Should the patient be started on amlodipine 5mg or 10mg?

Amlodipine Starting Dose Recommendation

Start with amlodipine 5 mg once daily, as this is the FDA-approved usual initial antihypertensive dose for adults, with dose escalation to 10 mg only after 7-14 days if blood pressure goals are not achieved. 1

Rationale for 5 mg Starting Dose

• The FDA label explicitly states that "the usual initial antihypertensive oral dose of amlodipine is 5 mg once daily, and the maximum dose is 10 mg once daily" 1
• Starting at 5 mg allows assessment of individual response and tolerability before escalation, as the American College of Cardiology recommends titrating based on blood pressure goals 1
• Clinical evidence demonstrates that 5 mg provides effective blood pressure control in many patients, with 84% achieving target diastolic blood pressure ≤90 mmHg at this dose 2

When to Consider 2.5 mg Starting Dose

• Small, fragile, or elderly patients should be started on 2.5 mg once daily 1
• Patients with hepatic insufficiency require the lower 2.5 mg starting dose 1
• The 2.5 mg dose is also appropriate when adding amlodipine to existing antihypertensive therapy 1

Dose Titration Strategy

• Wait 7-14 days between titration steps under normal circumstances 1
• More rapid titration is acceptable if clinically warranted, provided the patient is assessed frequently 1
• Research shows no advantage to early dose escalation—a dose increase should not be considered until after 6 weeks of treatment at 5 mg once daily, as blood pressure continues to decrease steadily through week 6 2

Why Not Start at 10 mg

• Starting at 10 mg unnecessarily exposes patients to higher risk of dose-dependent adverse effects, particularly peripheral edema, which is the most common side effect of amlodipine 3
• The FDA dosing guidelines do not support 10 mg as an initial dose for hypertension management 1
• Clinical studies demonstrate that 40% of patients required dose escalation from 5 mg to 10 mg, meaning 60% achieved adequate control on the lower dose 2

Monitoring and Follow-up

• Reassess blood pressure within 2-4 weeks after initiating therapy to evaluate response 4
• Target blood pressure should be <140/90 mmHg for most patients, with goals of <130/80 mmHg for higher-risk patients 4
• If blood pressure remains uncontrolled on amlodipine 10 mg after 6 weeks, add a second agent (ACE inhibitor/ARB or thiazide diuretic) rather than exceeding the maximum dose 4

Important Clinical Considerations

• Amlodipine's long half-life (30-50 hours) supports true once-daily dosing with sustained 24-hour blood pressure control 5, 6, 7
• The medication maintains effective blood levels throughout the dosing interval without requiring twice-daily administration 8, 7
• Peripheral edema may be attenuated by adding an ACE inhibitor or ARB if combination therapy becomes necessary 4