What is the next step for a patient with increasing hypertension who has been on amlodipine (calcium channel blocker) 5 mg for years?

Hypertension Management: Next Step After Amlodipine 5mg

Direct Answer

Increase amlodipine to 10 mg once daily first, then add an ACE inhibitor/ARB or thiazide diuretic if blood pressure remains uncontrolled after 7-14 days. 1

Stepwise Approach

Step 1: Optimize Current Monotherapy

• Uptitrate amlodipine from 5 mg to 10 mg once daily as the maximum FDA-approved dose, waiting 7-14 days between titration to assess response 1
• This dose escalation produces significant additional blood pressure reduction (approximately 12 mmHg systolic and 7 mmHg diastolic) in patients who did not respond adequately to 5 mg 2
• The 10 mg dose maintains effective 24-hour blood pressure control and is well-tolerated, with ankle edema being the most common side effect 3

Step 2: Add Second Agent if Target Not Achieved

If blood pressure remains ≥140/90 mmHg after optimizing to amlodipine 10 mg, add one of the following based on patient characteristics:

For most patients (non-Black):

• Add an ACE inhibitor or ARB as the preferred second agent, providing complementary mechanisms and particular benefit for patients with diabetes, chronic kidney disease, heart failure, or coronary artery disease 4
• The combination of amlodipine plus ACE inhibitor/ARB has superior blood pressure control compared to either agent alone and may reduce amlodipine-induced peripheral edema 4

For Black patients:

• Add a thiazide-like diuretic (chlorthalidone 12.5-25 mg or hydrochlorothiazide 25-50 mg daily) as this combination is more effective than amlodipine plus ACE inhibitor/ARB in this population 4

For elderly or volume-dependent hypertension:

• Add a thiazide-like diuretic as an effective combination for these specific populations 4

Step 3: Triple Therapy if Needed

• If blood pressure remains uncontrolled on dual therapy at optimal doses, add the third agent from the remaining class (ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic) to achieve guideline-recommended triple therapy 4
• Never combine ACE inhibitors with ARBs due to increased adverse effects without additional benefit 4

Monitoring Parameters

• Target blood pressure: <140/90 mmHg minimum for most patients 4
• Reassess blood pressure within 2-4 weeks after any dose adjustment 4
• When adding ACE inhibitor/ARB: monitor for cough, hyperkalemia, and acute kidney injury 4
• When adding thiazide diuretic: check serum potassium and creatinine 2-4 weeks after initiation to detect hypokalemia, hyperuricemia, or glucose intolerance 4

Critical Pitfalls to Avoid

• Do not add a second drug before maximizing amlodipine to 10 mg unless blood pressure is severely elevated (≥160/100 mmHg), as dose optimization should precede polypharmacy 1, 5
• Do not assume treatment failure without confirming medication adherence and ruling out secondary causes of hypertension, as non-adherence is the most common cause of apparent treatment resistance 4
• Do not add a beta-blocker as second-line therapy unless there are compelling indications (angina, post-MI, heart failure with reduced ejection fraction) 4

Special Considerations

• Confirm elevated readings with home blood pressure monitoring (target <135/85 mmHg) or 24-hour ambulatory monitoring (target <130/80 mmHg) to rule out white coat hypertension 6
• Reinforce lifestyle modifications including sodium restriction to <2g/day, which can provide additive blood pressure reduction of 5-10 mmHg 6