What is the plan for a 43-year-old patient with hypertension, currently taking amlodipine (calcium channel blocker) 5 mg for 1 month, presenting with elevated blood pressure (hypertension) of 150/85 mmHg?

From the Guidelines

The patient's amlodipine dose should be increased to 10 mg daily to achieve better blood pressure control, as the current dose of 5 mg has not adequately controlled the patient's blood pressure after one month of treatment. This decision is based on the guidelines for managing hypertension, which suggest that the initial dose of a drug should be at least half of the maximum recommended dose, so that only one up-titration is required to reach the maximum recommended level 1. The patient's blood pressure of 150/85 mmHg remains above the target goal of <140/90 mmHg, indicating that the current dose is insufficient for adequate control.

Some key points to consider in the management of this patient's hypertension include:

• The importance of lifestyle modifications, such as sodium restriction, regular physical activity, weight management, and limiting alcohol consumption, which can enhance the effectiveness of antihypertensive medications.
• The need for regular follow-up blood pressure checks, with a recommended timeframe of every 2-4 weeks to assess the effectiveness of the dose adjustment 1.
• The potential for adding a second antihypertensive agent from a different class, such as an ACE inhibitor or ARB, if blood pressure remains uncontrolled on maximum-dose amlodipine.
• The consideration of combining ACEI/ARB with a CCB and a diuretic when three drugs are required to achieve BP control, as recommended by several guidelines 1.

It is also important to note that the diagnosis of resistant hypertension should be based on accurate office BP measurements, and that contributing lifestyle factors should be identified and addressed 1. Additionally, the use of substances that interfere with antihypertensive therapy, such as nonsteroidal anti-inflammatory drugs, stimulants, and oral contraceptives, should be discontinued or minimized 1.

In terms of specific treatment options, the guidelines suggest that amlodipine can be safely titrated up to 10 mg daily, which is the maximum recommended dose for this calcium channel blocker. The patient should be instructed to take the medication consistently at the same time each day, preferably in the morning. After increasing the dose, the patient should return for a follow-up blood pressure check in 2-4 weeks to assess the effectiveness of the dose adjustment. If blood pressure remains uncontrolled on maximum-dose amlodipine, adding a second antihypertensive agent from a different class (such as an ACE inhibitor or ARB) would be the next step.

From the FDA Drug Label

2 DOSAGE & ADMINISTRATION 2.1 Adults The usual initial antihypertensive oral dose of Amlodipine besylate tablets is 5 mg once daily, and the maximum dose is 10 mg once daily.

Adjust dosage according to blood pressure goals. In general, wait 7 to 14 days between titration steps.

The patient's blood pressure is 150/85, which is not adequately controlled.

• The current dose is 5 mg once daily, which is the initial antihypertensive oral dose.
• The maximum dose is 10 mg once daily. The plan is to adjust the dosage of amlodipine according to blood pressure goals, considering an increase to 10 mg once daily, as the patient's blood pressure is not adequately controlled on the current dose of 5 mg once daily 2.

From the Research

Patient's Current Situation

• The patient is 43 years old and hypertensive, currently using amlodipine 5 mg for 1 month.
• The patient's blood pressure is now 150/85 mmHg, indicating that the current treatment may not be sufficient to control blood pressure.

Possible Next Steps

• According to the study 3, when monotherapy with amlodipine 5 mg is inadequate, the next step could be to either increase the dose to 10 mg or add another antihypertensive agent, such as valsartan.
• The study 3 found that the combination of amlodipine 5 mg and valsartan 160 mg was more efficacious than increasing the dose of amlodipine to 10 mg in patients with inadequate response to amlodipine 5 mg monotherapy.
• Another option could be to add amlodipine to another antihypertensive agent, such as quinapril or losartan, as shown in the study 4, which found that adding amlodipine 5 mg to quinapril or losartan monotherapy significantly reduced blood pressure in patients with hypertension and diabetes.

Increasing Amlodipine Dose

• The study 5 found that increasing the dose of amlodipine from 5 mg to 10 mg significantly reduced blood pressure in diabetic patients with hypertension, with a mean reduction of 12.5 mmHg in systolic blood pressure and 6.0 mmHg in diastolic blood pressure.
• However, the study 3 suggests that increasing the dose of amlodipine to 10 mg may not be as effective as adding another antihypertensive agent, such as valsartan.

Combination Therapy

• The study 6 found that the fixed-dose combination of irbesartan 150 mg and amlodipine 5 mg was more efficacious than amlodipine 5 mg monotherapy in lowering systolic blood pressure in patients with essential hypertension.
• The study 4 also found that adding amlodipine to quinapril or losartan monotherapy was effective in reducing blood pressure in patients with hypertension and diabetes.