What is the recommended dosage and treatment approach for hypertension using Amlodipine (calcium channel blocker)?

Amlodipine Dosage and Treatment Approach for Hypertension

The recommended initial dose of amlodipine for hypertension is 5 mg once daily, with a maximum dose of 10 mg once daily, and patients should wait 7-14 days between dose titration steps. 1

Initial Dosing Considerations

• Standard starting dose: 5 mg once daily for most adults 1
• Lower starting dose: 2.5 mg once daily for:
  • Elderly patients
  • Fragile patients
  • Patients with hepatic insufficiency
  • When adding amlodipine to other antihypertensive therapy 1

Dose Titration Protocol

1. Begin with appropriate initial dose (5 mg or 2.5 mg)
2. Wait 7-14 days between titration steps to assess response 1
3. Titrate more rapidly if clinically warranted, with frequent patient assessment
4. Maximum dose: 10 mg once daily 1

Place in Hypertension Treatment Algorithm

Amlodipine, a dihydropyridine calcium channel blocker (CCB), has specific roles in hypertension management:

• First-line therapy for black patients: Amlodipine is recommended as part of first-line therapy (with an ARB) for black patients with hypertension 2, 3
• Second-line therapy for non-black patients: Amlodipine is recommended as second-line therapy after ACE inhibitors or ARBs for non-black patients 3
• Component of optimal three-drug combination: The optimal three-drug combination for hypertension includes:
  1. RAS blocker (ACE inhibitor or ARB)
  2. Dihydropyridine CCB (like amlodipine)
  3. Thiazide-like diuretic 3

Efficacy and Advantages

• Amlodipine provides effective 24-hour blood pressure control with once-daily dosing 4
• No tolerance develops with long-term use 4
• Produces significant blood pressure reductions compared to placebo (16/12 mmHg supine, 14/4 mmHg standing) 5
• Dose-dependent blood pressure reductions: target BP reached in 41% with 2.5 mg, 56% with 5 mg, and 73% with 10 mg 6

Special Populations

Elderly Patients

• Start with 2.5 mg once daily 1
• Titrate cautiously based on response

Patients with Hepatic Insufficiency

• Start with 2.5 mg once daily 1
• Monitor closely for side effects

Pediatric Patients (6-17 years)

• Effective dose range: 2.5-5 mg once daily
• Doses above 5 mg daily have not been studied in pediatric patients 1

Combination Therapy

Amlodipine works effectively in combination with:

• ACE inhibitors
• ARBs
• Beta-blockers
• Thiazide diuretics 4

When added to benazepril 40 mg in patients not responding to benazepril monotherapy, the amlodipine/benazepril combination produced significantly greater BP reductions (17/14 mmHg) compared to benazepril alone (5/7 mmHg) 7

Timing of Dose Increases

Early dose increases may not provide additional benefit. Research suggests waiting 6 weeks before considering a dose increase from 5 mg to 10 mg, as BP continues to decrease steadily during this period 8

Monitoring and Follow-up

• Assess blood pressure response regularly
• Monitor for common side effects (ankle edema, headache, flushing)
• Consider home blood pressure monitoring to assess treatment efficacy 3

Common Pitfalls to Avoid

1. Premature dose escalation: Wait at least 7-14 days between dose increases to properly assess response 1
2. Inadequate starting dose for vulnerable populations: Use 2.5 mg for elderly, fragile patients, or those with hepatic insufficiency 1
3. Failure to recognize resistant hypertension: If BP remains uncontrolled on three medications including amlodipine, consider adding a mineralocorticoid receptor antagonist like spironolactone 3
4. Overlooking combination therapy benefits: Amlodipine produces important additional antihypertensive effects when combined with ACE inhibitors, ARBs, beta-blockers, or thiazide diuretics 4