Is lisinopril or amlodipine (calcium channel blocker) more suitable for an 89-year-old male (M) with dizziness?

Amlodipine is More Suitable for an 89-Year-Old Male with Dizziness

For an 89-year-old male with dizziness, amlodipine is more appropriate than lisinopril due to its better safety profile and lower risk of orthostatic hypotension in elderly patients. 1

Rationale for Choosing Amlodipine

Elderly-Specific Considerations

• The European Society of Hypertension (ESH) and European Society of Cardiology (ESC) guidelines specifically recommend calcium antagonists (like amlodipine) as one of the preferred agents for treating isolated systolic hypertension in elderly patients 1
• For very elderly patients (≥80 years), medication should be initiated more gradually with careful dose titration due to increased risk of adverse effects 1
• Amlodipine has a long duration of action, allowing once-daily dosing which improves compliance in elderly patients 1

Dizziness Considerations

• ACE inhibitors like lisinopril can cause or worsen postural hypotension in elderly patients, potentially exacerbating dizziness 1
• Lisinopril has a higher risk of first-dose hypotension, which can be particularly problematic in elderly patients with dizziness 1
• Amlodipine has a more gradual onset of action with less pronounced first-dose effects, making it less likely to cause acute dizziness 2

Pharmacological Properties Relevant to This Patient

Amlodipine Benefits

• Long-acting dihydropyridine calcium channel blocker with minimal effects on cardiac conduction 2
• Causes peripheral vasodilation without significant negative chronotropic effects 2
• Lower risk of orthostatic hypotension compared to ACE inhibitors in elderly patients 1
• Effective starting dose can be lower (2.5 mg) in elderly patients 3

Lisinopril Concerns

• May cause first-dose hypotension, especially in elderly or volume-depleted patients 1
• Can cause dizziness due to postural hypotension, particularly in elderly patients 1
• May cause dry cough (10-20% of patients), which can be bothersome 1

Dosing Recommendations

For Amlodipine

• Start with 2.5 mg once daily in this 89-year-old patient 3
• Studies show that low-dose amlodipine (2.5 mg) is effective and well-tolerated in elderly hypertensives 3
• Can be titrated up to 5-10 mg if needed, based on blood pressure response and tolerability 1

Monitoring Recommendations

• Measure blood pressure in both sitting and standing positions to detect orthostatic changes 1
• Monitor for peripheral edema, which is more common with amlodipine in elderly patients 1
• Check electrolytes and renal function periodically, especially if diuretics are added 1

Important Precautions

• Start with lower doses and titrate more slowly in this very elderly patient 1
• Monitor for signs of orthostatic hypotension (dizziness upon standing) 1
• If dizziness persists despite appropriate dosing, consider evaluation for other causes of dizziness (cardiac, neurological, vestibular) 2
• Avoid rapid dose escalation which may increase risk of adverse effects 1

Conclusion

For an 89-year-old male with dizziness, amlodipine starting at 2.5 mg daily is the preferred choice over lisinopril. This recommendation is based on guidelines that specifically address treatment in the very elderly and the more favorable side effect profile of amlodipine regarding dizziness and orthostatic hypotension.