When is Norvasc (amlodipine) used to treat high blood pressure and angina?

When to Use Norvasc (Amlodipine)

Norvasc (amlodipine) should be used as a first-line treatment for hypertension in most patients, and as a second-line agent for angina when beta-blockers cannot be tolerated or as an add-on therapy when angina persists despite beta-blocker treatment.

Indications for Amlodipine in Hypertension

Amlodipine is indicated for the treatment of hypertension with the following considerations:

• Initial therapy: 5 mg once daily for most patients, with titration to 10 mg once daily if necessary for adequate blood pressure control 1
• Lower starting dose: 2.5 mg once daily for elderly patients, those with hepatic insufficiency, or when adding to other antihypertensive therapy 1
• Target blood pressure:
  • General target: <140/90 mmHg
  • For patients with CAD, diabetes, chronic kidney disease, or CAD risk equivalents: <130/80 mmHg 2, 1

Indications for Amlodipine in Angina

For patients with angina pectoris, amlodipine should be used according to this algorithm:

Step 1: First-line therapy

• Beta-blockers are the preferred first-line treatment for angina due to their benefits in reducing heart failure hospitalization and mortality risk 2

Step 2: When beta-blockers cannot be used

• Amlodipine should be considered in patients unable to tolerate a beta-blocker to relieve angina (Class IIa recommendation, Level of Evidence A) 2
• Other alternatives include ivabradine or nitrates, but amlodipine has proven efficacy and safety in heart failure patients 2

Step 3: Add-on therapy

• When angina persists despite beta-blocker treatment, amlodipine should be added as a second anti-anginal drug (Class I recommendation, Level of Evidence A) 2
• Amlodipine is effective for both exertional and vasospastic angina 3, 4

Special Considerations

Heart Failure Patients

• Amlodipine is one of the few calcium channel blockers that can be safely used in patients with heart failure and angina 2
• Important distinction: Non-dihydropyridine CCBs (diltiazem, verapamil) should NOT be used in heart failure patients due to their negative inotropic effects and risk of worsening heart failure 2

Combination Therapy

• Amlodipine can be added to the basic regimen of beta-blocker, ACE inhibitor, and thiazide diuretic if either angina or hypertension remains uncontrolled 2, 1
• The combination of amlodipine with beta-blockers is safe and effective, unlike the combination of beta-blockers with non-dihydropyridine CCBs 2

Dosing and Administration

• Starting dose: 5 mg once daily 1, 5
• Maximum dose: 10 mg once daily 5
• Can be taken with or without food 5
• Once-daily dosing provides 24-hour efficacy for both hypertension and angina 3, 4

Advantages of Amlodipine

• Long half-life allows for once-daily dosing, improving adherence 6, 7
• Does not cause tolerance or rebound phenomena, unlike nitrates 6
• Effectively treats both hypertension and angina, reducing polypharmacy 6
• Gradual onset of action reduces side effects like reflex tachycardia 3
• Safe to use with beta-blockers and other standard cardiac medications 5, 7

Common Side Effects and Monitoring

• Monitor for peripheral edema, headache, flushing, and dizziness 1, 5
• Check blood pressure response 7-14 days after initiation or dose changes 1
• Watch for hypotension, particularly in elderly patients or those on multiple antihypertensive medications 1

By following these guidelines, amlodipine can be effectively used to manage hypertension and angina while minimizing risks and maximizing benefits for patient outcomes.