Maximum Dose of Cilnidipine
The maximum recommended dose of cilnidipine is 20 mg once daily for adults with hypertension. 1, 2, 3, 4
Dosing Algorithm
Standard Adult Dosing
- Starting dose: 5 mg once daily 1
- Titration: Increase to 10 mg once daily if blood pressure control is inadequate 2, 4
- Maximum dose: 20 mg once daily 1, 2, 3, 4
The dose escalation should occur over 1-3 weeks based on blood pressure response, with the goal of achieving adequate 24-hour blood pressure control without excessive heart rate elevation 1.
Clinical Efficacy at Maximum Dose
Blood pressure reduction: At the maximum 20 mg dose, cilnidipine produces significant reductions in 24-hour ambulatory blood pressure (approximately 8-15 mmHg systolic and 6-11 mmHg diastolic) without causing reflex tachycardia 1, 3.
Renoprotective effects: The 20 mg dose demonstrates superior reduction in albuminuria and urinary biomarkers of kidney injury compared to lower doses, particularly in patients with chronic kidney disease already receiving angiotensin receptor blockers 2, 4.
Key Advantages at Therapeutic Doses
- Dual L/N-type calcium channel blockade: Unlike pure L-type blockers (amlodipine), cilnidipine's N-type channel blockade inhibits sympathetic nerve activity, reducing reflex tachycardia that commonly occurs with other dihydropyridines 3, 5
- Efferent arteriole dilation: Provides balanced renal hemodynamics by dilating both afferent and efferent arterioles, reducing glomerular pressure 2, 4
- Antioxidant properties: Reduces urinary 8-hydroxy-2'-deoxyguanosine (oxidative stress marker) independent of blood pressure reduction 5
Dosing Considerations by Patient Population
Patients with chronic kidney disease: Use the full 5-20 mg dose range in combination with renin-angiotensin system inhibitors for optimal renoprotection 2, 4, 5
Patients with diabetes and CKD: The maximum 20 mg dose may provide greater antiproteinuric effects compared to other calcium channel blockers 4
High baseline blood pressure: Patients with higher baseline ambulatory blood pressure (>150/90 mmHg) demonstrate more pronounced 24-hour blood pressure reduction at maximum doses 1
Common Pitfalls to Avoid
Do not exceed 20 mg daily: No evidence supports doses above 20 mg, and higher doses do not provide additional benefit 1, 2, 3, 4
Monitor for peripheral edema: While cilnidipine causes less reflex tachycardia than other dihydropyridines, peripheral edema remains a class effect that may occur at higher doses 3
Assess response over weeks, not days: Full antihypertensive and renoprotective effects require 1-3 weeks at each dose level before further titration 1