What is the next step for a patient with uncontrolled hypertension (blood pressure 164/100 mmHg) after 3 hours of amlodipine (Ampodipine) 5 mg, with no symptoms?

From the Guidelines

The next step for a patient with uncontrolled hypertension (BP 164/100 mm Hg) despite amlodipine 5 mg would be to optimize the current treatment regimen, including health behavior change and considering the addition of a diuretic-based treatment, as recommended by the 2020 international society of hypertension global hypertension practice guidelines 1. To achieve better blood pressure control, it is essential to first exclude causes of pseudoresistance, such as poor BP measurement technique, white coat effect, nonadherence, and suboptimal choices in antihypertensive therapy. Considerations for the next steps include:

• Optimizing the current treatment regimen, which may involve increasing the dose of amlodipine or adding another antihypertensive agent from a different class, such as a diuretic, ACE inhibitor, or ARB.
• Screening patients for secondary causes of hypertension as appropriate.
• Adding a low dose of spironolactone as the 4th line agent in those whose serum potassium is <4.5 mmol/L and whose eGFR is >45 ml/min/1.73m2 to achieve BP targets, as suggested by the guidelines 1. Key points to consider when adjusting the treatment plan include:
• The importance of health behavior change, including lifestyle modifications such as sodium restriction, regular exercise, weight management, limiting alcohol consumption, and smoking cessation if applicable.
• The need to reassess the patient within 2-4 weeks after medication adjustment to evaluate the effectiveness of the new treatment plan.
• The potential benefits of referring the patient to a specialist center with sufficient expertise and resources to diagnose and treat resistant hypertension, if necessary, as recommended by the guidelines 1.

From the FDA Drug Label

2 DOSAGE & ADMINISTRATION 2.1 Adults The usual initial antihypertensive oral dose of Amlodipine besylate tablets is 5 mg once daily, and the maximum dose is 10 mg once daily.

Adjust dosage according to blood pressure goals. In general, wait 7 to 14 days between titration steps. Titrate more rapidly, however, if clinically warranted, provided the patient is assessed frequently

The patient's blood pressure is not controlled after 3 hours of amlodipine 5 mg.

• The initial dose of amlodipine is 5 mg once daily, and the patient has already received this dose.
• The maximum dose is 10 mg once daily.
• The label recommends waiting 7 to 14 days between titration steps, but it also allows for more rapid titration if clinically warranted. Since the patient's blood pressure is not controlled and the patient is symptomatic, the next step would be to titrate the dose more rapidly, considering the patient's condition and assessing them frequently 2. Increasing the dose to 10 mg could be considered, as it is the maximum recommended dose.

From the Research

Next Steps for Uncontrolled Hypertension

The patient's blood pressure is 164/100 mm Hg and is not controlled after 3 hours of amlodipine 5 mg. The next steps can be considered based on the following options:

• Increasing the dose of amlodipine: According to 3, amlodipine has a long half-life and duration of action, which allows it to sustain its anti-hypertensive effect for more than 24 hours. However, the study also mentions that side effects are more common with higher doses.
• Adding a new medication: 4 suggests that more than 70% of adults treated for primary hypertension will eventually require at least two antihypertensive agents. The study recommends considering thiazide diuretics, calcium channel blockers, angiotensin-converting enzyme inhibitors (ACEIs), and angiotensin receptor blockers (ARBs) as options for combination therapy.
• Combination therapy: 5 compares the efficacy of high-dose amlodipine/irbesartan versus a triple combination with amlodipine/irbesartan/indapamide. The results show that both combinations produce similar reductions in blood pressure.

Considerations for Combination Therapy

When considering combination therapy, the following points should be taken into account:

• ACEIs and ARBs should not be used simultaneously 4.
• In black patients, at least one agent should be a thiazide diuretic or a calcium channel blocker 4.
• Patients with heart failure with reduced ejection fraction should be treated initially with a beta blocker and an ACEI or ARB 4.
• Patients with diabetes mellitus should be treated similarly to those without diabetes unless proteinuria is present, in which case combination therapy should include an ACEI or ARB 4.

Comparison of Intensification Strategies

6 compares the effectiveness of adding a new medication versus maximizing the dose to intensify hypertension treatment in older adults. The results show that adding a new medication is associated with less intensification sustainability but slightly larger reductions in systolic blood pressure. However, the study also notes that the findings are based on observational data and that trials would provide more definitive support.