Amlodipine Dosing in Renal Impairment

No dose adjustment of amlodipine is necessary for patients with renal impairment, regardless of the severity of kidney dysfunction. 1, 2, 3

Standard Dosing Across All Levels of Renal Function

Patients with renal failure may receive the usual initial dose without modification, as the pharmacokinetics of amlodipine are not significantly influenced by renal impairment 1
The standard starting dose is 2.5-5 mg once daily, which can be titrated up to a maximum of 10 mg daily based on blood pressure response 1, 4
For elderly patients or those with hepatic insufficiency (not renal impairment), consider starting with 2.5 mg daily due to decreased drug clearance in these populations 1

The lack of need for dose adjustment is based on robust pharmacokinetic data:

Amlodipine is approximately 90% metabolized hepatically to inactive metabolites, with only 10% of the parent compound excreted renally 1
Studies in 27 subjects with renal function ranging from normal to dialysis-dependent showed no significant effect of renal impairment on elimination half-life (approximately 50 hours across all groups) 2, 3
Steady-state concentrations are reached after 7-8 days of consecutive dosing and do not vary with renal function 1, 2
Drug accumulation to steady-state levels was not significantly different from theoretical predictions and did not change with declining renal function 2, 3

Amlodipine has demonstrated both efficacy and safety specifically in patients with renal dysfunction:

In 35 hypertensive patients with renal impairment (serum creatinine ≥1.5 mg/dL), 80% achieved target blood pressure reduction with 2.5-5 mg daily 4
Renal function was not aggravated in the majority of patients; only 4 of 35 patients (11.4%) showed mild increases in serum creatinine 4, 5
Serum amlodipine concentrations showed no tendency for drug accumulation even after 8-10 weeks of treatment 4
Side effects were minimal, with headache reported in only 2.9% of patients with renal dysfunction 4

Unlike some other antihypertensives, amlodipine may offer renal benefits:

Amlodipine has demonstrated renoprotective effects in chronic kidney disease patients, particularly when combined with ARBs 6
The drug causes reduction in renal artery smooth muscle contraction, leading to higher renal blood flow even while systemic blood pressure is reduced 6
In hypertensive patients with normal renal function, therapeutic doses resulted in decreased renal vascular resistance and increased glomerular filtration rate without changes in proteinuria 1
A single dose can produce a demonstrable increase in estimated GFR in CKD patients 6

Renal Function Status	Starting Dose	Maximum Dose	Monitoring
Normal GFR	5 mg daily	10 mg daily	Standard BP monitoring [1]
Mild-Moderate CKD (GFR 30-89)	5 mg daily	10 mg daily	Monitor BP and serum creatinine [4]
Severe CKD (GFR <30)	5 mg daily	10 mg daily	Monitor BP and serum creatinine [4,2]
Dialysis-dependent	5 mg daily	10 mg daily	No special timing with dialysis needed [2,3]
Elderly with renal impairment	2.5 mg daily	10 mg daily	Monitor for hypotension [1]

Cyclosporine levels may increase by 40% when co-administered with amlodipine in renal transplant patients; monitor cyclosporine trough levels 1
Tacrolimus exposure can increase 2.5-4 fold with concurrent amlodipine use; dose reduction of tacrolimus may be necessary 1
Strong CYP3A inhibitors (itraconazole, clarithromycin) may increase amlodipine concentrations, though this is not specific to renal patients 1

Do not reduce amlodipine dose based solely on renal function—this is unnecessary and may lead to inadequate blood pressure control 1, 2, 3
Do not confuse renal dosing with hepatic dosing—hepatic impairment requires dose reduction (start 2.5 mg), but renal impairment does not 1
Monitor for peripheral edema, which is a common side effect unrelated to renal function and does not indicate worsening kidney disease 6
In patients with both advanced age and renal impairment, the lower starting dose (2.5 mg) is indicated for age, not renal function 1