---

Telmisartan Pediatric Dose Calculation

Regulatory Status

---

Recommended Pediatric Dose

• Minimum weight threshold: Generally ≥20 kg body weight (to allow for practical tablet dosing)
• Route: Oral, once daily
• Age range studied: 6 to <18 years; data are limited for <12 years

---

Dose Calculation Example

---

Dose Titration

• Start at the lower weight-based dose (1 mg/kg/day)
• Assess BP response after 2–4 weeks
• Titrate up to 2 mg/kg/day if needed, not exceeding 80 mg/day (the adult maximum)
• Dosage adjustments should be made at weekly to biweekly intervals

---

Pharmacokinetic Notes (Pediatric Relevance)

• Telmisartan has a long half-life (~24 hours), supporting once-daily dosing
• Women and likely adolescent girls may achieve plasma levels 2–3× higher than males, but this does not necessarily correlate with greater BP response
• Primarily eliminated via biliary/fecal route — no renal dose adjustment needed
• Not dialyzable
• Hepatic impairment: use with caution; reduce or avoid in significant hepatic disease

---

Key Comparator: Available ARB Pediatric Doses

---

Clinical Cautions in Children

• Contraindicated with aliskiren in children with diabetes (as in adults)
• Avoid in pregnancy (teratogenic — Category D/X)
• Monitor serum potassium and renal function at initiation and after dose changes
• Telmisartan is not available as a liquid formulation — this limits use in younger or smaller children who cannot swallow tablets

---

Summary

Telmisartan in children (6–<18 years): Start at 1 mg/kg/day once daily (round to nearest available tablet strength: 20, 40, or 80 mg). Titrate to 2 mg/kg/day as needed. Do not exceed 80 mg/day. Use with caution in children under 12 due to limited data.

---

Normal Pediatric Blood Pressure

Key Concept: BP is Age-, Sex-, and Height-Dependent

---

Quick Estimation Formulas (≥1 Year)

Example: 6-year-old → Average SBP = (6×2) + 90 = 102 mmHg; lower limit = (6×2) + 70 = 82 mmHg

---

Normal BP by Age Group (Average Values)

---

Minimum Acceptable SBP (5th Percentile — Shock Threshold)

---

BP Classification in Children (AAP 2017 / Fourth Report)

Diagnosis requires elevated readings on ≥3 separate occasions.

---

Newborn/Infant Reference (Averaged by Age)

---

Practical Points

• Cuff size matters: Bladder should cover ~80% of arm circumference and ~40% of arm length. A cuff too small → falsely high BP; too large → falsely low.
• Measure in right upper arm, sitting, after 5 minutes of rest
• In suspected coarctation of aorta: measure BP in all 4 limbs — lower leg BPs indicate coarctation
• Children maintain normal BP even with 30–40% volume loss due to high vascular tone — tachycardia and poor perfusion are earlier signs of shock than hypotension
• Ambulatory BP monitoring (ABPM) is the gold standard; masked hypertension (normal office, elevated 24-hr) occurs in up to 35% of children with CKD

---

For Precise Percentile Lookup

---

Management of Hypertension in Pediatric Patients

---

Step 1 — Confirm the Diagnosis

• BP must be elevated on ≥3 separate occasions
• Use correct cuff size (bladder ~80% of arm circumference)
• Rule out white coat hypertension (up to 25% of office-elevated BPs) — use 24-hr Ambulatory BP Monitoring (ABPM)
• Rule out masked hypertension (normal office BP but elevated on ABPM) — common in CKD children (~35%)

---

BP Classification (AAP 2017)

---

Step 2 — Identify the Cause (Secondary vs. Primary)

---

Step 3 — Initial Work-Up

• Urinalysis, electrolytes, BUN, creatinine, lipid profile
• Renal ultrasound (if UA or renal function abnormal, or age <6 yr)
• Do NOT routinely do renal US in children >6 yr with normal renal function

• Renin, aldosterone (renovascular/adrenal causes)
• Urine/plasma catecholamines (pheochromocytoma)
• Cortisol (Cushing syndrome)
• Advanced imaging: CT angiography, MRA, renal scintigraphy (DMSA) as indicated

• Recommended at initiation of pharmacologic therapy (assess for LVH, end-organ damage)
• Not required as part of initial screening

---

Step 4 — Management Algorithm

Elevated BP / Stage 1 HTN (asymptomatic, no end-organ damage)
        ↓
THERAPEUTIC LIFESTYLE CHANGES (TLC) × 3–6 months
        ↓ (if no improvement or Stage 2 / symptomatic / secondary HTN)
PHARMACOLOGIC THERAPY
        ↓ (if BP >30 mmHg above 95th %ile, or symptomatic)
INPATIENT MANAGEMENT
        ↓ (end-organ damage: encephalopathy, AKI, heart failure)
HYPERTENSIVE EMERGENCY — IV therapy

---

Lifestyle Modifications (First-line for Elevated BP & Stage 1 HTN)

• DASH diet (low sodium, high fruits/vegetables, low-fat dairy) — proven to lower BP in children
• Weight loss — especially in obese children with primary HTN
• Aerobic exercise — ≥60 min/day of moderate-vigorous activity
• Reduce screen time, improve sleep
• Stress reduction

---

Pharmacologic Therapy

• Stage 1 HTN not improved after TLC trial
• Stage 2 HTN
• Symptomatic HTN
• Secondary HTN (e.g., renal disease)
• End-organ damage (LVH, microalbuminuria)

First-Line Oral Antihypertensive Agents

• CKD / Glomerulonephritis / Proteinuria: → ACE inhibitor or ARB first (renoprotective)
• Diabetes mellitus: → RAAS inhibition (delays diabetic nephropathy)
• Asthma: → Avoid beta-blockers
• Obesity / Essential HTN: → Any first-line agent; lifestyle modification essential
• If single agent insufficient: Add a loop diuretic (furosemide 2–4 mg/kg/day), then amlodipine

---

Treatment Targets (BP Goals)

---

Hypertensive Urgency vs. Emergency

Do NOT reduce BP too rapidly — overly aggressive lowering risks cerebral hypoperfusion and watershed infarcts.

---

Monitoring After Starting Therapy

• BP checks at 2–4 weeks after initiation
• Electrolytes and renal function at 1–2 weeks and again at 3 months
• ABPM at least annually (especially in CKD); repeat within 1–2 months of therapy change
• Counsel sexually active adolescents: ACE inhibitors and ARBs are teratogenic — contraception counseling required

---

Key Points

1. Primary (essential) HTN now the most common cause in obese children >6 yr
2. TLC is always first-line for Stage 1 HTN without end-organ damage
3. Drug choice should be individualized by comorbidity (CKD → RAAS; asthma → avoid β-blockers)
4. Many adult antihypertensives lack liquid formulations — limits use in young children
5. Inpatient management for BP >30 mmHg above 95th %ile or symptomatic Stage 2 HTN
6. Hypertensive emergency → IV therapy, 25% BP reduction in 8 hrs