mg
Dosing
Hypertension
- Starting: 20/12.5 - 40/12.5 mg once daily
- Max: 40/25 mg once daily
- May take without regard to food
Generic / Price
- YES/$Diovan HCT® (valsartan + HCTZ)
Dosage forms
Tablet
- Valsartan - HCTZ
- 80 mg - 12.5 mg
- 160 mg - 12.5 mg
- 160 mg - 25 mg
- 320 mg - 12.5 mg
- 320 mg - 25 mg
Dosing
Hypertension
- Starting: 160/12.5 mg once daily
- Max: 320/25 mg once daily
- Titrate dose at intervals of 1 - 2 weeks
- May take without regard to food
Generic / Price
- YES/$Other
- Maximum effect seen within 2 - 4 weeks
Edarbyclor® (azilsartan + chlorthalidone)
Dosage forms
Tablet
- Azilsartan - Chlorthalidone
- 40 mg - 12.5 mg
- 40 mg - 25 mg
Dosing
Hypertension
- Starting: 40/12.5 mg once daily
- Max: 40/25 mg once daily
- Increase dose if needed after 2 - 4 weeks
- May take without regard to food
Generic / Price
- NO/$$$$Other
- Most of the antihypertensive effect is seen within 1 - 2 weeks
Hyzaar® (losartan + HCTZ)
Dosage forms
Tablet
- Losartan - HCTZ
- 50 mg - 12.5 mg
- 100 mg - 12.5 mg
- 100 mg - 25 mg
Dosing
Hypertension
- Starting: 50/12.5 mg once daily
- Max: 100/25 mg once daily
- Increase dose at intervals of 3 weeks
- May take without regard to food
Hypertension with LVH to reduce the risk of stroke
- Starting: 50/12.5 mg once daily
- Max: 100/25 mg once daily
- May take without regard to food
Generic / Price
- YES/$Micardis HCT® (telmisartan + HCTZ)
Dosage forms
Tablet
- Telmisartan - HCTZ
- 40 mg - 12.5 mg
- 80 mg - 12.5 mg
- 80 mg - 25 mg
- Comes in sealed blister pack of 30 tablets
Dosing
Hypertension
- Starting: 80/12.5 mg once daily
- Max: 160/25 mg once daily
- Titrate dose at intervals of 2 - 4 weeks
- May take without regard to food
Generic / Price
- YES/$Other
- Do not remove tablet from blister pack until ready to take
- ARB + AMLODIPINE
Azor® (amlodipine + olmesartan)
Dosage forms
Tablet
- Amlodipine - Olmesartan
- 5 mg - 20 mg
- 5 mg - 40 mg
- 10 mg - 20 mg
- 10 mg - 40 mg
Dosing
Hypertension
- Starting: 5 mg/20 mg once daily
- Maintenance: 5 mg/20 mg - 10 mg/40 mg once daily
- Max: 10 mg/40 mg once daily
- Titrate dose at intervals of 1 - 2 weeks
- May take without regard to food
Generic / Price
- YES/$Exforge® (amlodipine + valsartan)
Dosage forms
Tablet
- Amlodipine - Valsartan
- 5 mg - 160 mg
- 5 mg - 320 mg
- 10 mg - 160 mg
- 10 mg - 320 mg
Dosing
Hypertension
- Starting: 5 mg/160 mg once daily
- Maintenance: 5 mg/160 mg - 10 mg/320 mg once daily
- Max: 10 mg/320 mg once daily
- Full antihypertensive effect typically seen within 2 weeks
- May take without regard to food
Generic / Price
- YES/$Twynsta® (amlodipine + telmisartan)
Dosage forms
Tablet
- Telmisartan - Amlodipine
- 40 mg - 5 mg
- 40 mg - 10 mg
- 80 mg - 5 mg
- 80 mg - 10 mg
Dosing
Hypertension
- Starting: 40 mg/5 mg once daily
- Maintenance: 40 mg/5 mg - 80 mg/10 mg once daily
- Max: 80 mg/10 mg once daily
- Most of the antihypertensive effect is typically seen within 2 weeks
- May take without regard to food
Generic / Price
- YES/$$- ARB + BETA BLOCKER
Byvalson® (nebivolol + valsartan)
Dosage forms
Tablet
- Nebivolol - Valsartan
- 5 mg - 80 mg
Dosing
Hypertension
- Dosing: 5/80 mg once daily
- Maximum effect occurs within 2 - 4 weeks
- Increasing dose does not results in any meaningful further blood pressure reduction
- May take without regard to food
Generic / Price
- NO/$$$- ARB + AMLODIPINE + HCTZ
Exforge HCT® (amlodipine + valsartan + HCTZ)
Dosage forms
Tablet
- Amlodipine - Valsartan - HCTZ
- 5 mg - 160 mg - 12.5 mg
- 5 mg - 160 mg - 25 mg
- 10 mg - 160 mg - 12.5 mg
- 10 mg - 160 mg - 25 mg
- 10 mg - 320 mg - 25 mg
Dosing
Hypertension
- Starting: 5/160/12.5 once daily
- Maintenance: 5/160/12.5 mg - 10/320/25 mg once daily
- Max: 10/320/25 mg once daily
- Titrate dose at intervals of 2 weeks
- Full antihypertensive effect is seen after 2 weeks
- May take without regard to food
Generic / Price
- YES/$$Tribenzor® (amlodipine + olmesartan + HCTZ)
Dosage forms
Tablet
- Amlodipine - Olmesartan - HCTZ
- 5 mg - 20 mg - 12.5 mg
- 5 mg - 40 mg - 12.5 mg
- 5 mg - 40 mg - 25 mg
- 10 mg - 40 mg - 12.5 mg
- 10 mg - 40 mg - 25 mg
Dosing
Hypertension
- Starting: 5/20/12.5 mg once daily
- Maintenance: 5/20/12.5 mg - 10/40/25 mg once daily
- Max: 10/40/25 mg once daily
- Titrate dose at intervals of 2 weeks
- May take without regard to food
Generic / Price
- YES/$$-$$$- Kidney disease dosing
- While ARBs are often beneficial in kidney disease, their inhibitory effects on the RAAS system may be detrimental when kidneys are severely compensated
- Elevations in potassium, serum creatinine, and BUN may occur in patients with significant kidney disease
- ARBs should be started at their lowest doses in patients with significant kidney disease, and frequent monitoring of kidney function and electrolytes (particularly potassium) should be performed
- Azilsartan (Edarbi®)
- No dose adjustment necessary
- Candesartan (Atacand®)
- Use caution
- Manufacturer makes no specific dosage recommendation
- Eprosartan (Teveten®)
- Moderate-to-severe kidney disease (CrCl < 60 ml/min): Max dose 600 mg a day
- Irbesartan (Avapro®)
- No dose adjustment necessary
- Losartan (Cozaar®)
- No dose adjustment necessary
- Olmesartan (Benicar®)
- No dose adjustment necessary
- Telmisartan (Micardis®)
- No dose adjustment necessary
- Valsartan (Diovan®)
- In mild-to-moderate kidney disease, no dose adjustment necessary
- Use caution in severe kidney disease
- Liver disease dosing
- Azilsartan (Edarbi®)
- In mild-to-moderate liver disease, no dose adjustment necessary
- Has not been studied in severe liver disease
- Candesartan (Atacand®)
- In mild liver disease, no dose adjustment necessary
- In moderate liver disease, starting dose should be 8 mg when treating hypertension
- Has not been studies in severe liver disease
- Eprosartan (Teveten®)
- No dose adjustment necessary in patients with liver disease
- Irbesartan (Avapro®)
- No dose adjustment necessary in patients with liver disease
- Losartan (Cozaar®)
- Starting dose should be 25 mg in patients with liver disease
- Olmesartan (Benicar®)
- No dose adjustment necessary for patients with moderate to marked liver disease
- Telmisartan (Micardis®)
- Telmisartan should be started at low doses and titrated slowly in patients with liver disease and/or biliary disorders
- Valsartan (Diovan®)
- In mild-to-moderate liver disease, no dose adjustment necessary
- Care should be used when using in severe liver disease
- DRUG INTERACTIONS
- NOTE: Drug interactions presented here are NOT all-inclusive. Other interactions may exist. The interactions presented here are meant to encompass commonly prescribed medications and/or interactions that are well-documented. Always consult your physician or pharmacist before taking medications concurrently. CLICK HERE for more information on drug interactions.
- All ARBs
- ACE inhibitors - see combining ARBs and ACE inhibitors
- Aliskiren (Tekturna®) - Aliskiren should not be prescribed with ARBs in patients with diabetes or decreased kidney function (GFR<60ml/min)
- Lithium - ARBs can increase lithium levels. This combination should be avoided, or lithium levels should be checked frequently if they are taken together.
- Medications that can raise potassium levels - ARBs have the potential to raise potassium levels and cause hyperkalemia. When taken with other potassium-raising medications, the risk is increased. While it is often appropriate to prescribe ARBs with these medications, patients and providers should be aware of the potential risks. See RAAS inhibitor-induced hyperkalemia for recommendations on addressing hyperkalemia induced by these medications.
- Examples of medications that may raise potassium levels include:
- Aldosterone antagonists (spironolactone and eplerenone)
- ACE inhibitors
- Aliskiren (Tekturna®)
- Cyclosporine (Neoral®)
- ENaC inhibitors (triamterene, amiloride)
- Finerenone (Kerendia®)
- Heparin - heparin raises potassium secondarily by inhibiting aldosterone synthesis. LMWH does not appear to have the same effect. [3]
- Penicillin G potassium injection (1 million units contains 1.68mEq of potassium)
- Potassium supplements (K-Dur®, etc)
- Tacrolimus (Prograf®)
- Trimethoprim (part of Bactrim® and Septra®)
- Voclosporin (Lupkynis®)
- NSAIDS (Advil®, Aleve®, etc.) - NSAIDS can attenuate the effect of ARBs. This is more of a concern when NSAIDS are taken on a chronic basis. Cases of decreased kidney function have been reported when NSAIDS were taken with ARBs. The risk appears to be greater with advanced age, dehydration, and underlying kidney disease.
- Salt substitutes (No-Salt®, etc.) - Salt substitutes typically contain a high amount of potassium (16.4 mEq per 1/4 teaspoon). Since ARBs can raise potassium levels, caution should be used when consuming salt substitutes.
- Telmisartan (Micardis®)
- Digoxin - telmisartan has been shown to increase digoxin levels. When taken together, digoxin levels should be monitored.
- Ramipril (Altace®) - Ramipril, an ACE inhibitor, should not be taken with telmisartan. Telmisartan has been shown to significantly increase ramipril levels.
- Metabolism and clearance
- Azilsartan (Edarbi®)
- CYP2C9 - substrate
- Candesartan (Atacand®)
- No significant liver metabolism
- Eprosartan (Teveten®)
- No significant liver metabolism
- Irbesartan (Avapro®)
- CYP2C9 - substrate
- Losartan (Cozaar®)
- CYP2C9 - substrate
- CYP3A4 - substrate
- P-glycoprotein - substrate
- Olmesartan (Benicar®)
- OATP - substrate
- Telmisartan (Micardis®)
- Valsartan (Diovan®)
- OATP - substrate
- PRICE ($) INFO
Pricing legend
- $ = 0 - $50
- $$ = $51 - $100
- $$$ = $101 - $150
- $$$$ = > $150
- Pricing based on one month of therapy at standard dosing in an adult
- Pricing based on information from GoodRX.com®
- Pricing may vary by region and availability
- BIBLIOGRAPHY
- 1 - Manufacturer's Package Insert for each drug listed
- 2 - PMID 28827377 - Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents, Pediatrics (2017)
- 3 - PMID 22560830 - Use and safety of unfractionated heparin for anticoagulation during maintenance hemodialysis, Am J Kidney Dis (2021)