What is the recommended dosage and management of Amlodipine (calcium channel blocker) for patients with hypertension or coronary artery disease?

Amlodipine Dosage and Management for Hypertension and Coronary Artery Disease

The recommended initial dose of amlodipine for hypertension is 5 mg once daily, with titration up to 10 mg once daily if needed, while patients who are elderly, fragile, or have hepatic insufficiency should start with 2.5 mg once daily. 1

Initial Dosing Guidelines

For Hypertension:

• Standard initial dose: 5 mg once daily 1
• Maximum dose: 10 mg once daily 1
• Special populations (elderly, fragile, hepatic insufficiency): Start with 2.5 mg once daily 1
• Pediatric patients (ages 6-17 years): 2.5-5 mg once daily 1

For Coronary Artery Disease:

• Recommended dose range: 5-10 mg once daily 1
• Most patients require: 10 mg for adequate effect 1
• Chronic stable or vasospastic angina: 5-10 mg once daily (lower dose for elderly and hepatic insufficiency) 1

Titration Protocol

• Wait 7-14 days between dose adjustments to assess response 1
• More rapid titration may be appropriate if clinically warranted with frequent patient assessment 1
• Response rates at 10 mg (73%) are significantly higher than at 5 mg (56%) 2
• Consider dose increase only after 6 weeks if blood pressure remains uncontrolled on 5 mg 3

Monitoring Recommendations

• Measure blood pressure before each dose adjustment
• For patients on combination therapy with ACE inhibitors, ARBs, or diuretics:
  • Monitor serum creatinine/eGFR and potassium levels at least annually 4
  • Consider more frequent monitoring in patients with reduced renal function

Treatment Algorithm for Hypertension

1. Initial Assessment:

   • If BP ≥130/80 mmHg: Initiate pharmacologic therapy 4
   • If BP ≥150/90 mmHg: Start with two-drug combination or single-pill combination 4

2. First-line Options:

   • Amlodipine (calcium channel blocker)
   • ACE inhibitor
   • ARB
   • Thiazide-like diuretic

3. Special Considerations:

   • For patients with albuminuria (UACR ≥300 mg/g): ACE inhibitor or ARB is first-line 4
   • For coronary artery disease: ACE inhibitor or ARB is first-line, with amlodipine as excellent add-on therapy 4

4. Resistant Hypertension Management:

   • If BP not controlled on three classes (including a diuretic), consider adding a mineralocorticoid receptor antagonist 4

Administration in Special Circumstances

• For patients with swallowing difficulties:
  • Amlodipine tablets can be crushed 5
  • Mix with small amount of soft food or liquid 5
  • Administer immediately after crushing 5
  • Ensure entire mixture is consumed 5

Efficacy and Clinical Outcomes

• Amlodipine effectively reduces blood pressure throughout the entire 24-hour period 6
• In coronary artery disease, amlodipine significantly increases exercise time (12.8% increase with 10 mg dose) 1
• In patients with documented CAD, amlodipine reduces hospitalizations for angina (42% risk reduction) and coronary revascularization procedures (27% risk reduction) 1

Common Pitfalls and Caveats

1. Edema: Most common side effect, occurs dose-dependently. Can be reduced by combining with ACE inhibitors 7

2. Dosing in hepatic impairment: Start with 2.5 mg and titrate cautiously 1

3. Pregnancy: Calcium channel blockers are generally preferred over ACE inhibitors/ARBs, which are contraindicated 4

4. Combination therapy: Avoid combining ACE inhibitors with ARBs or direct renin inhibitors due to increased risk of adverse events without added benefit 4

5. Medication adherence: Once-daily dosing of amlodipine improves adherence compared to medications requiring multiple daily doses 6

Amlodipine's long half-life provides consistent 24-hour blood pressure control with once-daily dosing, making it an excellent choice for both hypertension and coronary artery disease management when used at appropriate doses and with proper monitoring.