Black Health
Angiotensin-receptor blocker (ARB) Hypertension Diabetic kidney disease Stroke prevention in LVH

Losartan (Cozaar) and Black patients

Brand names: Cozaar

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What Losartan does

Losartan is an angiotensin-receptor blocker that prevents the hormone angiotensin II from binding to blood-vessel and heart receptors. The end result is similar to an ACE inhibitor — lower blood pressure, reduced strain on the heart, protection of the kidneys in diabetes — but losartan doesn't raise bradykinin, so it rarely causes the dry cough or angioedema associated with ACE inhibitors.

What the evidence says for Black patients

ARBs share the same efficacy caveat in Black patients that ACE inhibitors do: as monotherapy for uncomplicated hypertension, ARBs lower blood pressure less effectively than thiazides or calcium-channel blockers in Black adults. The 2017 ACC/AHA guideline (Whelton et al., 2018) groups ACE inhibitors and ARBs together as non-preferred first-line agents in Black adults without CKD. Flack et al. (Hypertension 2010;56:780–800) summarize the race-stratified response data.

Losartan is the preferred ARB when an ACE inhibitor is indicated but has caused cough. It is also the first-line choice when a Black patient has:

  • Diabetic nephropathy with proteinuria — the RENAAL trial (Brenner et al., NEJM 2001;345:861–9, PMID 11565518) showed losartan reduced doubling of serum creatinine and end-stage renal disease in type-2 diabetes, including in Black participants.
  • Left ventricular hypertrophy — though the LIFE trial showed reduced efficacy of losartan for stroke prevention specifically in the Black subgroup (Julius et al., Hypertension 2004;43:1214–22, PMID 15117901), which clinicians should know when weighing options.

Angioedema does occur with ARBs but at roughly one-tenth the rate of ACE inhibitors. Switching from an ACE inhibitor to an ARB after ACE-induced angioedema is generally acceptable after a drug-free interval, though rare cross-reactivity has been reported.

Common alternatives

For uncomplicated hypertension in a Black adult, guideline-preferred alternatives are a thiazide-type diuretic (chlorthalidone, indapamide) or a calcium-channel blocker (amlodipine). For diabetic nephropathy with proteinuria, either losartan or an ACE inhibitor is appropriate; both are proven to reduce progression to end-stage renal disease.

Side effects

  • Dizziness, especially on the first dose
  • Elevated potassium
  • Rise in creatinine (expected; large rise suggests renal-artery stenosis)
  • Angioedema — rare but possible; stop the drug permanently
  • Fetal toxicity — contraindicated in pregnancy

Factors that affect adherence

Losartan's lack of cough makes it better tolerated than ACE inhibitors for many Black patients who've tried lisinopril or enalapril first. Generic losartan is inexpensive. Patients should know that generic losartan had an FDA-flagged NDMA impurity recall cluster in 2018–2020; supply is now stable, and current generic tablets meet the FDA's interim NDMA limit.

Questions to ask your doctor

Bring this list to your next appointment.

  • I'm Black and don't have kidney disease or diabetes — is an ARB the right first-line choice, or should we start with a thiazide or CCB?
  • If I have diabetes or kidney disease, is losartan enough, or do I need a second drug?
  • When will we recheck my potassium and creatinine?
  • What should I do if my face or tongue swells?

References

  1. Brenner BM, Cooper ME, de Zeeuw D, et al. Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy (RENAAL). NEJM. 2001;345:861–869. PMID 11565518.
  2. Julius S, Alderman MH, Beevers G, et al. Cardiovascular risk reduction in hypertensive black and nonblack patients with left ventricular hypertrophy (LIFE). Hypertension. 2004;43:1214–1222. PMID 15117901.
  3. Flack JM, Sica DA, Bakris G, et al. Management of high blood pressure in Blacks: an update of the ISHIB consensus statement. Hypertension. 2010;56:780–800. PMID 20921433.
  4. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA Hypertension Guideline. Hypertension. 2018;71:e13–e115.
  5. U.S. Food and Drug Administration. Cozaar (losartan potassium) label. https://www.accessdata.fda.gov/drugsatfda_docs/label/2014/020386s060lbl.pdf

Medical disclaimer

This page is patient education, not prescribing guidance. It summarizes the published evidence about how this medication has been studied in Black patients — it is not a substitute for the judgment of your personal clinician. Never start, stop, or change a prescription based on something you read here. If you have questions about your medication, call your prescriber or pharmacist. For emergencies, call 911.

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