From the Guidelines
If hypertension remains uncontrolled on amlodipine, adding low-dose spironolactone to existing treatment is recommended. This approach is based on the latest guidelines from the European Heart Journal, which suggest that spironolactone can be an effective addition to treatment for patients with resistant hypertension 1. The guidelines recommend reinforcement of lifestyle measures, especially sodium restriction, and the addition of low-dose spironolactone as a first step in managing resistant hypertension.
Some key points to consider when adding spironolactone to amlodipine include:
- Starting with a low dose and monitoring for side effects such as hyperkalemia
- Regularly checking blood pressure to assess the effectiveness of the treatment
- Considering alternative options, such as eplerenone or further diuretic therapy, if spironolactone is not effective or tolerated
- Evaluating the patient's overall clinical profile, including comorbidities and potential drug interactions, to determine the best course of treatment
It's also important to note that the addition of other medications, such as beta-blockers or alpha-blockers, may be considered if spironolactone is not effective or tolerated, as outlined in the guidelines 1. However, spironolactone is the recommended first-line addition to amlodipine for patients with uncontrolled hypertension, due to its efficacy and safety profile as demonstrated in recent studies 1.
From the Research
Treatment Options for Uncontrolled Hypertension with Amlodipine
If hypertension remains uncontrolled with amlodipine, several treatment options can be considered:
- Adding an angiotensin II receptor blocker (ARB) or an angiotensin-converting enzyme inhibitor (ACEI) to amlodipine, as these combinations have been shown to be effective in lowering blood pressure 2, 3
- Adding a thiazide diuretic to amlodipine, as this combination has been found to be effective in reducing blood pressure and improving cardiovascular outcomes 2, 4
- Considering a triple fixed-dose combination therapy with an ARB, a calcium channel blocker (such as amlodipine), and a thiazide diuretic, which has been shown to be effective in patients with uncontrolled hypertension 2
Patient-Specific Considerations
When adding a new medication to amlodipine, patient-specific considerations should be taken into account:
- In black patients, a thiazide diuretic or a calcium channel blocker should be included in the treatment regimen 3
- In patients with heart failure, a beta blocker and an ACEI or ARB should be used as initial therapy, with add-on therapy as needed 3
- In patients with chronic kidney disease and proteinuria, an ACEI or ARB should be used in combination with a thiazide diuretic or a calcium channel blocker 3
- In patients with diabetes mellitus, treatment should be similar to that for patients without diabetes, unless proteinuria is present, in which case an ACEI or ARB should be used in combination with a thiazide diuretic or a calcium channel blocker 3
Safety and Efficacy of Combination Therapy
Combination therapy with amlodipine and other antihypertensive agents has been shown to be safe and effective:
- The combination of ACEIs and thiazide diuretics has been found to be safe and well-tolerated, with a favorable clinical outcome 4
- Amlodipine has been shown to be a wise choice for older adults, with a low risk of adverse events and a high efficacy in controlling blood pressure 5
- The combination of amlodipine with other antihypertensive agents has been found to be cost-effective and predicted to be cost-saving compared to usual care 5