When do you increase the dose of S-amlodipine (calcium channel blocker) from 5 mg to 10 mg in patients with uncontrolled hypertension?

When to Increase S-Amlodipine from 5 mg to 10 mg

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

Timing of Dose Escalation

• Wait 7 to 14 days between titration steps as the standard approach, though more rapid titration is acceptable if clinically warranted with frequent patient assessment 2
• The FDA label specifies that dose adjustments should be made according to blood pressure goals, with the general recommendation of 7-14 days between increases 2
• Research evidence suggests waiting at least 6 weeks before increasing the dose may be optimal, as one study found no advantage to early dose escalation and 84% of patients achieved target BP on 5 mg alone by 6 weeks 3
• However, the American Heart Association recommends a shorter interval of 2-6 weeks for dose titration in clinical practice 1

Blood Pressure Targets to Guide Escalation

• Target BP is <130/80 mmHg for most adults with hypertension 1
• Confirm inadequate control with home BP monitoring (≥135/85 mmHg) or 24-hour ambulatory monitoring (≥130/80 mmHg) before escalating therapy 1
• Measure BP at trough (just before the next dose) to ensure 24-hour control 1

Maximum Dosing

• The maximum dose is 10 mg once daily for adults 2
• Small, fragile, or elderly patients may be started on 2.5 mg once daily 2
• Patients with hepatic insufficiency should start at 2.5 mg and may require lower maintenance doses 2

Alternative Strategy: Adding a Second Agent

• Consider adding a second agent rather than maximizing amlodipine if BP control is inadequate after 4-6 weeks at 5 mg 1
• Preferred combinations include amlodipine plus an ACE inhibitor/ARB, or amlodipine plus a thiazide-type diuretic 1
• Research comparing high-dose amlodipine (10 mg) versus adding indapamide to standard-dose amlodipine (5 mg) found that increasing amlodipine to 10 mg provided greater systolic BP reduction without elevating serum uric acid 4

Critical Considerations Before Dose Escalation

• Check medication adherence before escalating the dose, as non-adherence is the most common cause of apparent treatment failure 1
• Confirm true hypertension rather than white-coat effect with out-of-office BP measurements 1
• For pediatric patients ages 6-17 years, the maximum dose is 5 mg once daily, and doses exceeding this have not been studied 2

Clinical Evidence for Dose Response

• Clinical trials demonstrate that BP reduction is dose-related within the recommended dosing range of 5-10 mg 2
• Once-daily administration produces sustained 24-hour BP control, with average reductions of approximately 12/6 mmHg in standing position and 13/7 mmHg in supine position 2
• Studies show effective 24-hour duration of action with both 5 mg and 10 mg doses, with mean daytime BP reduced from 165/103 to 147/89 mmHg and nighttime BP from 137/79 to 121/69 mmHg 5