Cough was reported in 2.6% of losartan; hydrochlorothiazide-treated patients compared to 2.3% of placebo-treated patients in controlled clinical trials. The incidence of cough appears to be lower with losartan than with an angiotensin converting enzyme inhibitor (ACEI); losartan does not inhibit angiotensin converting enzyme (kinase II), which is thought to be responsible for the ACEI-induced cough. In comparative studies, the incidence of cough in losartan-treated patients with a prior history of ACEI-induced cough was similar to that associated with hydrochlorothiazide or placebo therapy. Cases of cough, including positive re-challenges, have been reported with the use of losartan in postmarketing experience.[32333]

Dizziness was reported in 5.7% of losartan; hydrochlorothiazide-treated patients in clinical trials compared to 2.9% of placebo-treated patients. Asthenia/fatigue and headache were also reported in 1% or more of losartan; hydrochlorothiazide-treated patients, but were as or more common in the placebo group. Nervous system/psychiatric events reported in patients treated with losartan monotherapy without regard to causality include: anxiety, ataxia, confusion, depression, dream abnormality, hypoesthesia, insomnia, libido decrease, memory impairment, migraine, nervousness, panic disorder, paresthesias, peripheral neuropathy, sleep disorder, drowsiness, tremor, and vertigo. Restlessness and weakness have been reported during hydrochlorothiazide monotherapy.[32333]

Impotence (erectile dysfunction) has been reported in patients taking losartan monotherapy and is possible in patients taking losartan; hydrochlorothiazide.[32333]

Adverse reactions reported in losartan; hydrochlorothiazide-treated patients in clinical trials and more frequently than placebo include: edema/swelling (1.3% vs. 1.2%) and palpitations (1.4% vs. 0%). Patients treated with diuretics may become intravascularly volume-depleted (hypovolemia), and symptomatic hypotension may occur after initiation of therapy with losartan; hydrochlorothiazide. Chest pain (unspecified), orthostatic effects (e.g., orthostatic hypotension), syncope, angina pectoris, arrhythmia exacerbation (including atrial fibrillation, sinus bradycardia, sinus tachycardia, ventricular tachycardia and ventricular fibrillation), CVA (stroke), myocardial infarction, and second degree AV block have been reported with losartan.[32333]

Angioedema, including swelling of the larynx and glottis, causing airway obstruction and/or swelling of the face, lips, pharynx, and/or tongue has been reported with postmarketing use of losartan; hydrochlorothiazide. Anaphylactic reactions (anaphylactoid reactions) can present as respiratory distress (including pneumonitis and pulmonary edema).[32333] Theoretically, angiotensin II receptor antagonists (ARBs) should be less likely than angiotensin converting enzyme inhibitors (ACEIs) to precipitate angioedema because ARBs do not cause accumulation of kinins. However, angioedema (swelling of lips and eyelids, facial rash) has been reported in patients receiving ARBs, including in patients with a prior history of angioedema during ACE inhibitor therapy. Some of these patients previously experienced angioedema with other drugs including ACEIs.[32325]

Hypersensitivity reactions may occur during therapy with losartan; hydrochlorothiazide. Vasculitis, including Henoch-Schoenlein purpura, has been reported with losartan. Necrotizing angiitis (vasculitis and cutaneous vasculitis) has been reported with hydrochlorothiazide.[32333]

Clinically significant laboratory abnormalities are rarely reported with losartan. Small decreases in hemoglobin (0.14 grams percent) and hematocrit (0.72 volume percent) occurred frequently during losartan; hydrochlorothiazide therapy; no patient discontinued due to anemia. However, anemia has been reported with losartan monotherapy. Elevated hepatic enzymes and elevated bilirubin concentrations (hyperbilirubinemia) have been reported occasionally during antihypertensive therapy with losartan; hydrochlorothiazide; without requiring discontinuation from therapy. Hepatitis is rarely reported with losartan. Thiazide diuretics have been associated with intrahepatic cholestatic jaundice.[32333]

Rash (unspecified) was reported in 1.4% of losartan; hydrochlorothiazide-treated patients compared to 0% of placebo-treated patients in clinical trials. Superficial peeling of the palms with hemolysis has been reported in one patient receiving losartan monotherapy. Erythroderma (exfoliative dermatitis) has been reported during losartan postmarketing experience. Alopecia, dermatitis, dry skin (xerosis), ecchymosis, erythema, flushing, photosensitivity, pruritus, diaphoresis, and urticaria have also been reported in patients treated with losartan. Adverse dermatologic reactions to hydrochlorothiazide and other thiazide diuretics are uncommon but may occur. These reactions include photosensitivity, urticaria, erythema multiforme including Stevens-Johnson syndrome, and exfoliative dermatitis including toxic epidermal necrolysis (TEN).[32333].

Hydrochlorothiazide has been associated with hyperglycemia and glycosuria without regard to causality. Diabetic patients receiving losartan; hydrochlorothiazide may require dosage adjustment of insulin or oral hypoglycemic agents.[32333]

While serious hematological reactions are rare; aplastic anemia, agranulocytosis, leukopenia, hemolytic anemia, and thrombocytopenia have been reported with hydrochlorothiazide therapy. Thrombocytopenia has also been reported during postmarketing experience with losartan; hydrochlorothiazide.[32333]

Hyperuricemia may occur in patients receiving thiazide diuretics. In predisposed individuals, frank gout or nephrolithiasis may be precipitated. Diuretic-induced acute gouty arthritis and nephrolithiasis are extremely rare in patients with no prior history of gout. Losartan in combination with hydrochlorothiazide attenuates the diuretic-induced hyperuricemia. Although gout has been reported in losartan-treated patients, in a single dose study of losartan, there was a small uricosuric effect leading to a mean decrease in serum uric acid of less than 0.4 mg/dL during chronic oral administration. If some manifestation of gout occurs in a patient who requires diuretic therapy for effective treatment of hypertension, allopurinol or a uricosuric agent can be given to prevent recurrent gouty attacks without diminishing the antihypertensive effect of losartan; hydrochlorothiazide.[32333]

Thiazide diuretics have been shown to increase the urinary excretion of magnesium; this may result in hypomagnesemia. Thiazides may also decrease urinary calcium excretion and may cause intermittent and slight elevations of serum calcium in the absence of known disorders of calcium metabolism. The development of marked hypercalcemia may be evidence of hidden hyperparathyroidism. If hypercalcemia occurs, losartan; hydrochlorothiazide should be discontinued before carrying out tests for parathyroid function.[32333]

Although hypercholesterolemia and/or hypertriglyceridemia have been associated with thiazide diuretic therapy, data from long-term studies suggest that diuretic-induced lipid abnormalities are not clinically significant.[24090] After approximately one year of treatment, total serum cholesterol concentrations will subside to baseline or lower, suggesting that diuretic therapy does not increase coronary heart disease risk. Nevertheless, it would be prudent to monitor serum cholesterol and triglyceride concentrations periodically in hypertensive patients receiving losartan; hydrochlorothiazide.[32333]

Abdominal pain was reported in 1.2% of losartan; hydrochlorothiazide-treated patients vs. 0.6% of placebo-treated patients in clinical trials. Diarrhea and nausea were also reported in 1% or more of losartan; hydrochlorothiazide-treated patients, but were as, or more common in the placebo group. Anorexia, constipation, dental pain, xerostomia, dyspepsia, flatulence, gastritis, and vomiting have been reported with losartan. Sialadenitis, cramping, and gastric irritation have been reported with hydrochlorothiazide.[32333]

Back pain was reported in 2.1% of losartan; hydrochlorothiazide-treated patients in clinical trials compared to 0.6% of placebo-treated patients. Muscle spasm has been reported with hydrochlorothiazide. Arm pain, arthralgia, arthritis, fibromyalgia, hip pain, joint swelling, knee pain, leg pain, muscle cramps, myasthenia (muscle weakness), musculoskeletal pain, myalgia, shoulder pain, and stiffness have been reported with losartan. Rare cases of rhabdomyolysis have been reported during postmarketing experience with angiotensin II receptor antagonists.[32333]

Dysgeusia has been reported in patients taking losartan; hydrochlorothiazide therapy.[32333]

Respiratory-related adverse events that occurred more frequently in losartan; hydrochlorothiazide-treated patients in clinical trials than in placebo-treated patients include: sinusitis (1.2% vs. 0.6%) and upper respiratory infection (6.1% vs. 4.6%). Bronchitis and pharyngitis were reported in 1% or more of losartan; hydrochlorothiazide-treated patients but were as, or more, common in the placebo group. Fever, malaise, dyspnea, epistaxis, nasal congestion, pharyngeal discomfort, respiratory congestion, rhinitis, and sinus disorder have been reported with losartan. Fever and respiratory distress including pneumonitis and pulmonary edema have been reported with hydrochlorothiazide.[32333]

Pancreatitis has been reported rarely in patients receiving thiazide diuretics. Clinical manifestations frequently include pain in the abdomen, abdominal distention, nausea, vomiting, and low-grade fever. Pancreatitis can occur within 2 weeks of initiation of therapy or after several months of therapy. If signs and/or symptoms suggestive of pancreatitis develop in a patient receiving losartan; hydrochlorothiazide, drug therapy should be discontinued.[32333]

Due to the potential for teratogenesis, losartan; hydrochlorothiazide should not be used during pregnancy. Drugs that affect the renin-angiotensin system have been associated with fetal and neonatal abnormalities when administered to women during the second or third trimesters of pregnancy. Adverse fetal and neonatal effects have included hypotension, neonatal skull hypoplasia, anuria, reversible or irreversible renal failure, oligohydramnios, and death. Oligohydramnios has been associated with craniofacial deformation and hypoplastic lung development. If oliguria or hypotension occurs in a neonate with a history of in utero exposure to losartan; hydrochlorothiazide, blood pressure and renal perfusion support may be required, as well as exchange transfusion or dialysis to reverse hypotension and/or support decreased renal function.[32333]

Losartan; hydrochlorothiazide may result in ophthalmic and otic adverse reactions. Hydrochlorothiazide, a sulfonamide, can cause an idiosyncratic reaction, resulting in transient myopia and acute angle-closure glaucoma. Symptoms include acute onset of decreased visual acuity or ocular pain and typically occur within hours to weeks of drug initiation. Untreated acute angle-closure glaucoma can lead to permanent vision loss. Discontinue hydrochlorothiazide as rapidly as possible and consider prompt medical or surgical treatment if the ocular hypertension remains uncontrolled.[42865] Transient blurred vision and xanthopsia have also been reported during hydrochlorothiazide monotherapy. Blurred vision, ocular irritation (i.e., burning/stinging in the eye), conjunctivitis, visual impairment (i.e., decrease in visual acuity), and tinnitus have been reported with losartan.[32333]

Minor increases in blood urea nitrogen or serum creatinine were observed in 0.6% and 0.8%, respectively, of patients treated with losartan; hydrochlorothiazide for hypertension. Treatment with angiotensin converting enzyme inhibitors has been associated with oliguria and/or progressive azotemia and (rarely) with acute renal failure (unspecified) and/or death in patients whose renal function may depend on the activity of the renin-angiotensin-aldosterone system (e.g., patients with severe congestive heart failure). Similar outcomes have been reported with losartan.[32333] In the ELITE study, renal dysfunction (defined as a persistent increase in serum creatinine of 0.3 mg/dl) occurred in 10.5% of elderly heart failure patients treated with losartan and in 10.5% of patients treated with an ACE inhibitor (captopril).[24866] Nocturia, increased urinary frequency, and urinary tract infection have also been reported with losartan. Renal failure, renal dysfunction, and interstitial nephritis have been reported with hydrochlorothiazide.[32333]

Hypokalemia (serum potassium less than 3.5 mEq/L) has been observed in 6.7% patients; whereas hyperkalemia (serum potassium greater than 5.7 mEq/L) has been observed in 0.4% of patients receiving losartan; hydrochlorothiazide. No patients required discontinuation of therapy from the combination product in controlled clinical trials due to changes in serum potassium. Hyponatremia has also been reported with losartan monotherapy. All patients receiving thiazide therapy should be observed for clinical signs of fluid or electrolyte imbalance: hyponatremia, hypochloremic alkalosis, and hypokalemia. Although any chloride deficit is generally mild and usually does not require specific treatment except under extraordinary circumstances (as in liver disease or renal disease), chloride replacement may be required in the treatment of metabolic alkalosis. Dilutional hyponatremia may occur in edematous patients in hot weather; appropriate therapy is water restriction, rather than administration of salt except in rare instances when the hyponatremia is life-threatening. In actual salt depletion, appropriate replacement is the therapy of choice.[32333]

Hydrochlorothiazide has been associated with an increased risk of non-melanoma skin cancer. An FDA Sentinel Initiative study found that increased risk was mostly for squamous cell carcinoma and in White patients taking large cumulative doses. The increased risk for the overall population was approximately 1 additional case per 16,000 patients per year. For White patients taking a cumulative dose more than 50,000 mg, the risk increased to approximately 1 additional case per 6,700 patients per year.[32333]

Thiazide diuretics are contraindicated in patients with known thiazide diuretic hypersensitivity. According to the manufacturer, hydrochlorothiazide is specifically contraindicated in patients with sulfonamide hypersensitivity. Hypersensitivity reactions may occur in patients with or without a history of allergy or bronchial asthma; however, reactions are more likely to occur in patients with such history. Although thiazide diuretics are sulfonamide derivatives, sulfonamide cross-sensitivity has rarely been documented.[23511] [26922] [32381] Until further data are available, thiazide diuretics should be used with caution in patients with sulfonamide hypersensitivity. Thiazide diuretics do not contain the N4-aromatic amine or the N1-substituent which are present in sulfonamide antibiotics.[32380] Non-arylamine sulfonamide derivatives, such as thiazide diuretics, have been proposed to have a lower risk of allergic reactions in patients with sulfonamide allergy, presumably due to lack of an arylamine group at the N4 position (a proposed structural site of action for sulfonamide allergy).[32380] [32381] One large retrospective cohort study has reported that in patients with the presence of an allergic reaction after exposure to a sulfonamide antibiotic, 9.9% had an allergic reaction after receiving a non-antibiotic sulfonamide derivative, while in patients who lacked an allergic reaction after sulfonamide antibiotic exposure, 1.6% had an allergic reaction after administration of a non-antibiotic sulfonamide derivative (adjusted odds ratio 2.8; 95% CI, 2.1 to 3.7).[32382] A causal relationship between sulfonamide hypersensitivity and allergic reactions with non-arylamine sulfonamide derivatives has not been definitively established and remains controversial.[23511] [26922] [32380] [32381] In general, patients with a documented sulfonamide allergy are considered to be predisposed for development of allergic drug reactions.[32380] [32382] Also, patients with a history of sulfonamide hypersensitivity or penicillin hypersensitivity who receive hydrochlorothiazide may also be at increased risk for the development of an idiosyncratic reaction resulting in transient myopia and acute angle-closure glaucoma. Discontinue hydrochlorothiazide promptly if this reaction occurs.[42865]

Losartan; hydrochlorothiazide is contraindicated in patients with anuria since thiazide diuretics are considered ineffective when the creatinine clearance is less than 30 ml/minute. Hydrochlorothiazide should be used cautiously in patients with renal disease resulting in renal failure or severe renal impairment because the drug decreases the glomerular filtration rate and may precipitate azotemia in these patients. Losartan should be used with caution in patients whose renal function is critically dependent on the activity of the renin-angiotensin-aldosterone system (RAS) (e.g., patients with heart failure). Changes in renal function have been reported in susceptible individuals receiving losartan, with these changes reversible upon discontinuation of therapy in some patients. Angiotensin converting enzyme inhibitors (ACEIs) and angiotensin II receptor antagonists affect the RAS system and have caused increases in serum creatinine in susceptible individuals. Although serum creatinine returns to baseline or stabilizes in most patients with continued use, oliguria, progressive azotemia, and rarely, acute renal failure have occurred. In addition, ACEIs have been associated with azotemia in patients with unilateral or bilateral renal artery stenosis. Although losartan has not been studied in renal artery stenosis, similar effects to the ACEIs might be anticipated due to losartan's pharmacology. Renal function should be monitored in patients receiving losartan; hydrochlorothiazide.

Losartan; hydrochlorothiazide is not recommended for titration in patients with hepatic impairment since the appropriate 25 mg starting dose of losartan cannot be administered. Losartan requires dosage adjustment in patients with hepatic disease. Patients with mild to moderate alcoholic cirrhosis demonstrated significantly increased losartan and active metabolite plasma concentrations which were 5 and 1.7 times higher, respectively, compared to normal subjects. Hydrochlorothiazide should be used with caution in patients with hepatic disease since minor alterations of fluid and electrolyte balance may precipitate hepatic coma.

Losartan; hydrochlorothiazide should be used with caution in patients who have hypovolemia. Intravascular volume depletion increases the risk of symptomatic hypotension during therapy. When initiating therapy in these patients, lower doses are recommended. Losartan; hydrochlorothiazide should be used with great care in patients who exhibit signs of hypotension. Volume depletion should be corrected prior to the administration of losartan; hydrochlorothiazide. Orthostatic hypotension may occur during treatment with thiazide diuretics.[32529] Orthostatic hypotension can be exacerbated by concurrent use of alcohol, narcotics, or antihypertensive drugs. Excessive hypotension during thiazide diuretic therapy can result in syncope. An increased risk of falls has been reported for elderly patients receiving thiazide diuretics.[32527] [32528] In addition, the antihypertensive effects of thiazides may be enhanced in other patients predisposed for orthostatic hypotension, including the post-sympathectomy patient.

Angioedema has been reported with angiotensin II receptor antagonists, including losartan.[32325] [32328] [32329] [32333] Theoretically, angiotensin II receptor antagonists should be less likely than angiotensin converting enzyme inhibitors (ACEIs) to precipitate angioedema because angiotensin II receptor antagonists do not cause accumulation of kinins.[32325] However, angioedema (swelling of lips and eyelids, facial rash) has rarely been reported in patients receiving angiotensin II receptor antagonists, including in patients with a prior history of ACE inhibitor induced angioedema. While angiotensin II receptor antagonists have been suggested as potential alternatives to ACE inhibitors for patients who experience angioedema due to a lower frequency of associated angioedema [32325] [32327], the safety of angiotensin II receptor antagonists in patients with a prior history of ACE inhibitor induced angioedema has not been definitively established.[32326] [32328] [32329] [32330] It is prudent to use substantial caution when prescribing losartan; hydrochlorothiazide in patients with a history of ACE inhibitor induced angioedema. Some authors have recommended that angiotensin II receptor antagonists should be avoided in patients with a history of angioedema, especially those with ACE inhibitor induced angioedema.[32331] Anaphylactic reactions, which can present as respiratory distress (including pneumonitis and pulmonary edema), have been reported with postmarketing use of losartan; hydrochlorothiazide.[32333]

In patients undergoing major surgery or during anesthesia with agents that lower blood pressure, losartan may enhance hypotensive effects via angiotensin II blockade. Therefore, losartan; hydrochlorothiazide should be used with caution prior to surgery. If hypotension occurs during surgery and/or anesthesia and is considered to be due to blockade of angiotensin II formation, it can be corrected by volume expansion.

Once pregnancy is detected, discontinue losartan; hydrochlorothiazide as soon as possible. Use of medications that affect the renin-angiotensin system (e.g., ACE inhibitors, angiotensin II receptor antagonists) are generally not recommended for use during pregnancy due to the risk of injury or death to the developing fetus.[32333] [63903] [65551] [68837] [68860] When used during the second and third trimesters, medications that affect the renin-angiotensin system reduce fetal renal function and increase fetal and neonatal morbidity and death. Individuals of child-bearing age should be made aware of the potential risk, and losartan; hydrochlorothiazide should only be given after careful counseling and consideration of individual risks and benefits. Use of medications that affect the renin-angiotensin system during pregnancy can cause fetal death or injury such as hypotension, neonatal skull hypoplasia, craniofacial deformation, fetal limb contractures, hypoplastic lung development, anuria, fetal growth restriction, and reversible or irreversible renal failure. Anhydramnios and oligohydramnios have also been reported. Development of oligohydramnios may be associated with fetal lung hypoplasia and skeletal deformations.[32333] [63903] [65551] [68837] [68860] Use of medications that affect the renin-angiotensin system during the first trimester of pregnancy may increase the risk of fetal harm, such as congenital malformations; however, available data are conflicting.[32294] [46406] [64367] [71327] [71329] Thiazide diuretics have been reported to cross the placenta. The pregnancy risk factor for thiazide diuretics increases for those pregnant patients with reduced uteroplacental perfusion (e.g., preeclampsia or intrauterine growth retardation (IUGR)).[30735] [30736] In general, evidence does not indicate that thiazide diuretics are teratogenic in the first trimester; however, many experts limit their use to the second and third trimesters.[30736] Neonatal thrombocytopenia has been reported following maternal use of thiazide diuretics near term. Potential risks from thiazide use include electrolyte imbalances in the newborn, pancreatitis, jaundice, or neonatal complications resulting from such maternal complications such as hyperglycemia, electrolyte imbalance, or hypotension. Thiazide diuretics should be used during pregnancy only if clearly needed.[41497] In rare cases when another antihypertensive agent cannot be used to treat a pregnant patient, serial ultrasound examinations should be performed to assess the intra-amniotic environment. If oligohydramnios is observed, discontinue losartan; hydrochlorothiazide unless it is considered life-saving for the mother. Oligohydramnios may not appear until after the fetus has sustained irreversible injury. Closely observe neonates with histories of in utero exposure to losartan; hydrochlorothiazide for hypotension, oliguria, and hyperkalemia. If oliguria or hypotension occurs, blood pressure and renal perfusion support may be required, as well as exchange transfusion or dialysis to reverse hypotension and/or support decreased renal function.[32333]

Patients with pre-existing significant hyponatremia, hyperkalemia, hypokalemia, hypomagnesemia, and/or hypercalcemia should have their electrolyte imbalances corrected before losartan; hydrochlorothiazide is initiated. Thiazide diuretics such as hydrochlorothiazide have been shown to increase the urinary excretion of magnesium and decrease urinary calcium excretion. Losartan; hydrochlorothiazide may reduce, elevate or leave potassium levels unchanged in individual patients. All patients should be monitored closely for clinical signs of fluid or electrolyte imbalance. Thiazides may worsen dilutional hyponatremia, especially in elderly individuals. Greater sensitivity to the usual dosage of hydrochlorothiazide may occur in some elderly patients. In general, drug dose selection for an elderly patient should be cautious, usually starting at the low end of the adult dosage range. Losartan and active metabolite plasma concentrations are similar in elderly and younger hypertensive adults. Plasma losartan concentrations are about twice as high in females versus males, but the plasma concentrations of the active metabolite are unchanged. However, blood pressure responses to losartan are similar, regardless of age or gender.

Use losartan; hydrochlorothiazide with caution in breast-feeding patients. It is not known whether losartan is excreted into human breast milk.[70364] [70365] [32333] Due to low levels in breast milk, guidelines generally consider captopril and enalapril to be compatible with breast-feeding unless high doses are required.[63903] [68837] In addition, benazepril and quinapril are excreted in low quantities into breast milk and have been suggested as options during breast-feeding.[65551] [68835] [68836] Hydrochlorothiazide distributes into breast milk at low quantities and is usually considered compatible with breast-feeding.[70364] [70365] High hydrochlorothiazide dosages (100 mg to 150 mg/day) have been used to suppress lactation. Suppression of lactation has not been reported with hydrochlorothiazide doses of 50 mg or less.[63903] [65551] [68835] [68836] [68860]

Safety and effectiveness of losartan; hydrochlorothiazide have not been established in neonates, infants, and children less than 18 years old.

Losartan; hydrochlorothiazide is contraindicated for use in patients with diabetes when coadministered with certain medications, which includes aliskiren-containing medications. Hyperglycemia or impaired glucose tolerance can occur during hydrochlorothiazide therapy. In patients with diabetes mellitus who are receiving losartan; hydrochlorothiazide, blood glucose levels should be monitored frequently. Adjustment of insulin and/or oral hypoglycemic agents may be required.[32333]

Thiazide diuretics have been reported to cause pancreatitis. Losartan; hydrochlorothiazide should be used with caution in patients with a history of pancreatitis.

Losartan; hydrochlorothiazide should be administered cautiously to patients with gout or hyperuricemia since thiazide diuretics such as hydrochlorothiazide have been reported to reduce the clearance of uric acid.

Hydrochlorothiazide has been reported to activate or exacerbate systemic lupus erythematosus (SLE).

Instruct patients taking hydrochlorothiazide to avoid excessive sunlight (UV) exposure and undergo regular skin cancer screening. Hydrochlorothiazide has been associated with an increased risk of non-melanoma skin cancer. An FDA Sentinel Initiative study found that increased risk was mostly for squamous cell carcinoma and in White patients taking large cumulative doses. The increased risk for the overall population was approximately 1 additional case per 16,000 patients per year. For White patients taking a cumulative dose more than 50,000 mg, the risk increased to approximately 1 additional case per 6,700 patients per year.[32333] Photosensitivity has also been reported with thiazide diuretics like hydrochlorothiazide; discontinue if phototoxicity occurs.[30713]

No overall differences in effectiveness were observed between geriatric and younger adults during clinical trials of losartan; hydrochlorothiazide; reported adverse events were somewhat more frequent in the geriatric vs. younger adult patients for both treatment and control groups. Greater sensitivity to the usual dosage of hydrochlorothiazide or losartan may occur in some geriatric patients, and care should be taken in initial dose selection, usually starting at the low end of the usual adult dose range.[32333] Thiazides may worsen dilutional hyponatremia, especially in geriatric individuals. An increased risk of falls has been reported for older adults receiving thiazide diuretics. Monitor renal function and for clinical signs of acid/base, fluid, or electrolyte imbalances.[32527] [32528] According to the Beers Criteria, diuretics such as hydrochlorothiazide are considered potentially inappropriate medications (PIMs) in geriatric adults and should be used with caution due to the potential for causing or exacerbating SIADH or hyponatremia. Sodium levels should be closely monitored when starting or changing dosages of diuretics.[63923]