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

Amlodipine Dosage and Treatment Regimen for Hypertension and Coronary Artery Disease

For patients with hypertension, the recommended initial dose of amlodipine is 5 mg once daily, with a maximum dose of 10 mg once daily. For patients with coronary artery disease, the recommended dose range is 5-10 mg once daily, with most patients requiring 10 mg for adequate effect. 1

Dosing Guidelines for Adults

• The standard initial dose for hypertension is 5 mg once daily, which can be titrated up to 10 mg once daily if blood pressure control is inadequate 1
• Small, fragile, elderly patients, or those with hepatic insufficiency should start with 2.5 mg once daily 1
• Dose titration should generally occur after 7-14 days, allowing time to assess the full effect of each dose 1
• For coronary artery disease, including chronic stable or vasospastic angina, the dose range is 5-10 mg once daily 1
• In clinical studies for coronary artery disease, the majority of patients required 10 mg for optimal effect 1

Efficacy and Blood Pressure Control

• Amlodipine effectively reduces blood pressure throughout the entire 24-hour period with once-daily dosing while maintaining the normal circadian pattern 2
• Studies show significant reductions in both systolic and diastolic blood pressure, with mean reductions of 16/12 mmHg (supine) and 14/4 mmHg (standing) compared to placebo 3
• Amlodipine is particularly effective in reducing systolic blood pressure, with an average reduction of 17.5 mmHg from baseline, making it valuable for managing systolic hypertension 4
• The effect is more pronounced in elderly patients (≥60 years) and those with isolated systolic hypertension 4

Timing of Dose Adjustments

• Early dose increases (before 6 weeks) do not provide significant advantages in antihypertensive effect 5
• Consider dose increases only after at least 6 weeks of treatment at 5 mg once daily if blood pressure remains uncontrolled 5
• Response rates (diastolic BP ≤90 mmHg) of approximately 84% can be achieved with proper dosing 5

Use in Combination Therapy

• Amlodipine can be effectively combined with other antihypertensive medications when monotherapy is insufficient 6
• When added to hydrochlorothiazide therapy, amlodipine (mean dose 9 mg/day) produces additional significant reductions in blood pressure (14.2/11.7 mmHg) compared to placebo 6
• For patients with coronary artery disease and hypertension, a combination regimen that includes a β-blocker, an ACE inhibitor or ARB, and a thiazide or thiazide-like diuretic is recommended, with amlodipine added if angina or hypertension remains uncontrolled 7

Special Populations and Considerations

• For pediatric patients (ages 6-17 years), the effective antihypertensive dose is 2.5-5 mg once daily, with doses exceeding 5 mg daily not studied in this population 1
• In patients with bevacizumab therapy who develop hypertension, amlodipine 5 mg daily is recommended as first-line treatment if blood pressure is ≥160/100 mmHg 7
• For patients with heart failure and preserved ejection fraction who have hypertension, amlodipine may be effective in minimizing symptoms 7
• Avoid non-dihydropyridine CCBs (verapamil, diltiazem) in patients with heart failure with reduced ejection fraction, but amlodipine (a dihydropyridine CCB) can be used safely 7

Blood Pressure Targets

• For patients with stable coronary artery disease, the target blood pressure is <140/90 mmHg 7
• A lower target (<130/80 mmHg) may be considered in some individuals with CAD, previous stroke or transient ischemic attack, or CAD risk equivalents 7
• In older hypertensive individuals with wide pulse pressures, avoid lowering diastolic BP below 60 mmHg to prevent myocardial ischemia 7

Monitoring and Follow-up

• Regular blood pressure monitoring is essential to assess treatment efficacy 7
• Home blood pressure monitoring twice daily is recommended for patients requiring antihypertensive treatment to evaluate effectiveness 7
• Monitor for common side effects including peripheral edema, headache, flushing, and dizziness 7

Common Pitfalls and Caveats

• Immediate-release nifedipine should not be administered to patients with acute coronary syndromes in the absence of beta-blocker therapy, but amlodipine does not carry this restriction 7
• Unlike non-dihydropyridine CCBs (verapamil, diltiazem), amlodipine has minimal effects on heart rate and cardiac conduction, making it safer in various cardiac conditions 7
• Ankle edema is a common side effect that may require dose reduction or discontinuation in some patients 2, 3
• Amlodipine has been shown not to worsen heart failure in patients with NYHA Class II/III heart failure, making it safer than other CCBs in this population 1

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