What is the recommended dosage and treatment regimen for amlodipine (calcium channel blocker) in patients with hypertension or coronary artery disease?

Recommended Dosage and Treatment Regimen for Amlodipine in Hypertension and Coronary Artery Disease

For adults with hypertension, the recommended initial dose of amlodipine is 5 mg once daily, with a maximum dose of 10 mg once daily. 1

Dosing for Hypertension

• The usual initial antihypertensive oral dose for adults is 5 mg once daily 1
• Small, fragile, or elderly patients, or those with hepatic insufficiency should start with 2.5 mg once daily 1
• Dose titration should typically occur after 7-14 days between steps, though more rapid titration may be appropriate if clinically warranted with frequent patient assessment 1
• Maximum dose is 10 mg once daily 1
• Once-daily dosing is effective for 24-hour blood pressure control while maintaining normal circadian patterns 2

Dosing for Coronary Artery Disease

• For chronic stable or vasospastic angina, the recommended dose is 5-10 mg once daily 1
• For elderly patients and those with hepatic insufficiency, a lower starting dose of 5 mg is suggested 1
• For coronary artery disease, the recommended dose range is 5-10 mg once daily, with most patients requiring 10 mg for adequate effect 1
• Amlodipine is effective for exercise-induced angina, with significant increases in exercise time observed at both 5 mg and 10 mg doses 1

Special Populations

Elderly Patients

• Start with 2.5 mg once daily 1
• Amlodipine shows greater systolic blood pressure reduction in elderly patients (≥60 years) 3
• Long-acting dihydropyridine CCBs like amlodipine may be particularly useful in older patients with systolic hypertension 4

Patients with Hepatic Insufficiency

• Start with 2.5 mg once daily 1
• Careful monitoring is recommended due to slower drug metabolism 1

Pediatric Patients

• For children ages 6-17 years, the effective antihypertensive dose is 2.5-5 mg once daily 1
• Doses exceeding 5 mg daily have not been studied in pediatric patients 1

Treatment Algorithm and Monitoring

1. Initial Treatment:

   • Start with 5 mg once daily for most adults 1
   • Start with 2.5 mg once daily for elderly, fragile patients, or those with hepatic insufficiency 1

2. Monitoring and Titration:

   • Assess blood pressure response after 7-14 days 1
   • If target blood pressure is not achieved, increase to 10 mg once daily 1
   • Early dose increases (before 6 weeks) show no advantage over maintaining the initial 5 mg dose 5

3. Target Blood Pressure:

   • For patients with coronary artery disease, target BP is <140/90 mmHg 4
   • A lower target (<130/80 mmHg) may be considered in some individuals with CAD, previous stroke/TIA, or CAD risk equivalents 4

Combination Therapy

• Amlodipine can be effectively combined with other antihypertensive medications when monotherapy is insufficient 6
• In patients with coronary artery disease, amlodipine can be added to regimens including beta-blockers, ACE inhibitors, and thiazide diuretics 4
• If beta-blockers are contraindicated or produce intolerable side effects, a dihydropyridine CCB like amlodipine may be substituted 4

Common Side Effects and Management

• Most common side effects include peripheral edema, headache, flushing, and dizziness 4, 2
• Ankle edema is a common side effect, particularly at the 10 mg dose 7, 6
• Unlike non-dihydropyridine CCBs (verapamil, diltiazem), amlodipine has minimal effects on heart rate and cardiac conduction 4
• Amlodipine is generally well-tolerated in patients with mild left ventricular dysfunction 4

Important Clinical Considerations

• Avoid immediate-release nifedipine in patients with acute coronary syndromes; amlodipine is preferred among dihydropyridine CCBs 4
• Amlodipine can be safely used in patients with heart failure with preserved ejection fraction 4
• In patients with hypertension and heart failure with reduced ejection fraction, amlodipine should be used with caution and only if other preferred agents (ACE inhibitors, ARBs, beta-blockers) are insufficient 4
• For patients receiving bevacizumab therapy who develop hypertension, amlodipine 5 mg daily is recommended as first-line therapy 4

By following these dosing recommendations and monitoring protocols, amlodipine can effectively control blood pressure and improve symptoms in patients with hypertension and coronary artery disease while minimizing adverse effects.