What is the recommended dosage and treatment regimen for Amlodipine (calcium channel blocker) in patients with hypertension or coronary artery disease?

Amlodipine Dosage and Treatment Regimen for Hypertension and Coronary Artery Disease

For patients with hypertension or coronary artery disease, amlodipine should be initiated at 5 mg once daily, with titration to 10 mg once daily if necessary for adequate blood pressure control or symptom management. 1, 2

Initial Dosing

Hypertension

• Standard initial dose: 5 mg once daily 1
• Special populations: 2.5 mg once daily for:
  • Elderly patients
  • Fragile patients
  • Patients with hepatic insufficiency
  • When adding to other antihypertensive therapy 1

Coronary Artery Disease

• Stable or vasospastic angina: 5-10 mg once daily 1
• Documented CAD: 5-10 mg once daily (majority of patients require 10 mg for optimal effect) 1

Dose Titration Protocol

1. Start with recommended initial dose
2. Wait 7-14 days between titration steps 1
3. May titrate more rapidly if clinically warranted, with frequent patient assessment
4. Maximum dose: 10 mg once daily 1

Efficacy Considerations

• Target blood pressure for hypertension: <130/80 mmHg 3
• For angina, 10 mg dose increases exercise time by approximately 12.8% (63 sec) compared to 7.9% (38 sec) for 5 mg dose 1
• Amlodipine 10 mg has been shown to:
  • Increase time to 1 mm ST segment depression
  • Decrease angina attack rate 1
  • Reduce hospitalizations for angina by 42% compared to placebo 1

Place in Therapy

Hypertension

• Amlodipine is a first-line therapy option as a dihydropyridine calcium channel blocker 2
• Can be used as monotherapy or in combination therapy
• Preferred combinations include a RAS blocker (ACE inhibitor or ARB) with amlodipine 3, 2
• For patients with confirmed BP ≥150/90 mmHg, initial therapy with two drugs or a single-pill combination is recommended 3

Coronary Artery Disease

• For stable angina, beta-blockers are preferred first-line, with amlodipine as an alternative when beta-blockers cannot be used 2
• Adding amlodipine to beta-blocker therapy is recommended when symptoms persist 2
• In vasospastic angina, amlodipine decreases attacks by approximately 4/week compared to placebo 1

Special Populations

Pediatric Patients

• For ages 6-17 years: 2.5-5 mg once daily 1
• Doses above 5 mg have not been studied in pediatric patients 1

Heart Failure Patients

• Safe to use in patients with NYHA Class II/III heart failure 1
• No evidence of worsened heart failure in clinical trials 1
• Unlike non-dihydropyridine CCBs (diltiazem, verapamil), amlodipine can be used in patients with left ventricular dysfunction 3

Common Side Effects and Monitoring

• Peripheral edema (most common)
• Headache
• Flushing
• Dizziness 2

Clinical Pearls

1. Once-daily dosing improves adherence compared to multiple daily dosing regimens 2
2. Timing flexibility: Amlodipine can be taken at any time of day due to its long half-life 2
3. Combination therapy: Fixed-dose single-pill combinations improve adherence 2
4. Avoid rapid dose escalation: Early dose increases (before 6 weeks) show no advantage in antihypertensive effect 4
5. 24-hour coverage: Amlodipine effectively reduces blood pressure throughout the entire 24-hour period while maintaining normal circadian patterns 5

Common Pitfalls to Avoid

1. Premature dose escalation: Consider waiting 6 weeks before increasing from 5 mg to 10 mg, as early dose increases may not provide additional benefit 4
2. Overlooking edema management: Peripheral edema is dose-dependent and may require dose reduction rather than diuretic addition
3. Drug interactions: While generally safe with beta-blockers, be cautious with concomitant CYP3A4 inhibitors which may increase amlodipine levels
4. Inadequate follow-up: Monitor blood pressure response 7-14 days after initiation or dose changes 1

Amlodipine's smooth, dose-dependent blood pressure reduction and convenient once-daily dosing make it an excellent choice for both hypertension and coronary artery disease management when used at appropriate doses.