What is the recommended dosage and treatment approach for patients taking amlodipine (calcium channel blocker) for hypertension or coronary artery disease?

Amlodipine Dosage and Treatment Approach for Hypertension and Coronary Artery Disease

The recommended initial dose of amlodipine for hypertension or coronary artery disease is 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 Considerations

• Standard initial dose: 5 mg once daily for most patients 2
• Lower initial dose (2.5 mg once daily) recommended for:
  • Elderly patients
  • Fragile patients
  • Patients with hepatic insufficiency
  • When adding amlodipine to other antihypertensive therapy 1, 2
• Pediatric dosing: 2.5-5 mg once daily for children ages 6-17 years 2

Dose Titration

• Wait 7-14 days between titration steps to assess blood pressure response 2
• Maximum dose is 10 mg once daily 2
• Titration may be more rapid if clinically warranted, provided the patient is assessed frequently 2
• For angina management, most patients will require 10 mg for adequate effect 2

Efficacy by Indication

Hypertension

• Amlodipine effectively reduces blood pressure throughout the entire 24-hour period while maintaining normal circadian patterns 1, 3
• Mean daytime blood pressure reductions of 18/14 mmHg and nighttime reductions of 16/10 mmHg have been observed 3

Angina

• For chronic stable or vasospastic angina, the recommended dose is 5-10 mg once daily 2
• Amlodipine 10 mg increases exercise time by approximately 12.8% (63 seconds) compared to 7.9% (38 seconds) for 5 mg 2
• In vasospastic angina, amlodipine decreases attacks by approximately 4/week compared to placebo 2

Coronary Artery Disease

• Amlodipine 5-10 mg daily reduces hospitalizations for angina by 42% and coronary revascularization procedures by 27% 2
• When combined with standard therapy (including aspirin, statins, beta-blockers), amlodipine significantly reduces cardiovascular events 2

Treatment Approach in Special Populations

Heart Failure Patients

• Unlike non-dihydropyridine CCBs, amlodipine can be safely used in patients with left ventricular dysfunction 1
• No evidence of worsened heart failure has been observed in clinical trials of patients with NYHA Class II/III heart failure 2
• For patients with hypertension and heart failure, the treatment regimen should include ACE inhibitors or ARBs, beta-blockers, and aldosterone receptor antagonists, with amlodipine added if needed for additional blood pressure control 4

Combination Therapy

• For patients with hypertension and chronic stable angina, a regimen that includes a beta-blocker (especially with prior MI) is recommended 4
• If beta-blockers are contraindicated or produce intolerable side effects, a non-dihydropyridine CCB may be substituted, but not if there is LV dysfunction 4
• If either angina or hypertension remains uncontrolled, amlodipine can be added to the basic regimen of beta-blocker, ACE inhibitor, and thiazide diuretic 4
• The combination of beta-blockers with non-dihydropyridine CCBs (diltiazem or verapamil) should be used with caution due to risk of bradyarrhythmias and heart failure 4

Blood Pressure Targets

• For patients with stable angina, the BP target is <140/90 mmHg 4
• A lower target BP (<130/80 mmHg) may be considered in some individuals with CAD, previous stroke/TIA, or CAD risk equivalents 4, 1

Monitoring and Adverse Effects

• Monitor blood pressure response 7-14 days after initiation or dose changes 1, 2
• Common adverse effects include peripheral edema, headache, flushing, and dizziness 1
• Watch for signs of hypotension, particularly within the first 1-2 weeks of therapy 1

By following these evidence-based recommendations for amlodipine dosing and treatment approach, clinicians can effectively manage hypertension and coronary artery disease while minimizing adverse effects and optimizing patient outcomes.