Starting Dose for Amlodipine
Start with amlodipine 5 mg once daily in most adults with hypertension. This is the standard initial dose recommended by FDA labeling and supported by international guidelines 1.
Dosing Algorithm
Standard Starting Dose: 5 mg Daily
For the majority of hypertensive patients, 5 mg once daily is the appropriate starting dose 1. This applies to:
- Adults with uncomplicated hypertension
- Most patients requiring a calcium channel blocker as first-line or add-on therapy
- Black patients (where CCBs are preferred first-line agents) 2, 3
Wait 7-14 days before considering dose titration to allow adequate time to assess response 1. Clinical trials demonstrate that early dose escalation (at 2 weeks) provides no advantage over maintaining 5 mg for 6 weeks before increasing 4.
Lower Starting Dose: 2.5 mg Daily
Start with 2.5 mg once daily in patients who are 1:
- Small or fragile in body habitus
- Elderly (age >65-80 years)
- Hepatic insufficiency (any degree of liver dysfunction)
- Being added to existing antihypertensive therapy where additional BP lowering may cause hypotension
The 2.5 mg starting dose is particularly important in elderly patients, where guidelines emphasize individualization based on frailty 2. Women also tend to achieve higher drug concentrations and may experience more dose-related side effects like peripheral edema 5, 1, 6.
When to Consider 10 mg
Never start at 10 mg. The 10 mg dose is reserved for:
- Titration after 7-14 days if BP remains uncontrolled on 5 mg 1
- Patients with chronic stable angina who require maximal anti-anginal effect (though most respond to 5 mg) 1
- Coronary artery disease patients, where most require 10 mg for adequate effect 1
Key Clinical Considerations
Pharmacokinetic factors that increase amlodipine exposure (and support lower starting doses) include 6:
- Female sex (higher concentrations at same dose)
- Advanced age (increased drug levels)
- Reduced kidney function (elevated concentrations)
- CYP3A4*22 genetic variant (reduced metabolism)
Common pitfalls to avoid:
- Starting at 10 mg increases risk of dose-dependent peripheral edema (occurs in 10.8% at 10 mg vs 3% at 5 mg) 1
- Escalating dose before 7 days doesn't improve BP control but increases side effects 1, 4
- Gingival hyperplasia risk increases substantially at 10 mg dosing 7
The 5 mg starting dose provides effective 24-hour BP control with once-daily dosing due to amlodipine's long half-life, maintaining therapeutic levels throughout the dosing interval 8, 9. This gradual absorption profile minimizes reflex tachycardia and headache compared to shorter-acting calcium channel blockers 10.
For pediatric patients (ages 6-17), start with 2.5 mg once daily, with maximum dose of 5 mg daily 1.