Maximum Dose of Amlodipine in Hypertension with Renal Impairment
The maximum recommended dose of amlodipine is 10 mg once daily for adults with hypertension, including those with impaired renal function, as no dose adjustment is required for renal impairment. 1
Standard Dosing Guidelines
The FDA-approved dosing regimen for amlodipine in hypertension follows a straightforward escalation pattern 1:
- Initial dose: 5 mg once daily for most adults 1
- Maximum dose: 10 mg once daily 1
- Titration timing: Wait 7-14 days between dose adjustments, though more rapid titration is acceptable with frequent patient assessment 1
For small, fragile, or elderly patients, a starting dose of 2.5 mg once daily may be appropriate, with subsequent titration as needed 1.
Renal Impairment Considerations
Amlodipine is uniquely advantageous in patients with renal dysfunction because it requires no dose adjustment and demonstrates renoprotective effects. 2, 3
Key evidence supporting full-dose use in renal impairment:
- Amlodipine has minimal renal clearance (only 7 mL/min/mg), making accumulation unlikely even in severe renal dysfunction 2
- Clinical studies in 35 hypertensive patients with renal dysfunction showed that amlodipine 2.5-5 mg daily achieved blood pressure targets in 80% of patients with minimal worsening of renal function 3
- No tendency for drug accumulation was observed in patients with renal impairment, even after 8-10 weeks of treatment 3
- Amlodipine may actually provide renoprotective effects, particularly when combined with ACE inhibitors or ARBs 4, 2
Practical Dosing Algorithm
Step 1: Start with 5 mg once daily in most patients, including those with renal impairment 1
Step 2: Assess blood pressure after 7-14 days 1
Step 3: If blood pressure remains ≥130/80 mmHg (or above individualized target), increase to 10 mg once daily 2, 1
Step 4: If blood pressure control remains inadequate after 4-6 weeks at 10 mg, add a second agent rather than exceeding the maximum dose 2
Preferred combination strategies include 2:
- Amlodipine + ACE inhibitor or ARB (particularly beneficial in renal impairment)
- Amlodipine + thiazide-type diuretic
Special Populations
Pediatric patients (ages 6-17 years) have different dosing limits 1:
- Starting dose: 2.5 mg once daily
- Maximum dose: 5 mg once daily (doses above 5 mg have not been studied in children)
Elderly or hepatically impaired patients may benefit from starting at 2.5 mg once daily, but can still be titrated to the standard maximum of 10 mg if needed and tolerated 1.
Safety Monitoring
Common dose-dependent side effects at 10 mg include 2:
- Peripheral edema (10-30% of patients)
- Headache
- Flushing
- Constipation
In patients with renal dysfunction, monitor for 3:
- Blood urea nitrogen and serum creatinine (mild increases may occur but are typically not clinically significant)
- Blood pressure at trough (just before next dose) to ensure 24-hour control 2
Critical Pitfall to Avoid
Do not withhold or reduce amlodipine dosing based solely on renal impairment. The drug's pharmacokinetics make it safe at standard doses even in severe renal dysfunction, and dose reduction may result in inadequate blood pressure control, which itself accelerates renal decline 2, 3.