What is the recommended use and dosage of Amlodipine (calcium channel blocker) for managing hypertension and coronary artery disease?

Amlodipine for Hypertension and Coronary Artery Disease

Initial Dosing

Start amlodipine at 5 mg once daily for most adults with hypertension or coronary artery disease, with a maximum dose of 10 mg once daily. 1

• For small, fragile, elderly patients, or those with hepatic insufficiency, initiate at 2.5 mg once daily 1
• In pediatric patients ages 6-17 years with hypertension, start at 2.5 mg once daily with a maximum of 5 mg once daily 1
• Amlodipine can be administered at any convenient time of day to improve adherence 2

Dose Titration Strategy

Wait 7 to 14 days between dose adjustments, though more rapid titration is acceptable if clinically warranted with frequent patient assessment. 1

• If blood pressure remains ≥130/80 mmHg after 2-6 weeks at 5 mg, increase to 10 mg once daily 2
• Confirm inadequate control with home blood pressure monitoring (≥135/85 mmHg) or 24-hour ambulatory monitoring (≥130/80 mmHg) before escalating 2
• Measure blood pressure at trough (just before next dose) to ensure 24-hour control 2
• Check medication adherence before dose escalation, as non-adherence is a common cause of apparent treatment failure 2

Combination Therapy Approach

Add a second antihypertensive agent rather than maximizing amlodipine to 10 mg if blood pressure control is inadequate after 4-6 weeks at 5 mg. 2

• Preferred combinations include amlodipine plus ACE inhibitor/ARB, or amlodipine plus thiazide-type diuretic 2
• For most adults with hypertension, especially Black adults, two or more antihypertensive medications are required to achieve BP target <130/80 mmHg 2
• In Black adults without heart failure or chronic kidney disease, initial treatment should include a thiazide-type diuretic or calcium channel blocker like amlodipine 2
• Fixed-dose single-pill combinations are recommended when patients receive combination therapy 2

Specific Indications and Dosing

Chronic Stable or Vasospastic Angina

• Recommended dose is 5-10 mg once daily, with lower doses (5 mg) suggested for elderly patients and those with hepatic insufficiency 1
• Most patients require 10 mg for adequate anginal control 1

Coronary Artery Disease

• Recommended dose range is 5-10 mg once daily 1
• In clinical studies (CAMELOT), the majority of patients required 10 mg daily, which reduced hospitalizations for angina by 42% and coronary revascularization procedures by 27% compared to placebo 1

Bevacizumab-Associated Hypertension

• For antihypertensive-naive patients requiring treatment before or during bevacizumab therapy, initiate amlodipine 5 mg daily 3
• Reassess after at least 2 weeks and follow treatment algorithm until blood pressure falls below 150/95 mmHg (ABPM/HBPM) or 160/100 mmHg (clinic) 3

Blood Pressure Targets

Target blood pressure is <130/80 mmHg for most adults with hypertension. 2

• For patients with mild-moderate hypertension (140-159/90-99 mmHg), aim to reduce blood pressure by at least 20/10 mmHg within 3 months 2
• In heart failure patients, target BP is <140/90 mmHg, with consideration for lowering to <130/80 mmHg in appropriate patients 3
• Avoid systolic BP <130 mmHg and diastolic BP <65 mmHg in octogenarians; check for orthostatic changes 3

Contraindications and Cautions

Avoid Amlodipine In:

• Patients with severe systolic heart failure (NYHA class III-IV) with significant left ventricular dysfunction should use amlodipine cautiously, though it appeared safe in the PRAISE trial 3, 1
• Do NOT use immediate-release nifedipine (another dihydropyridine) in acute coronary syndromes without beta-blocker therapy 3

Use With Caution:

• Nondihydropyridine calcium channel blockers (diltiazem, verapamil) should be avoided in ischemic systolic heart failure due to negative inotropic effects 3
• Long-acting dihydropyridines like amlodipine are preferred over short-acting formulations 3, 2

Common Side Effects

• Peripheral edema (more common with 10 mg dose) 4
• Headache 4
• Flushing 4
• Palpitations 4
• Dizziness 4
• Constipation 2

Monitoring and Follow-up

• Schedule monthly visits until blood pressure target is achieved 2
• Replace 30-day with 90-day refills when possible to improve adherence 2
• Consider telehealth strategies to augment office-based management 2
• Amlodipine maintains effective blood levels throughout the 24-hour dosing interval, providing continuous protection even if a dose is missed 4

Special Populations

Elderly Patients

• Start at 2.5 mg once daily 1
• Amlodipine is particularly beneficial in older adults due to stroke and myocardial infarction protection 4

Hepatic Insufficiency

• Start at 2.5 mg once daily 1

Chronic Kidney Disease

• Amlodipine controls blood pressure without worsening kidney function 4
• No dose adjustment required based on renal function due to low renal clearance (7 mL/min/mg) 4

Diabetes

• Amlodipine successfully lowers blood pressure without worsening glycemic control 4