What are the next steps for a patient with elevated blood pressure (hypertension) on amlodipine (calcium channel blocker) 5mg with a blood pressure reading of 140/82?

Management of Hypertension with Amlodipine 5mg and BP 140/82

For a patient with a blood pressure of 140/82 mmHg on amlodipine 5mg, the next step should be to increase the dose to amlodipine 10mg once daily. 1

Assessment of Current Blood Pressure Control

The patient's current blood pressure of 140/82 mmHg falls into Stage 2 Hypertension category (≥140 mmHg systolic) according to current guidelines 2. This indicates that the current dose of amlodipine 5mg is not providing adequate blood pressure control to reach the target of <130/80 mmHg for the general population.

Medication Adjustment Algorithm

1. Increase amlodipine dose:

   • The FDA label for amlodipine clearly states that the initial antihypertensive dose is 5mg once daily, with a maximum dose of 10mg once daily 1
   • Titration should typically occur after 7-14 days if blood pressure goals are not met 1

2. Wait appropriate time before reassessing:

   • After increasing to 10mg, reassess blood pressure in 4 weeks 2
   • Some evidence suggests waiting 6 weeks before considering the dose increase ineffective 3

3. If BP remains uncontrolled after maximizing amlodipine:

   • Add a thiazide/thiazide-like diuretic (e.g., hydrochlorothiazide 12.5mg) 2
   • Alternative: add an ARB (e.g., losartan 50mg daily) 2

Evidence Supporting Dose Increase

Amlodipine has demonstrated effective 24-hour blood pressure control with once-daily dosing 4, 5. Clinical studies have shown that increasing from 5mg to 10mg provides additional antihypertensive effect for patients not adequately controlled on the lower dose 6.

The FDA-approved labeling specifically recommends dose adjustment according to blood pressure goals, with 10mg being the maximum daily dose for hypertension 1. This higher dose has been well-studied and is effective for patients requiring additional blood pressure reduction.

Monitoring Recommendations

• Measure blood pressure in both arms at follow-up visits
• Ensure proper positioning: back supported, legs uncrossed, arm at heart level 2
• Consider home blood pressure monitoring to assess treatment efficacy between office visits
• Monitor for potential side effects of increased amlodipine dose, particularly peripheral edema

Important Considerations

• If the patient is elderly or has hepatic insufficiency, a more cautious approach may be warranted, but the current 5mg dose is already appropriate for these populations 1
• If increasing to 10mg does not achieve target blood pressure, combination therapy will be the next step rather than exceeding the maximum recommended dose
• Lifestyle modifications should continue to be emphasized alongside medication adjustments, including DASH diet, sodium restriction, regular physical activity, and limiting alcohol consumption 2

By following this approach, you can systematically address the patient's elevated blood pressure while adhering to evidence-based guidelines for hypertension management.