From the Guidelines
Amlodipine can potentially cause falls in elderly patients due to orthostatic hypotension, and it is recommended to test for orthostatic hypotension before starting or intensifying BP-lowering medication, especially in very old and frail patients. Amlodipine, a calcium channel blocker commonly prescribed for hypertension and angina, works by relaxing blood vessels, which can sometimes lead to excessive blood pressure lowering when changing positions. Elderly patients are particularly vulnerable to this side effect due to age-related changes in blood pressure regulation, decreased baroreceptor sensitivity, and reduced autonomic nervous system function, as noted in studies such as 1 and 1. The risk is typically highest during the initial treatment period or after dose increases. Orthostatic hypotension manifests as dizziness, lightheadedness, or unsteadiness when standing up, which can directly contribute to falls.
To minimize this risk, the 2024 ESC guidelines for the management of elevated blood pressure and hypertension recommend maintaining BP-lowering drug treatment lifelong, even beyond the age of 85 years, if well tolerated, and pursuing non-pharmacological approaches as the first-line treatment of orthostatic hypotension among persons with supine hypertension 1. It is also recommended to switch BP-lowering medications that worsen orthostatic hypotension to an alternative BP-lowering therapy and not to simply de-intensify therapy. Patients should be advised to change positions slowly, especially when getting up from lying or sitting positions, stay well-hydrated, and report any dizziness symptoms promptly. Healthcare providers should regularly assess for orthostatic changes in blood pressure during follow-up visits, particularly in the first few weeks of treatment, as suggested by studies such as 1 and 1.
Some key points to consider when prescribing amlodipine to elderly patients include:
- Starting with lower doses (typically 2.5 mg daily instead of 5 mg) and gradually increasing as needed
- Regularly assessing for orthostatic changes in blood pressure
- Advising patients to change positions slowly and stay well-hydrated
- Considering alternative BP-lowering therapies if orthostatic hypotension is a concern
- Prioritizing non-pharmacological approaches for managing orthostatic hypotension in patients with supine hypertension, as recommended by 1.
From the FDA Drug Label
Elderly patients have decreased clearance of amlodipine with a resulting increase of AUC of approximately 40 to 60%, and a lower initial dose may be required [see Dosage and Administration (2.1)].
Amlodipine may cause falls in the elderly due to orthostatic hypotension, as elderly patients have decreased clearance of the drug, leading to increased levels in the body.
- Key factors to consider:
- Decreased hepatic, renal, or cardiac function
- Concomitant disease or other drug therapy
- Increased AUC of approximately 40 to 60% It is recommended to start with a lower initial dose in elderly patients to minimize the risk of falls and other adverse effects 2.
From the Research
Amlodipine and Falls in the Elderly
- Amlodipine, a calcium channel blocker, has been studied for its potential to cause falls in the elderly due to orthostatic hypotension.
- According to a study published in 2019 3, amlodipine increased the risk of falls during the first year of follow-up compared with chlorthalidone or lisinopril.
- The study found that the choice of antihypertensive agent had no effect on the risk of fall, syncope, or orthostatic hypotension long-term, but amlodipine increased the risk of falls within 1 year of initiation.
Orthostatic Hypotension and Antihypertensive Treatment
- Orthostatic hypotension is a marker of poor prognosis in older and middle-aged patients, and it should be primarily sought at diagnosis of hypertension, at therapeutic modification, and when suspected by symptoms 4.
- Antihypertensive treatment in older patients should be initiated with low dosages and subsequent dose titration, and should not be associated with medications that have the potential to induce orthostatic hypotension 4.
- A review article published in 2015 5 suggests a dose-dependent relationship between blood pressure lowering therapy and falls among older individuals with preexisting risk factors for falls.
Drug-Induced Orthostatic Hypotension
- Drug-induced orthostatic hypotension is an important clinical problem, especially in the elderly, and can be caused by various medications, including calcium channel blockers, beta-blockers, and ACE inhibitors 6, 7.
- Changing pharmacokinetics in the elderly can result in a delayed elimination and/or a greater bioavailability of these drugs, leading to a more pronounced effect and an increased risk of orthostatic hypotension 6.