Sacubitril Valsartan
Contraindicated
Textbook
Potentially excessive hypotension, increased risk of adverse effects.
Do not use in conjunction with other ARBs.
Source: G&G 14e · p602
Drug reference
Losartan
ARB · Antihypertensive
Also known as Losartan potassium, Cozaar, Lozap
START
50 mg PO once daily
TYPICAL MAX
100 mg/day
STOP IF
Pregnancy · bilateral RAS · hyperkalemia
WATCH
K⁺ · creatinine · BP
CDSCO approvedSchedule HJan AushadhiATC C09CA01
KDIGO 2024 + manufacturer label
- ONSET
- 6h · BP effect onset
- PEAK
- 1h · Cmax (parent)
- t½
- 9h · active metabolite EXP-3174 t½
- DURATION
- 1d · once-daily dosing window
EXCRETION
60% biliary · 35% renal · CYP2C9/3A4
route + CYP
INTERACTIONS
12 major
incl. contraindicated
PREGNANCY
Category D — contraindicated; fetal renal injury
FDA category + note
Top interactionssee all 12 →
- Sacubitril ValsartanContraindicatedTextbookG&G 14e · p602
- AliskirenContraindicatedDatabaseDDInter
- Angiotensin Converting Enzyme InhibitorsSevereTextbookHarrison 22e · p2396
- EnalaprilatSevereTextbookG&G 14e
Available in India
542 branded formulations and 270 fixed-dose combinations. Look up specific brands in the Drugs workspace.
Jan Aushadhi — generic available at GoI pharmacies
Mechanism
Losartan selectively blocks the binding of angiotensin II to the AT1 receptor, primarily in vascular smooth muscle and the adrenal gland. This action prevents the vasoconstrictor and aldosterone-secreting effects of angiotensin II, leading to peripheral vasodilation, decreased systemic vascular resistance, and reduced blood pressure. It also contributes to a reduction in cardiac hypertrophy and vascular remodeling.
Indications
HypertensionHypertensive patients with left ventricular hypertrophy (LVH) to reduce the risk of strokeDiabetic nephropathy in Type 2 diabetic patients with a history of hypertensionHeart failure (off-label)diabetic nephropathystroke prophylaxisheart failureCongestive heart failure (CHF)Myocardial infarction (MI)Diabetic nephropathy (renoprotective in type 2 diabetes mellitus)Stroke prevention (in hypertensive patients with left ventricular hypertrophy)Control of portal hypertension (in cirrhotics)
Dosing
- Adult
- Hypertension: Initial 50 mg orally once daily. May be increased to 100 mg once daily or given as 25 mg twice daily. Diabetic Nephropathy (Type 2 DM with HTN): Initial 50 mg orally once daily, may be increased to 100 mg once daily based on blood pressure response. For hypertensive patients with LVH, initial 50 mg orally once daily, may be combined with a low-dose diuretic.
- Pediatric
- Hypertension (6 to 16 years): Initial 0.7 mg/kg orally once daily (maximum 50 mg/day). Dosing range is typically 0.7 to 1.4 mg/kg once daily, not exceeding 100 mg/day. Not recommended for children under 6 years of age or with GFR < 30 mL/min/1.73m.
- Renal adjustment
- For mild-to-moderate renal impairment (CrCl > 30 mL/min), no initial dose adjustment is required. For severe impairment (CrCl < 30 mL/min) or patients on dialysis, a lower initial dose (e.g., 25 mg once daily) may be considered, but generally not required. Monitor serum potassium and renal function closely.
- Hepatic adjustment
- For mild to moderate hepatic impairment, an initial dose of 25 mg once daily is recommended due to higher plasma levels. Contraindicated in severe hepatic impairment.
- Geriatric
- No specific dose adjustment is needed based on age; however, consider starting with a lower dose (e.g., 25 mg once daily) in elderly patients with potential volume depletion or impaired renal function, and titrate carefully.
- Max dose
- 100 mg orally once daily for most indications.
Pharmacokinetics
Onset
1-2 hours for blood pressure lowering effect
Peak effect
Losartan: 1 hour (plasma concentration); Active metabolite: 3-4 hours (plasma concentration). Peak blood pressure reduction occurs around 6 hours for Losartan and 24 hours for the metabolite.
Duration
Approximately 24 hours (due to active metabolite)
Half-life
Losartan: 1.5-2 hours; Active metabolite (E-3174): 6-9 hours
Bioavailability
Approximately 33%
Protein binding
Losartan: >98%; Active metabolite: >99%
Metabolism
Extensive first-pass hepatic metabolism, primarily by CYP2C9 and CYP3A4, to an active carboxylic acid metabolite (E-3174) responsible for most of the angiotensin II receptor antagonism.
Excretion
Approximately 35% renal (4% unchanged, 6% as active metabolite), 60% biliary/fecal
Contraindications
- Pregnancy (especially 2nd and 3rd trimesters)
- Known hypersensitivity to Losartan or any component of the formulation
- Concomitant use with aliskiren in patients with diabetes mellitus or renal impairment (GFR < 60 mL/min/1.73m)
- Severe hepatic impairment
- Bilateral renal artery stenosis (relative contraindication)
- Do not use in combination with ACE inhibitor
- Contraindicated in pregnancy
Side effects
Common
DizzinessFatigueHeadacheUpper respiratory infectionCough (less frequent than with ACE inhibitors)DiarrheaMild hyperkalemiaNasal congestionhyperkalemiahypotensionskin rashWeaknessUpper g.i. side effects (mild and occasional)Hyperkalemia in CKDReduced GFRAcute kidney failure in severe bilateral renal artery stenosis
Serious
- Angioedema (rare)
- Severe hypotension
- Acute kidney injury/Renal failure
- Severe hyperkalemia
- Rhabdomyolysis (rare)
- Anaphylaxis (rare)
- angioedema
- anaphylaxis
- abnormal hepatic function
- hepatitis
- neutropenia
- leukopenia
- agranulocytosis
- pruritus
- urticaria
- hyponatremia
- alopecia
- vasculitis
- anemia
- fetopathic syndrome
- hepatic failure (rare)
- agranulocytosis (rare)
- Hypotension (uncommon first dose)
- Hyperkalaemia
- Angioedema (fewer cases than ACEIs)
Pregnancy & lactation
Pregnancy
Category D — contraindicated; fetal renal injury
Lactation
Not recommended during breastfeeding. Losartan and its active metabolite are excreted into the milk of lactating rats, and potential adverse effects on the breastfed infant cannot be excluded. A decision should be made whether to discontinue nursing or discontinue the drug, taking into account the importance of the drug to the mother.
Drug interactions
Aliskiren
Contraindicated
Database
Increased risk of hypotension, hyperkalemia, and renal impairment.
Avoid concomitant use.
Source: DDInter
Angiotensin Converting Enzyme Inhibitors
Severe
Textbook
Greater incidence of acute kidney injury (AKI) and adverse cardiac events.
The combination of these two classes should be avoided.
Source: Harrison 22e · p2396
Enalaprilat
Severe
Textbook
Increased worsening of renal function, hypotension, syncope, and hyperkalemia without increased efficacy.
Not recommended for the treatment of hypertension. Previous studies indicate more harm than benefit.
Source: G&G 14e
Imidapril
Severe
Textbook
Greater incidence of acute kidney injury (AKI) and adverse cardiac events.
The combination of these two classes should be avoided.
Source: Harrison 22e · p2396
Ace Inhibitors
Severe
Database
Increased risk of hypotension, hyperkalemia, and renal impairment, especially in patients with diabetes or moderate-to-severe renal impairment
Concomitant use is generally not recommended and should be avoided, particularly in patients with diabetes or renal impairment. If deemed absolutely necessary, monitor blood pressure, renal function, and electrolytes very closely.
Amiloride
Severe
Database
Hyperkalemia.
Monitor K+ levels.
Source: DDInter
Benazepril
Severe
Database
Increased worsening of renal function, hypotension, syncope, and hyperkalemia without increased efficacy.
Not recommended for the treatment of hypertension. Previous studies indicate more harm than benefit.
Source: DDInter
Captopril
Severe
Database
Increased worsening of renal function, hypotension, syncope, and hyperkalemia without increased efficacy.
Not recommended for the treatment of hypertension. Previous studies indicate more harm than benefit.
Source: DDInter
Enalapril
Severe
Database
Increased worsening of renal function, hypotension, syncope, and hyperkalemia without increased efficacy.
Not recommended for the treatment of hypertension. Previous studies indicate more harm than benefit.
Source: DDInter
Fosinopril
Severe
Database
Increased worsening of renal function, hypotension, syncope, and hyperkalemia without increased efficacy.
Not recommended for the treatment of hypertension. Previous studies indicate more harm than benefit.
Source: DDInter
Lisinopril
Severe
Database
Increased worsening of renal function, hypotension, syncope, and hyperkalemia without increased efficacy.
Not recommended for the treatment of hypertension. Previous studies indicate more harm than benefit.
Source: DDInter
Related guidelines
Other ARB drugs
Ask House about Losartan
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Sources: KD Tripathi 7e, Goodman & Gilman 14e, Harrison 22e, Katzung·Verified: 2026-05-17 · House clinical team·Cockpit curated: 2026-05-16