What is the maximum recommended daily dose of amlodipine (calcium channel blocker) for a patient with hypertension or coronary artery disease, considering potential risk factors such as impaired renal function or older age?

Maximum Daily Dose of Amlodipine

The maximum recommended daily dose of amlodipine is 10 mg once daily for adults with hypertension or coronary artery disease. 1

Standard Adult Dosing

• Initial dose: 5 mg once daily is the usual starting dose for most adults with hypertension 1, 2
• Maximum dose: 10 mg once daily represents the ceiling dose for adults 1, 3, 2
• Titration interval: Wait 7 to 14 days between dose adjustments, though more rapid titration is acceptable if the patient is assessed frequently 1

The FDA-approved labeling explicitly states that 10 mg once daily is the maximum dose, and this is consistently supported across multiple guidelines 1, 3, 2.

Special Populations Requiring Dose Modification

Elderly Patients

• Starting dose: 2.5 mg once daily for elderly, small, or fragile patients 1
• Maximum dose: Still 10 mg once daily, though many elderly patients achieve adequate control at lower doses 1, 4
• Elderly patients show prolonged elimination half-life (64 hours vs. 48 hours in younger patients) and may have greater blood pressure reductions at equivalent doses 4

Hepatic Insufficiency

• Starting dose: 2.5 mg once daily 1
• Maximum dose: 10 mg once daily, though dose escalation should be cautious 1
• For angina in patients with hepatic insufficiency, lower doses (5 mg) are suggested 1

Renal Impairment

• No dose adjustment required: Amlodipine has very low renal clearance (7 mL/min/mg) and does not require dose reduction based on renal function 5
• Amlodipine demonstrates renoprotective effects and does not worsen kidney function in CKD patients 3, 5

Pediatric Patients (Ages 6-17 Years)

• Starting dose: 2.5 mg once daily 1, 2
• Maximum dose: 5 mg once daily (doses exceeding 5 mg have not been studied in children) 1, 2

Clinical Context for Dose Escalation

When to escalate from 5 mg to 10 mg:

• Blood pressure remains ≥130/80 mmHg after 2-6 weeks at 5 mg 2
• Confirm inadequate control with home blood pressure monitoring (≥135/85 mmHg) or 24-hour ambulatory monitoring (≥130/80 mmHg) before escalating 2
• Check medication adherence before increasing dose, as non-adherence is a common cause of apparent treatment failure 2

Alternative to maximizing amlodipine monotherapy:

• Consider adding a second agent (ACE inhibitor/ARB or thiazide diuretic) rather than escalating to 10 mg if blood pressure control is inadequate after 4-6 weeks at 5 mg 2
• Combination therapy is often more effective than maximizing single-agent doses 2

Important Clinical Considerations

Side effects are dose-dependent:

• Common adverse effects include peripheral edema, headache, flushing, and constipation 3, 2, 5
• These side effects are more common at the 10 mg dose 5
• Edema occurs in approximately 10-30% of patients and is more frequent at higher doses 3

Pharmacokinetic advantages:

• Long half-life (35-50 hours) provides sustained antihypertensive effect for more than 24 hours 5
• Blood pressure control is maintained even when a dose is missed, providing protection against incidental non-adherence 5
• Can be administered at any convenient time of day to improve adherence 2

Cardiovascular benefits:

• The 10 mg dose was required for adequate effect in most patients with coronary artery disease in clinical studies 1
• For chronic stable or vasospastic angina, the recommended dose range is 5-10 mg, with most patients requiring 10 mg for adequate effect 1, 3