When should the dose of amlodipine (calcium channel blocker) be increased?

When to Increase Amlodipine Dose

Increase amlodipine from 5 mg to 10 mg once daily if blood pressure remains above target (≥130/80 mmHg) after 2-6 weeks of treatment at the initial dose. 1, 2

Timing of Dose Escalation

• Wait at least 2 weeks before considering dose increase, as amlodipine reaches steady-state plasma levels after 7-8 days of consecutive daily dosing 3

• Optimal timing is 4-6 weeks after initiating 5 mg daily, as research demonstrates no advantage to early dose escalation—blood pressure continues to decrease steadily through the sixth week of treatment 2, 4

• Measure blood pressure just prior to the next dose (trough effect) to determine if satisfactory control is obtained throughout the 24-hour dosing interval 1

Blood Pressure Targets

• Target BP <130/80 mmHg for most adults with hypertension 1, 5

• For patients with mild-moderate hypertension (140-159/90-99 mmHg), aim to reduce BP by at least 20/10 mmHg within 3 months 1

• Confirm inadequate control with home BP monitoring (≥135/85 mmHg) or 24-hour ambulatory monitoring (≥130/80 mmHg) before escalating therapy 1

Dosing Algorithm

• Start with amlodipine 5 mg once daily as the most appropriate initial dose 1, 6, 7

• If diastolic BP remains >90 mmHg after 2 weeks, dose can be increased to 10 mg, though waiting 4-6 weeks is preferable 2, 4

• Maximum dose is 10 mg once daily for adults 1, 8, 3

• In elderly or hepatically impaired patients, consider starting at 2.5 mg daily due to 40-60% increased drug exposure, and increase more cautiously 3

Alternative Strategies Before Dose Escalation

• Add a second agent rather than maximizing amlodipine if BP control is inadequate after 4-6 weeks at 5 mg 1, 5

• For most adults, especially Black patients, combination therapy with two or more agents is needed to achieve BP targets <130/80 mmHg 5

• Preferred combinations include: amlodipine + ACE inhibitor/ARB, or amlodipine + thiazide-type diuretic 1, 5

Common Pitfalls

• Avoid increasing dose too early (before 2 weeks)—steady-state levels are not yet achieved and BP continues to decline through week 6 2, 4

• Don't assume tachyphylaxis—tolerance does not develop with long-term amlodipine use 6

• Monitor for peripheral edema, which is dose-dependent and occurs more frequently at 10 mg than 5 mg 5, 3

• Check medication adherence before escalating dose, as non-adherence is a common cause of apparent treatment failure 1

Monitoring Schedule

• Monthly visits until BP target is achieved 5

• Measure BP at trough (just before next dose) to ensure 24-hour control 1, 4, 9

• Consider 90-day refills once stable to improve adherence 5