Amlodipine Dosing and Usage Guidelines
For hypertension, start amlodipine at 5 mg once daily in most adults, with a maximum dose of 10 mg once daily; for angina, the effective dose range is 5-10 mg once daily, with most patients requiring 10 mg for adequate symptom control. 1
Standard Dosing for Adults
Hypertension
- Initial dose: 5 mg once daily 1
- Maximum dose: 10 mg once daily 1
- Titrate dosage according to blood pressure goals, waiting 7-14 days between titration steps 1
- More rapid titration is acceptable if clinically warranted with frequent patient assessment 1
- Amlodipine provides smooth 24-hour blood pressure control with once-daily dosing, with plasma concentration fluctuation of only 20-25% between doses 2
Angina (Chronic Stable or Vasospastic)
- Recommended dose: 5-10 mg once daily 1
- Most patients require 10 mg for adequate anti-anginal effect 1, 3
- Exercise testing confirms full 24-hour anti-ischemic efficacy when measured 24 hours post-dose 3
Coronary Artery Disease
- Recommended dose range: 5-10 mg once daily 1
- Clinical studies demonstrate that the majority of patients required 10 mg for optimal outcomes 1
Special Population Dosing
Elderly, Small, or Fragile Patients
- Start at 2.5 mg once daily 1
- This lower starting dose is also appropriate when adding amlodipine to existing antihypertensive therapy 1
- The elderly may benefit from the lower 5 mg dose for angina 1
Hepatic Insufficiency
- Start at 2.5 mg once daily 1
- Lower doses (5 mg) are suggested for angina in patients with hepatic impairment 1
Pediatric Patients (Ages 6-17 Years)
- Effective dose: 2.5-5 mg once daily 1
- Doses exceeding 5 mg daily have not been studied in pediatric patients 1
Pediatric Pulmonary Hypertension
- Starting dose: 0.1-0.3 mg/kg/day orally 4
- Dose range: 2.5-7.5 mg/day 4
- Maximum adult dose: 10 mg/day 4
- Always uptitrate from a lower dose 4
- Duration of benefit may be limited even with initial favorable response; periodic reassessments for responsiveness are indicated 4
Renal Function Considerations
No dose adjustment is required for renal impairment. Amlodipine is a low-clearance drug with high oral bioavailability (60-80%) that is not significantly affected by renal function 2. The drug accumulates to steady-state over 1-1.5 weeks with once-daily administration 2.
Key Pharmacokinetic Properties
- Elimination half-life: 40-60 hours, allowing true once-daily dosing 2
- Peak plasma concentration: 6-8 hours post-dose, contributing to gradual onset of effect 2
- Steady-state achieved: 7-10 days of once-daily dosing 2
- Blood pressure decreases gradually over 4-8 hours after single doses, with no reflex tachycardia due to gradual onset 2
Combination Therapy
Amlodipine combines effectively with other antihypertensive classes when monotherapy is insufficient 5:
- ACE inhibitors: produces important additional antihypertensive effects 5
- Beta-blockers: provides improved anti-anginal efficacy in patients with uncontrolled chronic stable angina 3
- Thiazide diuretics: enhances blood pressure reduction 5
Common Adverse Effects
The primary side effects are vasodilatory and dose-dependent 4:
- Peripheral edema
- Bradycardia (less common than with other calcium channel blockers)
- Decreased cardiac output
- Rash
- Gum hyperplasia
- Constipation
Critical Clinical Pearls
- No tolerance develops with long-term use 5, 6
- No rebound hypertension upon discontinuation; blood pressure returns slowly to baseline over 7-10 days 2
- No orthostatic hypotension due to gradual onset of action 6
- Blood pressure control shows a smooth profile over 24 hours with minimal fluctuation 6
- Superior to long-acting nitrates for angina, producing fewer angina episodes per week and treating concurrent hypertension without tolerance 7
Contraindications and Cautions
While amlodipine and felodipine have demonstrated neutral effects on survival in heart failure patients, they may be used safely for concomitant hypertension or angina not controlled by other agents 4. However, avoid all calcium channel blockers in patients with pulmonary edema or severe left ventricular dysfunction 4.