What is the next step for a patient with uncontrolled asymptomatic hypertensive urgency on Amlodipine (Amlodipine) 10 milligrams?

From the Guidelines

The next step for a patient with uncontrolled asymptomatic hypertensive urgency on Amlodipine 10 milligrams is to intensify pharmacological therapy.

Rationale

• The patient is already on a single antihypertensive medication, Amlodipine, and their blood pressure is not controlled, indicating the need for adjustment of their treatment regimen 1.
• The 2024 ESC guidelines recommend starting BP-lowering treatment with a simultaneous combination of lifestyle interventions and pharmacological therapy, and intensifying treatment if blood pressure is not controlled within 3 months 1.
• The 2017 ACC/AHA guideline suggests that in adults with untreated office BPs that are consistently elevated, screening for masked hypertension with home blood pressure monitoring (HBPM) or ambulatory blood pressure monitoring (ABPM) is reasonable, but in this case, the patient is already being treated, so the focus should be on adjusting their medication regimen 1.
• The addition of a diuretic, such as chlorthalidone or indapamide, or a mineralocorticoid receptor antagonist, such as spironolactone or eplerenone, may be considered to maximize blood pressure control 1.
• The British Hypertension Society guidelines recommend increasing the dose of the current medication or adding a new medication from a different class, such as a diuretic or a beta-blocker, to achieve optimal blood pressure control 1.

Potential Next Steps

• Increase the dose of Amlodipine to 15-20 milligrams, if tolerated, to assess for improved blood pressure control.
• Add a diuretic, such as hydrochlorothiazide 12.5-25 milligrams, to the patient's regimen to enhance blood pressure lowering.
• Consider adding a mineralocorticoid receptor antagonist, such as spironolactone 25-50 milligrams, to the patient's regimen, especially if they have resistant hypertension or are at high risk for cardiovascular disease.

From the FDA Drug Label

2 DOSAGE & ADMINISTRATION

2.1 Adults The usual initial antihypertensive oral dose of Amlodipine besylate tablets is 5 mg once daily, and the maximum dose is 10 mg once daily. Adjust dosage according to blood pressure goals. In general, wait 7 to 14 days between titration steps. Titrate more rapidly, however, if clinically warranted, provided the patient is assessed frequently

The patient is already on the maximum dose of Amlodipine (10 milligrams). The next step would be to consider adding another antihypertensive therapy or changing to a different medication, as the current dose is not effectively controlling the patient's blood pressure. According to the label, when adding Amlodipine to other antihypertensive therapy, a dose of 2.5 mg once daily may be used, but since the patient is already on the maximum dose, this option is not applicable. 2

From the Research

Patient with Uncontrolled Asymptomatic Hypertensive Urgency on Amlodipine

• The patient is currently taking Amlodipine 10 milligrams, which is a commonly used calcium channel blocker for the treatment of hypertension 3, 4, 5.
• Amlodipine has been shown to be effective in reducing blood pressure and controlling hypertension, with a low risk of side effects 3, 4, 5.
• However, the patient's hypertension is uncontrolled, indicating that the current treatment regimen may not be sufficient 6, 7.

Next Steps for Management

• According to the study by 6, patients with severely elevated blood pressure without signs or symptoms of end-organ damage (severe asymptomatic hypertension) do not require immediate workup or treatment, but rather a gradual approach to lowering blood pressure.
• The study by 7 suggests that emergency physicians may consider prescribing oral antihypertensive medications, such as Amlodipine, for patients with a history of hypertension and referral from primary care.
• Considering the patient is already taking Amlodipine 10 milligrams, the next step may be to assess the patient's cardiovascular risk profile and consider adjusting the treatment regimen, such as adding another antihypertensive agent or increasing the dose of Amlodipine, if necessary 3, 4, 5.
• It is also important to confirm blood pressure readings and appropriately classify the hypertensive state, as well as provide repeated follow-up over weeks to months to reach desired blood pressure goals 6.