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

For adults with hypertension or coronary artery disease, start amlodipine at 5 mg once daily, with a maximum dose of 10 mg once daily; however, use 2.5 mg once daily as the initial dose in small, fragile, elderly patients, or those with hepatic insufficiency. 1

Standard Adult Dosing

Initial Dose

• 5 mg once daily is the usual initial antihypertensive dose for most adults 1
• 2.5 mg once daily should be used for:
  • Small or fragile patients 1
  • Elderly patients 1
  • Patients with hepatic insufficiency 1
  • When adding amlodipine to existing antihypertensive therapy 1

Titration Strategy

• Wait 7 to 14 days between titration steps under normal circumstances 1
• Titrate more rapidly if clinically warranted, provided the patient is assessed frequently 1
• Maximum dose is 10 mg once daily 1
• The dose-response relationship demonstrates that 2.5 mg is the minimum effective dose, with clear dose-related blood pressure reductions 2

Administration Timing

• Amlodipine can be administered at the most convenient time of day for the patient to improve adherence 3
• The long elimination half-life (40-60 hours) provides consistent 24-hour blood pressure control with once-daily dosing 4

Indication-Specific Dosing

Hypertension

• Start at 5 mg once daily (or 2.5 mg in special populations) 1
• Titrate to 10 mg if blood pressure goals are not achieved 1
• Most patients with hypertension will require combination therapy with two or more antihypertensive medications to achieve BP target of less than 130/80 mm Hg 3

Coronary Artery Disease (Chronic Stable or Vasospastic Angina)

• Recommended dose range is 5 to 10 mg once daily 1
• Use the lower dose (5 mg) in elderly patients and those with hepatic insufficiency 1
• Most patients will require 10 mg for adequate effect in angina management 1
• In clinical studies for coronary artery disease, the majority of patients required 10 mg 1

Pediatric Dosing (Ages 6-17 Years)

• Start at 2.5 mg once daily 3, 1
• Maximum dose is 5 mg once daily 3, 1
• Doses exceeding 5 mg daily have not been studied in pediatric patients 1
• Amlodipine can be compounded into stable extemporaneous suspensions for children who cannot swallow tablets 3

Monitoring and Follow-Up

• Schedule monthly visits until blood pressure target is achieved 3
• Blood pressure control is maintained throughout the 24-hour dosing interval with minimal fluctuation (20-25% between doses) 4
• Replace 30-day with 90-day refills when blood pressure is controlled 3
• Consider telehealth strategies to augment office-based management 3

Common Pitfalls and Clinical Pearls

Onset of Action

• Amlodipine has a gradual onset of effect over 4-8 hours after single doses due to intermediate absorption rate (peak plasma concentration at 6-8 hours) 4
• Steady-state blood levels are achieved over 1 to 1.5 weeks with once-daily dosing 4
• Do not expect immediate blood pressure reduction; this gradual onset prevents reflex tachycardia 4

Discontinuation

• When stopping amlodipine, blood pressure returns to baseline slowly over 7-10 days with no rebound effect 4

Side Effects

• Common adverse effects include peripheral edema, headache, flushing, and constipation 3
• These are generally mild to moderate in intensity 2

Combination Therapy

• In black adults with hypertension (without heart failure or chronic kidney disease), amlodipine is recommended as initial therapy along with thiazide-type diuretics 3
• Fixed-dose single-pill combinations are recommended when using combination blood pressure-lowering treatment 3
• Amlodipine produces important additional antihypertensive effects when combined with ACE inhibitors, beta-blockers, or thiazide diuretics 5