Adding Antihypertensive Medication to Amlodipine Twice Daily
For a patient already on amlodipine twice daily, the most appropriate next antihypertensive agent to add would be either a thiazide-like diuretic or an ACE inhibitor/ARB, depending on patient characteristics. 1, 2
First-Line Considerations
- Amlodipine is typically dosed once daily, not twice daily, due to its long half-life. Consider consolidating to a single daily dose before adding another agent 3
- For patients already on a calcium channel blocker like amlodipine, the next step should follow a logical progression in the hypertension treatment algorithm 1
Recommended Add-On Options
Option 1: ACE Inhibitor or ARB
- Adding an ACE inhibitor (like lisinopril 10-40mg daily) or ARB (like losartan 50-100mg daily) to amlodipine provides complementary mechanisms of action 1, 4
- The combination of amlodipine with an ACE inhibitor has demonstrated superior blood pressure control compared to either agent alone 4
- This combination is particularly beneficial for patients with:
Option 2: Thiazide-Like Diuretic
- Adding chlorthalidone (12.5-25mg daily) or hydrochlorothiazide (25-50mg daily) to amlodipine is an effective combination 1, 6
- This combination has shown enhanced antihypertensive effects without significant adverse interactions 6
- Particularly effective for:
- Volume-dependent hypertension
- Black patients
- Elderly patients 1
Special Considerations
- For Black patients, the combination of amlodipine plus a thiazide diuretic may be more effective than amlodipine plus an ACE inhibitor/ARB 1, 2
- For patients with diabetes, the combination of amlodipine with an ACE inhibitor or ARB has shown superior efficacy in achieving target blood pressure goals 5
- Monitor for peripheral edema, which is more common with amlodipine and may be attenuated by adding an ACE inhibitor or ARB 1
Monitoring After Addition
- Reassess blood pressure within 2-4 weeks after adding the new medication 2
- Target blood pressure should be <140/90 mmHg for most patients 1, 2
- Monitor for specific side effects:
- With ACE inhibitors: cough, hyperkalemia, acute kidney injury
- With ARBs: hyperkalemia, acute kidney injury
- With thiazide diuretics: hypokalemia, hyperuricemia, glucose intolerance 1
Dosing Adjustments
- If blood pressure remains uncontrolled after adding a second agent at optimal dose, consider adding a third agent from the remaining class (thiazide diuretic, ACE inhibitor/ARB, or calcium channel blocker) 1
- Avoid combining ACE inhibitors with ARBs due to increased risk of adverse effects without additional benefit 1