Amlodipine Dosing for Hypertension and Angina
Starting Dose for Adults
For hypertension, start amlodipine at 5 mg once daily in most adults, with a maximum dose of 10 mg once daily. 1
- The 5 mg starting dose provides effective blood pressure control in the majority of patients 1, 2
- Titration to 10 mg should occur after 7-14 days if blood pressure goals are not met, though more rapid titration is acceptable if clinically warranted with frequent patient assessment 1
- Research demonstrates no advantage to early dose escalation—wait at least 6 weeks at 5 mg before increasing to 10 mg, as blood pressure continues to decrease steadily through week 6 3
For chronic stable angina or vasospastic angina, the recommended dose range is 5-10 mg once daily, with most patients requiring 10 mg for adequate symptom control. 1, 4
Special Populations Requiring Lower Starting Doses
Elderly Patients (≥65 years)
Start at 2.5 mg once daily in elderly patients due to decreased drug clearance and prolonged elimination half-life (64 hours vs. 48 hours in younger patients). 1, 5
- Elderly patients experience 40-60% higher drug exposure (AUC) compared to younger adults 1, 6
- Despite lower starting doses, elderly patients achieve significant blood pressure reductions (systolic: 171→149 mmHg, diastolic: 100→90 mmHg) at doses ranging from 2.5-10 mg daily 5
- The 2007 European Society of Cardiology guidelines emphasize that initial doses and subsequent titration should be more gradual in elderly patients due to greater risk of adverse effects, especially in very old and frail subjects 7
Hepatic Impairment
Start at 2.5 mg once daily in patients with hepatic insufficiency. 1
- Elimination half-life is significantly prolonged in cirrhotic patients (60 hours vs. 34 hours in normal hepatic function), resulting in greater drug accumulation 6
- Clearance of amlodipine is decreased by approximately 40-60% in hepatic impairment 1
Low Baseline Blood Pressure
Start at 2.5 mg once daily in small, fragile patients or those with baseline blood pressure concerns. 1
- This lower starting dose is also appropriate when adding amlodipine to existing antihypertensive therapy to minimize risk of excessive blood pressure lowering 1
- The magnitude of blood pressure reduction correlates with pretreatment elevation—patients with moderate hypertension (diastolic 105-114 mmHg) experience 50% greater response than those with mild hypertension (diastolic 90-104 mmHg) 1
- Normotensive subjects experience minimal blood pressure changes (+1/-2 mmHg), providing a safety margin 1
Dosing in Pediatric Hypertension (Ages 6-17)
The effective dose range is 2.5-5 mg once daily, with doses exceeding 5 mg daily not studied in this population. 1
- Weight-adjusted clearance and volume of distribution are similar to adult values 1
Common Pitfalls and Monitoring
Titration Timing
- Do not increase the dose before 6 weeks of therapy at 5 mg, as blood pressure continues to decline throughout this period 3
- Steady-state plasma levels are reached after 7-8 days of consecutive daily dosing, but clinical effect continues to develop 1
Side Effect Management
- Peripheral edema, headache, dizziness, and flushing are more common with the 10 mg dose 8, 9
- The European Society of Cardiology notes that amlodipine may precipitate heart failure in predisposed patients, though it can be used in compensated heart failure if not controlled by other therapy 8
- Avoid switching to other dihydropyridines (nifedipine, felodipine) for headache management, as they share the same side effect profile 10
Drug Interactions
- Strong CYP3A inhibitors (itraconazole, clarithromycin) may significantly increase amlodipine exposure; diltiazem increases exposure by 60% 1
- Amlodipine increases simvastatin exposure by 77%, tacrolimus exposure by 2.5-4 fold, and cyclosporine levels by 40% on average 1