When should we give Amlodipine (amlodipine) to patients with hypertension?

When to Give Amlodipine for Hypertension

Amlodipine should be initiated as first-line therapy for hypertension in most adults at 5 mg once daily, with particular consideration for Black patients, elderly patients, and those with coronary artery disease or stable heart failure. 1, 2

Primary Indications for Amlodipine

First-Line Use

• Black adults with hypertension (without heart failure or chronic kidney disease) should receive either a thiazide-type diuretic or calcium channel blocker like amlodipine as initial therapy 3
• Elderly patients (≥65 years) benefit particularly well from amlodipine, with greater SBP reductions (25/16 mm Hg) compared to younger patients (21/15 mm Hg) 4, 5
• Isolated systolic hypertension responds especially well to amlodipine therapy 5

Coronary Artery Disease Patients

• Patients with chronic stable angina or vasospastic angina should receive amlodipine 5-10 mg daily, with most requiring 10 mg for adequate effect 1
• Documented coronary artery disease warrants amlodipine 5-10 mg once daily, with the majority of patients requiring 10 mg in clinical studies 1
• Amlodipine is safe in patients with chest pain and coronary disease, showing no increased risk of adverse cardiac events 2

Heart Failure with Hypertension

• Severe systolic heart failure patients can safely receive amlodipine when hypertension persists despite standard heart failure therapy (ACE inhibitors/ARBs, beta-blockers, aldosterone antagonists) 6, 7
• The PRAISE trial demonstrated amlodipine's safety in severe systolic HF, unlike non-dihydropyridine CCBs (diltiazem, verapamil) which should be avoided 6
• Amlodipine serves as a step 3 agent when BP remains elevated on guideline-directed HF therapy 7

Dosing Algorithm

Initial Dosing

• Standard starting dose: 5 mg once daily for most adults 1, 3
• Reduced starting dose: 2.5 mg once daily for small, fragile, elderly patients, or those with hepatic insufficiency 1
• Pediatric patients (ages 6-17): 2.5 mg once daily, maximum 5 mg daily 1, 3

Dose Titration

• Wait 7-14 days between titration steps under normal circumstances 1
• Titrate more rapidly if clinically warranted with frequent patient assessment 1
• Increase to 10 mg once daily (maximum dose) if BP remains ≥130/80 mm Hg after 2-6 weeks at 5 mg 3, 1
• Consider adding a second agent rather than maximizing amlodipine if BP control is inadequate after 4-6 weeks at 5 mg 3

Preferred Combinations

• Amlodipine + ACE inhibitor or ARB 3
• Amlodipine + thiazide-type diuretic 3
• These combinations are particularly effective as most adults require two or more agents to achieve BP <130/80 mm Hg 3

Blood Pressure Targets

General Population

• Target BP: <130/80 mm Hg for most adults with hypertension 3
• Confirm inadequate control with home BP monitoring (≥135/85 mm Hg) or 24-hour ambulatory monitoring (≥130/80 mm Hg) before escalating 3

Heart Failure Patients

• Target BP: <140/90 mm Hg, with consideration for lowering to <130/80 mm Hg 6
• In octogenarians, avoid SBP <130 mm Hg and DBP <65 mm Hg; check for orthostatic changes 6
• Older patients with wide pulse pressures may develop very low DBP (<60 mm Hg) when lowering SBP—monitor carefully for symptoms 6

Clinical Advantages and Outcomes

Cardiovascular Benefits

• Reduces stroke risk by 25% compared to atenolol-based therapy in diabetic patients 7
• Equivalent efficacy to chlorthalidone in preventing coronary heart disease mortality in the ALLHAT trial 7
• No significant difference in cardiac events compared to valsartan in the VALUE trial, with significant MI reduction 2, 7

Special Populations Safety

• Renal protection: Decreases renal function decline in hypertensive patients with non-diabetic nephropathies over 3 years 2
• Post-MI patients: Safe and effective when intolerant to ACE inhibitors with HF or EF ≤40% 6

Critical Contraindications and Cautions

Absolute Avoidance

• Do NOT use non-dihydropyridine CCBs (diltiazem, verapamil) in systolic HF—they worsen outcomes due to negative inotropic effects 6, 7
• Use amlodipine with caution in severe aortic stenosis or hypertrophic cardiomyopathy due to vasodilatory effects 2

Monitoring Requirements

• Check medication adherence before escalating dose—non-adherence is the most common cause of apparent treatment failure 3
• Measure BP at trough (just before next dose) to ensure 24-hour control 3
• Monthly visits until BP target achieved, then transition to 90-day refills 3

Common Pitfalls to Avoid

• Do not use short-acting nifedipine—it causes reflex sympathetic activation and worsening ischemia 6
• Do not combine with phosphodiesterase inhibitors (sildenafil-type drugs) when using nitrates concurrently 6
• Do not exceed 5 mg daily in pediatric patients—higher doses lack safety data 1
• Monitor for peripheral edema, headache, flushing, and constipation—the most common side effects 3