What is the recommended initial dose and titration of Amlodipine (calcium channel blocker) for managing hypertension or coronary artery disease?

Amlodipine Dosing for Hypertension and Coronary Artery Disease

Initial Dosing

For adults with hypertension or coronary artery disease, start amlodipine at 5 mg once daily, with the option to reduce to 2.5 mg once daily in small, fragile, elderly patients, or those with hepatic insufficiency. 1

• The FDA-approved initial antihypertensive dose is 5 mg once daily, with a maximum dose of 10 mg once daily 1
• For chronic stable angina or vasospastic angina, the recommended dose range is 5-10 mg once daily, with lower doses (2.5-5 mg) suggested for elderly patients and those with hepatic insufficiency 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 can be administered at any convenient time of day to improve adherence 2

Dose Titration Strategy

Wait 7 to 14 days between titration steps when adjusting amlodipine dosage, though more rapid titration is acceptable if clinically warranted with frequent patient assessment. 1

• If blood pressure remains uncontrolled after 4-6 weeks at 5 mg daily, increase to 10 mg once daily 3, 4
• Research demonstrates no advantage to early dose escalation before 6 weeks of treatment at 5 mg daily 4
• Dose-ranging studies confirm 2.5 mg is the minimum effective dose, with dose-related blood pressure reductions observed 3
• In clinical practice, approximately 40-60% of patients require dose escalation from 5 mg to 10 mg for adequate blood pressure control 5, 4

Special Populations

In pediatric patients ages 6-17 years with hypertension, start amlodipine at 2.5 mg once daily, with a maximum dose of 5 mg once daily. 6, 1

• Doses exceeding 5 mg daily have not been studied in pediatric patients 1
• Amlodipine can be compounded into stable extemporaneous suspensions for children 6

Combination Therapy Considerations

For most adults with hypertension, especially black adults, plan to use two or more antihypertensive medications to achieve blood pressure targets below 130/80 mm Hg. 2

• Fixed-dose single-pill combinations are recommended when patients receive combination blood pressure-lowering treatment 2
• Amlodipine produces additional antihypertensive effects when combined with ACE inhibitors, beta-blockers, or thiazide diuretics 7
• In black adults without heart failure or chronic kidney disease, amlodipine is recommended as initial therapy alongside thiazide-type diuretics 2

Common Pitfalls and Monitoring

Avoid premature dose escalation before 4-6 weeks of therapy, as blood pressure reductions continue to develop over this timeframe. 3, 4

• Common side effects include peripheral edema (most frequent), headache, flushing, and constipation 2
• Peripheral edema occurs in approximately 10% of patients and may be dose-related 8
• Schedule monthly visits until blood pressure target is achieved, then transition to 90-day refills when possible 2
• No tolerance develops with long-term amlodipine use 7

Angina-Specific Dosing

For chronic stable angina, most patients require 10 mg once daily for adequate symptom control, though starting at 5 mg is appropriate. 1, 8

• In clinical studies of angina patients, 83% required dose escalation from 5 mg to 10 mg daily 8
• Amlodipine significantly reduces both anginal attack frequency and sublingual nitrate consumption 8
• The lower 5 mg dose is suggested for elderly patients and those with hepatic insufficiency even in angina management 1