What Amlodipine regimen is appropriate for replacing lisinopril and Zestoretic (lisinopril and hydrochlorothiazide) in a patient with hypertension?

From the Guidelines

Amlodipine 5 mg once daily, titrated up to 10 mg daily if needed after 2-4 weeks, is an appropriate regimen to replace lisinopril and Zestoretic (lisinopril and hydrochlorothiazide) in a patient with hypertension.

Rationale

• The 2018 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults recommends amlodipine as a primary agent for the treatment of hypertension 1.
• The guideline suggests a usual dose range of 2.5-10 mg/d for amlodipine, with a daily frequency of 1 1.
• When switching from an ACE inhibitor (lisinopril) to a calcium channel blocker (amlodipine), it is essential to allow a washout period of 36-48 hours between the last dose of lisinopril and the first dose of amlodipine to avoid potential hypotension.
• Amlodipine works by blocking calcium channels in vascular smooth muscle, leading to vasodilation and reduced blood pressure, which is a different mechanism than ACE inhibitors, and may help control blood pressure in patients who didn't achieve full control with lisinopril alone.

Monitoring and Titration

• Start with Amlodipine 5 mg once daily, preferably in the morning.
• Monitor blood pressure closely for the first few weeks.
• If blood pressure remains above goal after 2-4 weeks, increase to 10 mg once daily.
• The maximum recommended dose is 10 mg daily.

Side Effects

• Monitor for common side effects such as peripheral edema, headache, or flushing.
• If these occur, they often improve with time.
• Advise the patient to report any significant side effects or concerns.

Key Considerations

• Amlodipine is associated with dose-related pedal edema, which is more common in women than men 1.
• Avoid use in patients with heart failure with reduced ejection fraction (HFrEF); however, amlodipine may be used if required 1.

From the FDA Drug Label

1 INDICATIONS & USAGE

1. 1 Hypertension Amlodipine besylate tablets is indicated for the treatment of hypertension, to lower blood pressure. Many patients will require more than one drug to achieve blood pressure goals. Amlodipine besylate tablets may be used alone or in combination with other antihypertensive agents.

The appropriate Amlodipine regimen for replacing lisinopril and Zestoretic (lisinopril and hydrochlorothiazide) in a patient with hypertension is to use Amlodipine alone or in combination with other antihypertensive agents. The specific dosage is not provided in the label, and it is recommended to follow published guidelines for goals and management, such as those of the National High Blood Pressure Education Program’s Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) 2.

From the Research

Amlodipine Regimen for Replacing Lisinopril and Zestoretic

• The appropriate Amlodipine regimen for replacing lisinopril and Zestoretic (lisinopril and hydrochlorothiazide) in a patient with hypertension can be determined based on the patient's response to the medication and their blood pressure goals.
• According to the study 3, amlodipine is effective in the treatment of patients with mild to moderate hypertension at doses of 5-10 mg daily.
• The study 4 also found that amlodipine treatment produced significant falls in blood pressure (-23.7/-17.3 mm Hg; p < 0.05) with no effect on heart rate, and was well tolerated, with most adverse events being mild or moderate.

Dose Titration and Combination Therapy

• The study 3 found that there is no advantage in an early increase in dosage of amlodipine in terms of antihypertensive effect, and a dose increase should not be considered until after six weeks of treatment at 5 mg once daily.
• The study 5 found that combination therapy with a calcium channel antagonist (such as amlodipine) and an inhibitor of the renin-angiotensin-aldosterone system (such as valsartan) is a rational approach to achieve blood pressure goals and provide protection against renal and cardiovascular morbidity and mortality.
• The study 6 found that a fixed-dose combination of bisoprolol and amlodipine is an effective and convenient treatment for hypertension, allowing more patients to achieve their therapeutic goals, while potentially reducing the burden of hypertension on health care systems.
• The study 7 found that high-dose amlodipine/irbesartan combination therapy is effective in controlling hypertension without elevation of serum uric acid, and may be a suitable option for patients who do not achieve their target blood pressure with standard-dose combination therapy.

Key Considerations

• When replacing lisinopril and Zestoretic with amlodipine, it is essential to monitor the patient's blood pressure closely and adjust the dose as needed to achieve optimal blood pressure control.
• Combination therapy with amlodipine and other antihypertensive medications, such as beta-blockers or diuretics, may be necessary to achieve optimal blood pressure control in some patients.
• The choice of amlodipine regimen should be individualized based on the patient's specific needs and medical history, and should be guided by evidence-based clinical guidelines and the results of clinical trials, such as those cited in 3, 5, 4, 6, 7.