In an 86‑year‑old woman with uncontrolled hypertension, orthostatic symptoms, high fall risk, and impaired renal function, how should I switch her from lisinopril (ACE inhibitor) to amlodipine (calcium‑channel blocker)?

How to Switch from Lisinopril to Amlodipine in an Elderly Patient with Orthostatic Symptoms

In this 86-year-old woman with orthostatic symptoms, high fall risk, and impaired renal function, stop lisinopril immediately and start amlodipine 2.5 mg once daily the next day—no tapering or overlap is needed because both agents have long half-lives and the switch eliminates the ACE inhibitor's contribution to orthostatic hypotension. 1

Why Amlodipine is the Preferred Choice

Long-acting dihydropyridine calcium-channel blockers like amlodipine are specifically recommended as first-line agents for elderly patients with hypertension and orthostatic hypotension because they have minimal orthostatic effects. 2, 1 This is critical in your patient given her documented orthostatic symptoms and high fall risk.

• ACE inhibitors like lisinopril worsen orthostatic hypotension in elderly patients, particularly those with impaired renal function 2, 1
• Amlodipine's 35-50 hour half-life provides sustained 24-hour blood pressure control even if a dose is missed, offering protection against compliance lapses common in elderly patients 3
• In patients with renal dysfunction, amlodipine has very low renal clearance (7 mL/min/mg) and does not accumulate or worsen kidney function 4, 3

Specific Switching Protocol

Step 1: Pre-Switch Assessment

• Measure blood pressure after 5 minutes of sitting, then at 1 and 3 minutes after standing to document baseline orthostatic changes 1, 5
• Document current orthostatic symptoms (dizziness, lightheadedness, falls) 1
• Check recent serum creatinine and potassium levels 2

Step 2: Medication Transition

• Discontinue lisinopril completely 1
• Start amlodipine 2.5 mg once daily the following day 1
• No tapering of lisinopril is required—ACE inhibitors can be stopped abruptly without rebound hypertension 1
• No overlap period is needed given the long half-lives of both medications 3

Step 3: Initial Monitoring (Week 1-2)

• Re-evaluate orthostatic blood pressure measurements and symptoms at 1-2 weeks 1
• Assess for peripheral edema, the most common side effect of amlodipine 1, 3
• Monitor for dizziness, palpitations, or flushing (more common at higher doses) 3

Step 4: Dose Titration

• If blood pressure remains elevated and orthostatic symptoms have improved, increase to amlodipine 5 mg daily after 1-2 weeks 1
• Steady-state is reached after 7-8 days at each dose level 1
• Maximum dose is 10 mg daily, titrated gradually as tolerated 1, 4

Critical Safety Considerations in This Patient

Renal Function Protection

• Amlodipine causes little or no aggravation of renal dysfunction in hypertensive patients with renal impairment 4
• Unlike lisinopril, amlodipine does not require dose adjustment for renal dysfunction 4, 3
• ACE inhibitors carry higher risk of hyperkalemia in elderly patients with impaired renal function 1

Fall Risk Mitigation

• Recent evidence demonstrates that intensive blood pressure lowering does not increase orthostatic hypotension or falls—in fact, it may reduce orthostatic hypotension by improving baroreflex function 2
• Asymptomatic orthostatic hypotension should not trigger automatic down-titration of amlodipine 2
• The switch from lisinopril to amlodipine specifically addresses her orthostatic symptoms by eliminating a medication class that worsens postural hypotension 1, 5

Blood Pressure Targets

• For community-dwelling adults ≥65 years, target systolic blood pressure <130 mmHg if tolerated 2
• For frail elderly patients (which may apply given her fall risk), a more conservative target of <150 mmHg systolic is reasonable 2
• Individualize based on frailty status and tolerance 2

Non-Pharmacologic Interventions to Implement Concurrently

These measures directly address orthostatic hypotension and should be started immediately:

• Increase fluid intake to 2-3 liters per day unless contraindicated by heart failure 1
• Increase dietary sodium to 6-9 grams per day unless contraindicated 1
• Elevate head of bed by approximately 10 degrees during sleep to reduce nocturnal polyuria 1
• Teach physical counter-maneuvers (leg crossing, squatting, muscle tensing) for symptomatic episodes 1, 5
• Consider compression garments (waist-high stockings or abdominal binders) to reduce venous pooling 1

Common Pitfalls to Avoid

• Do not taper lisinopril or use an overlap period—this unnecessarily prolongs exposure to a medication worsening her orthostatic symptoms 1
• Do not start amlodipine at 5 mg in frail elderly patients—begin at 2.5 mg to assess tolerance 1
• Do not automatically reduce amlodipine if asymptomatic orthostatic hypotension is detected—this finding alone does not predict adverse outcomes 2
• Do not add back an ACE inhibitor or ARB prematurely—allow at least 3 months of amlodipine monotherapy before considering combination therapy, and only if orthostatic symptoms are well-controlled and fall risk mitigated 1

When to Consider Adding a Second Agent

If blood pressure remains uncontrolled after approximately 3 months on amlodipine monotherapy (titrated to maximum tolerated dose), you may cautiously add a low-dose RAS blocker, but only if:

• Orthostatic symptoms are well-controlled 1
• Fall risk has been mitigated 1
• Renal function is stable 1

However, given her current presentation, amlodipine monotherapy is the appropriate initial strategy.