How does telmisartan compare to losartan? When would one be preferred over the other?

Comment by InpharmD Researcher

While direct head-to-head clinical trials comparing telmisartan to losartan are limited, available literature suggests telmisartan may provide more sustained blood pressure control. A meta-analysis of 15 randomized controlled trials revealed that telmisartan is associated with greater efficacy in reducing systolic and diastolic blood pressure compared to losartan, with a more pronounced effect observed among Asian populations. Due to its longer half-life, telmisartan was consistently preferred over losartan in maintaining blood pressure control across all time periods, particularly during early morning hours, when cardiovascular risk is heightened. Furthermore, telmisartan was associated with fewer adverse events, suggesting a potentially improved safety profile.

Background

A 2022 meta-analysis of 15 randomized controlled trials involving 1,926 subjects with mild to moderate essential hypertension assessed the comparative efficacy of telmisartan and losartan. The trials included varied designs, such as double-blinded, open-label, and crossover studies, carried out in diverse geographic regions, including Asia, Europe, and the Americas. Blood pressure outcomes, specifically systolic (SBP) and diastolic (DBP) pressure reduction, were measured and analyzed using a random-effects model. Statistical heterogeneity was assessed, and meta-regression analysis explored potential sources of heterogeneity across variables such as ethnicity, age, and gender. The analysis revealed that telmisartan demonstrated superior efficacy in lowering both SBP (weighted mean difference of 2.69 mm Hg, 95% confidence interval [CI] 1.38 to 4.00) and DBP (weighted mean difference of 1.26 mm Hg, 95% CI 0.45 to 2.08) compared to losartan. Subgroup analysis indicated a more pronounced effect in Asian populations, with significant reductions observed in both SBP and DBP, whereas Caucasian participants exhibited a milder response, particularly for DBP. There was no statistically significant difference in SBP lowering with telmisartan compared to losartan in Caucasian participants. Additionally, telmisartan was associated with fewer adverse events, though heterogeneity was noted in some open-label studies, highlighting the need for further consistency in study design. These findings suggest telmisartan may provide more effective blood pressure control, especially in certain ethnic groups, with fewer side effects than losartan. [1]

A 2024 network meta-analysis evaluated the comparative efficacy and safety of six commonly prescribed angiotensin II receptor blockers (ARBs) including losartan, valsartan, irbesartan, telmisartan, candesartan, and olmesartan in patients with hypertension. The analysis included 193 randomized controlled trials (RCTs) focused on changes in systolic and diastolic blood pressure (SBP and DBP) measured in a clinical setting and through 24-hour ambulatory blood pressure monitoring. The safety was assessed based on the incidence of adverse events among the interventions. Candesartan and telmisartan ranked highest for 24-hour ambulatory SBP (95.4%) and DBP (83.4%) reductions, respectively. This analysis also examined the safety profiles of the ARBs, indicating that olmesartan and telmisartan were associated with fewer adverse events compared to losartan, though no significant differences were observed between other ARBs. Despite demonstrating these trends, the meta-analysis reported significant heterogeneity within the included studies, particularly among Chinese clinical trials, with a call for further high-quality research to refine the results and strengthen treatment recommendations. [2]

A 2013 meta-analysis evaluated the comparative efficacy of telmisartan versus losartan in reducing ambulatory blood pressure in hypertensive patients. This meta-analysis pooled data from nine randomized controlled trials, encompassing a total of 2,409 patients. It systematically analyzed a wide range of ambulatory blood pressure parameters, including 24-hour, last 6-hour, morning, daytime, and nighttime measurements. The results demonstrated a statistically significant reduction in both 24-hour systolic and diastolic blood pressure with telmisartan relative to losartan (mean difference of –2.09/–1.57 mm Hg). Notable reductions were observed across different time intervals, with the most pronounced effect observed during the last 6-hour period (–2.96/–2.15 mm Hg). Further sensitivity analyses revealed that the results favoring telmisartan persisted even when excluding quasi-randomized crossover studies or low-quality studies. This evidence supports the superior role of telmisartan in sustained ambulatory blood pressure reduction, which may translate to improved clinical outcomes. However, it is important to note that this meta-analysis did not specifically assess cardiovascular event rates. [3]

While losartan requires metabolic activation to yield its active metabolite, telmisartan does not need conversion and is pharmacologically active as administered. This distinction, coupled with their differences in elimination patterns, suggests that telmisartan may offer sustained blood pressure control over a 24 hour period, potentially offering improved management of hypertension compared to losartan. A 2003 meta-analysis evaluated the efficacy and safety of telmisartan and losartan using data from two double-blind, titration-to-response studies conducted across various international centers. The analysis primarily focused on the reduction in mean ambulatory DBP during the last 6 hours of the dosing interval after eight weeks of treatment with telmisartan (40 to 80 mg) and losartan (50 to 100 mg). Results from this analysis indicated that 60.1% of telmisartan-treated patients required titration to the higher dose, in comparison to 69.5% of losartan-treated patients (p= 0.01). Furthermore, the analysis revealed that reductions from baseline in the last 6 hours mean ambulatory DBP with telmisartan and losartan were 6.6 ± 0.4 and 5.1 ± 0.4 mmHg, respectively (p<0.01, adjusted for baseline and study). Likewise, reductions from baseline in the last 6 hours adjusted mean ambulatory SBP for telmisartan and losartan were 9.9 ± 0.6 and 7.8 ± 0.6 mmHg, respectively (p= 0.01). [4]

Overall, telmisartan provided superior control, achieving greater reductions in both DBP and SBP compared to losartan with telmisartan’s effects being consistent throughout the dosing period. The results suggest telmisartan might offer better cardiovascular protection, particularly during the early morning when blood pressure typically rises and cardiovascular events are more likely owing to its longer half-life. [3], [4]

Literature Review

A search of the published medical literature revealed 4 studies investigating the researchable question:

When is telmisartan preferred over losartan?

Level of evidence

A - Multiple high-quality studies with consistent results Read more→

Please see Tables 1-4 for your response.

Ambulatory Blood Pressure Monitoring (ABPM) Comparison of the Antihypertensive Profiles of the Selective Angiotensin II Receptor Antagonists Telmisartan and Losartan in Patients with Mild-to-Moderate Hypertension
Design	Multinational, multicentre, randomized, double-blind, double-dummy, placebo-controlled, parallel-group study N= 223
Objective	To compare the efficacy and tolerability of telmisartan with losartan versus placebo in patients with mild-to-moderate hypertension, focusing on the 18-to-24-h period after dosing
Study Groups	Telmisartan 40 mg (n= 57) Telmisartan 80 mg (n= 54) Losartan 50 mg (n= 57) Placebo (n= 55)
Inclusion Criteria	Men and women aged 18-75 with mild-to-moderate hypertension: DBP >95 and <114 mm Hg, SBP >140 and <200 mm Hg, and 24-h ambulatory DBP >85 mm Hg
Exclusion Criteria	Women of childbearing potential, secondary hypertension, hepatic or renal disease, cardiovascular disease, arrhythmias, uncontrolled diabetes, and use of certain medications
Methods	Participants underwent a 4-week placebo run-in, followed by randomization to receive telmisartan 40 mg, telmisartan 80 mg, losartan 50 mg, or placebo once daily. ABPM and clinic blood pressure measurements were used to assess efficacy.
Duration	Double-blind treatment: 6 weeks following a 4-week placebo run-in
Outcome Measures	Primary: Change from baseline in ABPM-derived mean SBP and DBP over the 18 to 24-h postdose interval
Baseline Characteristics		Placebo (n= 55)	Losartan 50 mg (n= 57)	Telmisartan 40 mg (n= 57)	Telmisartan 80 mg (n= 54)
	Male/Female	80/20	58/42	67/33	65/35
	Mean age, years	54	56	58	57
	Body mass index, kg/m²	29.0	29.1	28.5	29.3
Results	Blood pressure Type/Period^a	Placebo (n= 53)	Losartan 50 mg (n= 50)	Telmisartan 40 mg (n= 52)	Telmisartan 80 mg (n= 52)
	18–24 h SBP	-2.3 ± 1.5	-6.0 ± 1.5	-10.7 ± 1.5**	-12.2 ± 1.5**
	18–24 h DBP	-1.3 ± 1.0	-3.7 ± 1.0	-6.8 ± 1.0**	-7.1 ± 1.0**
	24-h SBP	-1.8 ± 1.3	-8.0 ± 1.3*	-11.5 ± 1.3**	-13.3 ± 1.3**
	24-h DBP	-0.8 ± 0.8	-4.9 ± 0.8*	-7.4 ± 0.8**	-8.4 ± 0.8**
	*p< 0.05 vs. placebo; p< 0.05 vs. losartan 50 mg and placebo ^aAdjusted for baseline response, country, and treatment (relative to hours postdose)
Adverse Events	Headache, upper respiratory tract infection, dizziness, fatigue, pain, and bronchitis. No serious treatment-related adverse events reported.
Study Author Conclusions	Telmisartan 40 mg and 80 mg once daily were effective and well tolerated in treating mild-to-moderate hypertension, providing sustained 24-hour blood pressure control, and may offer advantages over losartan 50 mg once daily.
Critique	Despite the randomized, double-blind design and use of ABPM for accurate blood pressure measurement, the results are limited by potential variability in individual activity levels affecting ABPM results and the lack of evaluation of twice-daily dosing for losartan.

References:

Mallion J, Siche J, Lacourcière Y. ABPM comparison of the antihypertensive profiles of the selective angiotensin II receptor antagonists telmisartan and losartan in patients with mild-to-moderate hypertension. J Hum Hypertens. 1999;13(10):657-664. doi:10.1038/sj.jhh.1000925

Efficacy and Tolerability of Olmesartan, Telmisartan, and Losartan in Patients of Stage I Hypertension: A Randomized, Open-label Study
Design	Randomized, open-label, parallel-group, comparative study N= 60
Objective	To compare the efficacy and tolerability of losartan, telmisartan, and olmesartan as antihypertensive agents and evaluate and compare their effects on lipid profile and blood glucose
Study Groups	Olmesartan (n= 20) Telmisartan (n= 19) Losartan (n= 18)
Inclusion Criteria	Newly diagnosed patients of Stage I hypertension; age >18 years
Exclusion Criteria	Patients with diabetes, abnormal liver or kidney function, systemic illness, taking other medications including antihypertensives, pregnant and lactating women
Methods	Participants were randomly allocated to receive olmesartan (20 mg), telmisartan (40 mg), or losartan (50 mg) once daily. Blood pressure (BP) was assessed every 2 weeks for 3 months. Fasting blood glucose (FBG) and lipid profile were measured at baseline and after 12 weeks.
Duration	Data collection: January 2013 to September 2014 Intervention: 12 weeks
Outcome Measures	Primary: Change in sitting cuff diastolic BP from baseline to 12 weeks Secondary: Changes in blood glucose and lipid profile from baseline to 12 weeks
Baseline Characteristics	Characteristics	Telmisartan (n=19)	Losartan (n= 18)	Olmesartan (n= 20)	p-value
	Age, years	48.26 ± 9.88	49.94 ± 9.84	46.2 (8.66)	0.58
	Male/Female	12/7	12/6	12/7	-
	Baseline Parameters DBP SBP FBGL TC TG VLDL HDL LDL	94.53 ± 2.65 148.8 ± 6.02 92.80 ± 11.84 165.9 ± 7.58 120.7 ± 8.72 24.20 ± 3.13 45.84 ± 5.17 94.62 ± 8.17	93.44 ± 2.45 149.9 ± 3.48 89.50 ± 11.82 158.6 ± 7.39 120.8 ± 7.27 24.39 ± 2.83 47.78 ± 5.45 87.30 ± 7.91	95.05 ± 2.20 147.38 ± 5.80 87.85 ± 12.74 160.6 ± 6.38 124.9 ± 7.62 23.67 ± 2.63 47.70 ± 5.36 87.54 ± 5.99	0.14 0.48 0.91 0.07 0.49 0.72 0.46 0.14
	BP measured in mmHg and lipid profile in mg/dl FBGL=Fasting blood glucose level, TC=Total cholesterol, TG=Triglycerides, VLDL=Very low- density lipoprotein, HDL=High- density lipoprotein, LDL=Low- density lipoprotein, DBP=Diastolic blood pressure, SBP=Systolic blood pressure, SD=Standard deviation, BP=Blood pressure
Results	Medication	Baseline	2 weeks	4 weeks	8 weeks	12 weeks
	Olmesartan (n= 20) DBP SBP	95.05 ± 2.15 148.3 ± 6.07	85.90 ± 3.31* 136.5 ± 6.22*	84.86 ± 4.07* 135.7 ± 6.27*	83.71 ± 6.07* 133.2 ± 7.49*	81.24 ± 5.30* 131.0 ± 8.50*
	Telmisartan (n= 19) DBP SBP	94.53 ± 2.65 148.8 ± 6.02	87.37 ± 3.59* 140.4 ± 6.88*	86.32 ± 5.38* 140.4 ± 7.54*	85.16 ± 4.72* 138.6 ± 8.22*	82.53 ± 5.99* 137.1 ± 8.28*
	Losartan (n= 18) DBP SBP	93.44 ± 2.45 149.9 ± 3.84	88.78 ± 4.60* 143.00 ± 5.54*	87.33 ± 5.05* 142.00 ± 5.41*	87.67 ± 2.84 141.4 ± 5.81	86.11 ± 5.15 138.7 ± 5.61
		Olmesartan (n= 20)	Telmisartan (n= 19)	Losartan (n= 18)
	Blood glucose and lipid profile FBGL TC TG VLDL HDL LDL	2.45 ± 0.43 12.75 ± 2.12^a 5.55 ± 0.46^b −0.02 ± 0.01 0.60 ± 0.07 8.15 ± 1.86^$	3.73 ± 0.88 8.89 ± 2.65 8.94 ± 1.01^c 0.18 ± 0.02 −0.94 ± 0.02 14.65 ± 1.88^#,¥	−1.11 ± 0.03 0.83 ± 0.07 −0.05 ± 0.01 0.12 ± 0.03 0.05 ± 0.02 0.21 ± 0.06
	^ap<0.01 when compared with losartan group, ^bp<0.05 when compared with losartan group, ^cp<0.001 when compared with losartan group, ^#p<0.05 when compared with olmesartan group, ^$p<0.05 when compared with losartan group, ^¥p<0.0001 when compared with losartan group
	p<0.001, *p<0.0001 when compared with baseline
Adverse Events	Olmesartan: 1 headache (5%); Telmisartan: 1 dizziness (5.2%); Losartan: None
Study Author Conclusions	Olmesartan and telmisartan are equally efficacious in reducing DBP whereas losartan is least efficacious. Olmesartan, when compared to telmisartan and losartan is more efficacious in reducing SBP whereas telmisartan and losartan are equally efficacious. Telmisartan shows the most favorable effects on FBG and lipid profile.
Critique	The study is well-designed with a clear objective and appropriate methodology. However, the sample size is relatively small, and the study duration is short, limiting the generalizability and long-term applicability of the findings. The open-label design may introduce bias.

References:

Kalikar M, Nivangune KS, Dakhale GN, et al. Efficacy and Tolerability of Olmesartan, Telmisartan, and Losartan in Patients of Stage I Hypertension: A Randomized, Open-label Study. J Pharmacol Pharmacother. 2017;8(3):106-111. doi:10.4103/jpp.JPP_39_17

Comparative Effectiveness of Angiotensin-Receptor Blockers for Preventing Macrovascular Disease in Patients with Diabetes: A Population-Based Cohort Study
Design	Population-based retrospective cohort study N= 54,186
Objective	To evaluate the risk of myocardial infarction, stroke, and heart failure in patients with diabetes taking telmisartan compared to other angiotensin-receptor blockers
Study Groups	Telmisartan (n= 8,182) Candesartan (n= 10,940) Irbesartan (n= 12,691) Losartan (n= 8,411) Valsartan (n= 13,962)
Inclusion Criteria	Aged ≥ 66 years; Ontario residents with diabetes; started treatment with specified angiotensin-receptor blockers (ARB) between April 1, 2001, and March 31, 2011
Exclusion Criteria	Received a prescription for any angiotensin-receptor blocker in the year preceding the index date, those diagnosed with diabetes after starting treatment, those with myocardial infarction in the 5 years preceding treatment, and those receiving an angiotensin-converting enzyme (ACE) inhibitor with an ARB
Methods	Medication exposure determined using the Ontario Drug Benefit database. Patients were censored if they switched to a different ARB or stopped treatment. Multivariable Cox proportional hazards regression was used for analysis.
Duration	Follow-up: up to 5 years of observation
Outcome Measures	Primary: Composite of admission to hospital for acute myocardial infarction, stroke, or heart failure
Baseline Characteristics		Telmisartan (n= 8,182)	Candesartan (n= 10,940)	Irbesartan (n= 12,691)	Losartan (n= 8,411)	Valsartan (n= 13,962)
	Median age (interquartile range [IQR], years	73 (69 to 78)	73 (69 to 79)	73 (69 to 78)	73 (69 to 79)	73 (69 to 78)
	Female	58.4%	60.1%	57.7%	62.3%	60.6%
	Median duration of diabetes (IQR), years	6.0 (2.3 to 10.8)	6.3 (2.4 to 11)	6.5 (2.4 to 11.1)	6.2 (2.3 to 10.5)	6.1 (2.3 to 10.5)
	Charlson comorbidity index 0 1 ≥2	6.9% 7.3% 9.1%	7.3% 7.3% 10.6%	6.8% 7.4% 10.6%	6.1% 7.9% 10.6%	7.0% 7.2% 9.0%
Results	Endpoint	Telmisartan (n= 8,182)	Candesartan (n= 10,940)	Irbesartan (n= 12,691)	Losartan (n= 8,411)	Valsartan (n= 13,962)
Results	Composite of admission to hospital for acute myocardial infarction, stroke, or heart failure Unadjusted hazard ratio (95% confidence interval [CI] Adjusted hazard ratio (95% CI)	0.78 (0.68–0.89) 0.85 (0.74–0.97)	1.04 (0.93–1.16) 0.99 (0.89–1.11)	1.00 (reference) 1.00 (reference)	1.00 (0.89–1.13) 0.93 (0.83–1.05	0.84 (0.75–0.93) 0.86 (0.77–0.96)
Adverse Events	Not specifically reported.
Study Author Conclusions	Compared with other angiotensin-receptor blockers, telmisartan and valsartan were both associated with a lower risk of admission to hospital for acute myocardial infarction, stroke or heart failure among older adults with diabetes and hypertension. Telmisartan and valsartan may therefore be the preferred angiotensin-receptor blockers for use in these patients.
InpharmD Researcher Critique	Although this study included al arge sample size, real-world data, and comprehensive adjustment for confounders, the results are limited by its observational design, potential for residual confounding, and lack of clinical data such as smoking history or body mass index. Moreover, its applicability is limited to older population.

References:

Antoniou T, Camacho X, Yao Z, Gomes T, Juurlink DN, Mamdani MM. Comparative effectiveness of angiotensin-receptor blockers for preventing macrovascular disease in patients with diabetes: a population-based cohort study. CMAJ. 2013;185(12):1035-1041. doi:10.1503/cmaj.121771

A Comparative Study of the Efficacy of Telmisartan and Losartan in the Treatment of Hypertension
Design	Prospective observational study N= 40
Objective	To assess the efficacy and safety of telmisartan and losartan in the management of hypertension
Study Groups	Telmisartan 40 mg (n= 20) Losartan 50 mg (n= 20)
Inclusion Criteria	Adult individuals diagnosed with essential hypertension, aged 18-75 years, with baseline systolic blood pressure (SBP) between 140-160 mm Hg and diastolic blood pressure (DBP) between 90-100 mmHg
Exclusion Criteria	Individuals with contraindications to Telmisartan or Losartan, secondary hypertension, serious comorbidities, pregnant or breastfeeding women, and those on concurrent antihypertensive medications
Methods	Participants were randomly assigned to receive either Telmisartan 40 mg or Losartan 50 mg. Blood pressure was measured at each follow-up visit spaced by 15 days.
Duration	3 months
Outcome Measures	Primary: Reduction in systolic and diastolic blood pressure from baseline Secondary: changes in lipid profiles and adverse events
Baseline Characteristics		Telmisartan (n= 20)	Losartan (n= 20)
	Male	12 (60%)	13 (65%)
	Age Group
	20-40 Years	8 (40%)	9 (45%)
	41-60 Years	12 (60%)	11 (55%)
	Mean body mass index	26.98 ± 1.66	26.74 ± 1.78
Results	SBP
	Mean at First Visit	151.82 ± 5.96	149.35 ± 6.84
	Mean at Follow Up (3 Months)	121.34 ± 6.01	124.73 ± 6.48
	DBP
	Mean at First Visit	92.64 ± 3.11	92.83 ± 3.87
	Mean at Follow Up (3 Months)	79.29 ± 2.93	82.75 ± 3.19
Adverse Events	No significant differences in adverse events or discontinuations due to side effects between the two groups.
Study Author Conclusions	Telmisartan and Losartan are equally effective in reducing blood pressure in patients with essential hypertension. Both drugs demonstrated good safety profiles, and neither exhibited superiority in terms of adverse events or effects on lipid profiles.
Critique	The study's strengths include its prospective design and clear outcome measures. However, the small sample size and short duration limit the generalizability of the findings. Further long-term studies with larger populations are needed to confirm these results.

References:

Nama Netaji, 2024. A Comparative Study of the Efficacy of Telmisartan and Losartan in the Treatment of Hypertension. Res. J. Pharm., 18: 45‐48, doi: 10.36478/ makrjp.2024.1.45.48