Telmisartan vs Losartan: What to Choose and for Whom

Telmisartan and losartan are often regarded as interchangeable, since both are sartans. However, in specific clinical situations one of them may have notable advantages. The editorial team examines typical patient profiles — from a person with gout to a physically active man with elevated blood pressure — and explains what arguments doctors take into account when choosing a drug.

When a sartan is considered at all

Sartans are one of the five main classes of drugs for treating arterial hypertension, along with ACE inhibitors, calcium channel blockers, thiazide diuretics and beta-blockers. The European ESH 2023 guidelines recommend starting most patients with a combination of two drugs in a single tablet, and a sartan is often part of such a combination.

Sartans are especially appropriate when protection of the kidneys is needed (in cases of protein in the urine, diabetic kidney disease), in left ventricular hypertrophy, heart failure and in people who do not tolerate ACE inhibitors because of cough.

Before choosing a specific molecule, the doctor confirms the hypertension itself: repeated measurements in the office, home monitoring or 24-hour blood pressure monitoring. A single high reading, especially after a workout or coffee, is not a diagnosis.

They also assess overall cardiovascular risk, kidney function, potassium, glucose, lipid and uric acid levels. It is precisely these indicators that often suggest which sartan will be more appropriate.

When in favor of telmisartan

Even blood pressure control throughout the day is needed.Thanks to its long half-life, telmisartan retains its effect in the morning hours too, when blood pressure naturally rises. For people who occasionally skip a dose or take the tablet at different times, the long action also provides a certain reserve.

High cardiovascular risk.Telmisartan has a registered indication for reducing cardiovascular morbidity in patients with atherosclerotic disease or diabetes with target-organ damage — based on the ONTARGET and TRANSCEND studies.

Many concomitant drugs.Telmisartan is almost not metabolized via the cytochrome P450 system, so the risk of pharmacokinetic interactions is lower than with losartan, which is activated with the participation of CYP2C9 and CYP3A4.

Metabolic syndrome.Partial activation of PPAR-gamma may theoretically be beneficial, but clinical data are inconsistent. Doctors regard this as an additional, not a decisive, argument.

When in favor of losartan

Elevated uric acid or gout.Losartan is the only sartan with a clinically noticeable uricosuric effect. For a patient with gout who also needs to lower blood pressure, this is a weighty argument.

Left ventricular hypertrophy.In the LIFE study, losartan-based therapy reduced the rate of strokes compared with atenolol in patients with signs of myocardial hypertrophy on ECG.

Diabetic kidney disease.The RENAAL study showed a slowing of nephropathy progression in type 2 diabetes. At the same time, the nephroprotective effect is considered characteristic of the class as a whole.

Need for flexible dosing and price.Losartan is available in many dosages and generics, which sometimes matters for long-term therapy. In some patients the drug is taken twice a day for even blood pressure control — this is decided by a doctor.

Physically active people and athletes

Elevated blood pressure is not uncommonly found in young men who engage in strength sports. The causes can be various: genetics, excess weight, an excess of salt, stimulants in pre-workout supplements, caffeine abuse, and also the use of anabolic steroids or other hormonal drugs.

If blood pressure rose against the background of hormonal drugs, the editorial team emphasizes: a sartan does not make them safe. Treatment should begin with eliminating the cause and a complete cardiological examination, in particular echocardiography and a lipid profile.

While taking sartans, athletes face several specific risks. Dehydration after an intense workout or weight-cutting intensifies hypotension and dizziness. Potassium supplements and “electrolyte” drinks high in it, together with a sartan, can raise blood potassium. Regular NSAIDs for joint pain worsen kidney function.

Sartans are not on the WADA Prohibited List. However, fixed-dose combinations with hydrochlorothiazide contain a diuretic, which is always prohibited in sport, so professional athletes need to discuss the composition with a doctor.

Monitoring of effectiveness and safety

Regardless of the chosen molecule, treatment with a sartan is accompanied by standard monitoring. The goal is to make sure that blood pressure reaches target values and that the kidneys and electrolytes remain normal.

A small rise in creatinine after the start of therapy is expected and is usually not a reason for discontinuation. A substantial increase in creatinine or potassium is grounds for reviewing the treatment.

The blood pressure target per ESH 2023 for most adults is below 140/90 mm Hg, and with good tolerability — closer to 130/80. The specific value is determined individually by a doctor.

One should not change the dose or switch from one sartan to another on one’s own: the equivalent doses of different molecules do not match in milligrams.

Editorial conclusions

Telmisartan is more appropriate when even 24-hour action is important, when there is high cardiovascular risk or many concomitant drugs.

Losartan has advantages in gout and hyperuricemia, as well as a solid evidence base in left ventricular hypertrophy and diabetic nephropathy.

For most patients both drugs are effective and safe, and the decisive factors are comorbid conditions, tolerability and adherence to intake.

To better understand the pharmacological difference, read our article “Telmisartan or Losartan: What Is the Difference.” Articles on arterial blood pressure in strength sports and on nebivolol and bisoprolol will also be useful.

References

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