From the Guidelines
When treating orthostatic hypotension in elderly patients, it is generally preferable to reduce or discontinue amlodipine rather than perindopril, as supported by the most recent guidelines 1.
Rationale
Amlodipine, a calcium channel blocker, causes more peripheral vasodilation and is more likely to exacerbate orthostatic hypotension compared to perindopril, an ACE inhibitor.
- The 2024 ESC guidelines for the management of elevated blood pressure and hypertension recommend testing for orthostatic hypotension before starting or intensifying BP-lowering medication and pursuing non-pharmacological approaches as the first-line treatment of orthostatic hypotension among persons with supine hypertension 1.
- Additionally, the guidelines suggest switching BP-lowering medications that worsen orthostatic hypotension to an alternative BP-lowering therapy and not simply de-intensifying therapy 1.
Clinical Considerations
If a patient is on both medications and experiencing orthostatic symptoms, consider first reducing amlodipine by 50% (e.g., from 10mg to 5mg daily) or discontinuing it entirely, while maintaining the perindopril dose.
- ACE inhibitors like perindopril provide important cardioprotective and renoprotective benefits, especially in patients with heart failure, diabetes, or chronic kidney disease, making them valuable to continue when possible 1.
- The mechanism behind this recommendation relates to how these medications work - calcium channel blockers primarily affect vascular smooth muscle causing vasodilation, while ACE inhibitors work through the renin-angiotensin-aldosterone system with less direct effect on postural blood pressure changes.
Monitoring and Adjustment
When modifying either medication, blood pressure should be monitored closely, and doses adjusted gradually to prevent rebound hypertension or other adverse effects.
- It is also recommended to maintain BP-lowering drug treatment lifelong, even beyond the age of 85 years, if well tolerated 1.
From the Research
Orthostatic Hypotension Treatment
- The treatment of orthostatic hypotension (OH) is imperfect, and the goal is to improve standing blood pressure without generating excessive supine hypertension 2.
- A combination of fludrocortisone, a pressor agent (midodrine or droxidopa), and procedures to improve orthostatic defenses can help achieve this goal 2.
- There is no predefined blood pressure target, and the goal of therapy is the relief of symptoms and fall prevention 3.
Medication Management
- Medications can be a favoring factor for orthostatic hypotension, especially in elderly patients 3.
- There is no direct evidence comparing the effects of lowering amlodipine versus perindopril on orthostatic hypotension in the provided studies.
- Fludrocortisone is considered a first- or second-line pharmacological therapy for orthostatic hypotension, but the evidence on its effects is very uncertain 4.
Preferred Medication for Dose Reduction/Discontinuation
- There is no clear evidence suggesting which medication (amlodipine or perindopril) would be preferred to decrease the dose or discontinue entirely in the treatment of orthostatic hypotension.
- The decision to reduce or discontinue a medication should be based on individual patient factors and medical history, rather than a specific medication preference 5.