What is the preferred choice between amlodipine and nifedipine for treating hypertension?

Amlodipine vs Nifedipine for Hypertension

Amlodipine is the preferred choice over nifedipine for treating hypertension due to superior once-daily dosing, better patient compliance, longer duration of action, and fewer adverse effects. 1, 2

Key Clinical Advantages of Amlodipine

Compliance and Dosing

• Amlodipine provides significantly better patient compliance with 98.3% adherence compared to 87% for nifedipine slow-release, primarily due to once-daily dosing versus twice-daily requirements 2
• The medication event monitoring demonstrates that patients take the correct number of doses 92.5% of days with amlodipine versus only 74.8% with nifedipine 2
• Amlodipine's 36-45 hour half-life ensures true 24-hour coverage, while nifedipine requires multiple daily doses even in slow-release formulations 3

Blood Pressure Control

• Both agents reduce blood pressure equally overall, but amlodipine provides superior control at specific times of day, particularly during nocturnal hours 2
• Only 39.3% of amlodipine patients had elevated nocturnal systolic blood pressure compared to 71.4% with nifedipine (p=0.042) 2
• Therapeutic coverage (time with adequate drug levels) is significantly higher with amlodipine 2, 4

Tolerability Profile

• Amlodipine causes fewer adverse events and treatment withdrawals compared to nifedipine 2, 5
• While peripheral edema remains the most common side effect of both agents, it occurs less frequently with amlodipine 1, 3
• Amlodipine demonstrates better overall tolerability in multiple comparative trials 4, 6, 5

Dosing Recommendations

Amlodipine

• Start at 2.5-5 mg once daily, with a maximum of 10 mg daily 1
• Single daily administration provides complete 24-hour antihypertensive coverage 2, 3

Nifedipine (when used)

• Extended-release formulations: 30-60 mg daily in divided doses 1
• Immediate-release nifedipine must be avoided entirely due to reflex sympathetic activation and increased adverse cardiovascular events 7

Critical Safety Considerations

Absolute Contraindications for Short-Acting Nifedipine

• Rapid-release, short-acting nifedipine is contraindicated in the absence of concomitant beta blockade due to increased mortality risk 7
• The HINT trial was stopped early due to harm with nifedipine monotherapy 7

Heart Failure Patients

• Amlodipine is safe in patients with mild left ventricular dysfunction (NYHA class II-III), while diltiazem and verapamil are contraindicated 7
• For persistent hypertension in heart failure patients already on ACE inhibitors, beta-blockers, and diuretics, amlodipine is specifically recommended 7

Special Populations

• For pregnant patients with hypertension, nifedipine is recommended as first-line therapy, while amlodipine is preferred postpartum regardless of breastfeeding 1
• In pulmonary arterial hypertension with documented vasoreactivity, either agent may be used at higher doses (nifedipine 120-240 mg/day or amlodipine up to 20 mg/day) 7, 1

Clinical Decision Algorithm

Step 1: For uncomplicated hypertension, choose amlodipine 5 mg once daily 1, 2

Step 2: If blood pressure remains uncontrolled after 2-4 weeks, increase to amlodipine 10 mg once daily 1

Step 3: Consider nifedipine extended-release only if:

• Patient has documented intolerance to amlodipine 1
• Pregnancy-related hypertension requiring immediate treatment 7, 1
• Patient demonstrates superior response to nifedipine in prior therapy 1

Step 4: Never use immediate-release nifedipine for hypertension management 7

Important Caveats

• Do not abruptly discontinue either medication, particularly in patients with coronary artery disease, as this may precipitate rebound hypertension or angina 1
• Monitor for peripheral edema as a dose-limiting side effect, more common with nifedipine 1
• Both agents have minimal effects on cardiac conduction, heart rate, or myocardial contractility, making them suitable alternatives when beta-blockers or non-dihydropyridine calcium channel blockers are contraindicated 7, 3