Amlodipine: NHS prescribing information and NICE guidance

NICE guideline NG136, 'Hypertension in adults: diagnosis and management', offers a clear, evidence-based pathway for blood pressure treatment.

Amlodipine is a key part of this pathway.

Who should be offered amlodipine first?

NICE suggests a calcium channel blocker, like amlodipine, as a first choice for:

• Adults aged 55 and over with stage 1 hypertension. Their clinic BP should be 140-159/90-99 mmHg. They should also have a 10-year cardiovascular risk of 10% or more.
• Adults of Black African or Black Caribbean family origin, at any age.
• Patients who cannot take ACE inhibitors or ARBs.

Treatment steps:

• Step 1: Amlodipine alone. For those under 55, an ACE inhibitor or ARB is an option.
• Step 2: Combine amlodipine with an ACE inhibitor or ARB.
• Step 3: Add a thiazide-like diuretic. This creates triple therapy.
• Step 4: For resistant hypertension, consider adding spironolactone. This is if potassium is 4.5 mmol/L or less.

Blood pressure targets:

• Under 80 years: Clinic BP below 140/90 mmHg. ABPM/home BP should be below 135/85 mmHg.
• 80 years and over: Clinic BP below 150/90 mmHg. ABPM/home BP should be below 145/85 mmHg.

I always explain the NICE pathway to my patients. Understanding amlodipine's role helps them stick to their treatment. It also boosts their motivation.

Amlodipine is a prescription-only medicine. You cannot buy it over the counter. Here is how you can get it.

Diagnosis of hypertension:

Your GP will follow the NICE diagnostic pathway before prescribing amlodipine:

1. Clinic blood pressure: If your clinic reading is 140/90 mmHg or higher, you need further checks.
2. Ambulatory blood pressure monitoring (ABPM): You wear a device for 24 hours. It takes readings every 30 minutes. This is the best way to diagnose hypertension.
3. Home blood pressure monitoring (HBPM): This is an alternative to ABPM. You take readings twice daily for at least 4 days.
4. Cardiovascular risk assessment: A QRISK3 score helps assess your overall risk.

Starting amlodipine:

• Your GP will prescribe amlodipine 5 mg once daily. They may prescribe 2.5 mg if you are elderly or have liver problems.
• You will have baseline blood tests. These include a full blood count, renal function, electrolytes, lipid profile, and HbA1c.
• You will also have a urine test. This checks your albumin to creatinine ratio to screen for kidney issues.

Ongoing prescriptions:

• Once your blood pressure is stable, amlodipine is given as a repeat prescription.
• Electronic repeat dispensing means your pharmacy gets prescriptions automatically.
• You will have an annual review. This includes blood tests and a blood pressure check.

Cost:

Generic amlodipine is very good value. Standard NHS prescription charges apply in England. Prescriptions are free in Scotland, Wales, and Northern Ireland.

They are also free for exempt groups in England, such as those over 60 or under 16.

Regular monitoring is vital for all patients taking blood pressure medication. The NHS provides a structured approach. This involves GP practices and community pharmacies.

Annual hypertension review:

Your GP practice should offer an annual review. This review includes:

• Blood pressure measurement. Ideally, an automated device is used to avoid 'white-coat effect'.
• A review of cardiovascular risk factors.
• Blood tests: renal function, electrolytes, lipid profile, and HbA1c.
• A medication review. This checks adherence, side effects, and the correct dose.
• A lifestyle discussion: diet, exercise, smoking, and alcohol.

Home monitoring:

NICE recommends home blood pressure monitoring. This is part of ongoing management. Many GP practices lend monitors to patients. Validated devices are available to buy for about £20 to £30.

Community pharmacy services:

• NHS Blood Pressure Check Service: Adults aged 40 and over can get a free blood pressure check. This is available at participating pharmacies without a GP appointment.
• New Medicine Service (NMS): If you have just started amlodipine, your pharmacist may call you. They will check for side effects and answer questions at 7 and 14 days.
• Medicines Use Review (MUR): This is a detailed review of all your medications.

NHS Health Check:

Every adult in England aged 40 to 74 can get a free NHS Health Check every 5 years. This is for those without an existing cardiovascular condition.

It includes blood pressure assessment, cholesterol testing, and cardiovascular risk scoring. Often, this is when hypertension is first found.

The NHS and NICE stress that lifestyle changes are key. They are a cornerstone of hypertension management. This applies both with and, sometimes, before medication.

Salt reduction:

• Aim for less than 6 g of salt per day. This is about one teaspoon.
• Check food labels. Many processed foods, bread, and cereals contain hidden salt.
• Reducing salt intake by 6 g per day can lower systolic blood pressure by about 5 mmHg.

Diet:

• Follow the DASH diet. This stands for Dietary Approaches to Stop Hypertension. Alternatively, follow a Mediterranean-style diet.
• Eat at least 5 portions of fruit and vegetables daily.
• Choose whole grains instead of refined carbohydrates.
• Include potassium-rich foods. Bananas, potatoes, and spinach help balance sodium effects.

Physical activity:

• Do at least 150 minutes of moderate-intensity activity each week.
• Even 10-minute bursts of brisk walking count towards your weekly total.
• Regular exercise can lower systolic BP by 5 to 8 mmHg.

Weight management:

• Keeping a healthy BMI (18.5 to 24.9) greatly improves blood pressure control.
• NHS weight management programmes are available. Your GP can refer you.

Alcohol:

• Stay within 14 units per week. Spread these units over at least 3 days.
• Reducing alcohol intake can lower blood pressure within weeks.

Smoking:

• Smoking does not directly cause ongoing hypertension. However, it greatly increases cardiovascular risk.
• The NHS Stop Smoking Service is free and very effective.

These measures can reduce the need for higher amlodipine doses. Sometimes, they may even allow for a dose reduction over time.

Proactive monitoring and timely medical reviews are vital. They ensure good blood pressure management.

Book a routine GP appointment if:

• Your home blood pressure readings are consistently above 135/85 mmHg. This is despite taking amlodipine as prescribed.
• You are experiencing side effects that affect your quality of life.
• You want to discuss adjusting your dose.
• You have not had a blood pressure review in the last 12 months.
• You plan to become pregnant. Amlodipine should be changed to a pregnancy-safe alternative.

Seek urgent medical advice if:

• Your blood pressure reading is above 180/120 mmHg. This is a hypertensive crisis.
• You have a severe headache with visual problems, nausea, or confusion.
• You experience chest pain, breathlessness, or one-sided weakness. These could be signs of a stroke or heart attack. Call 999 immediately.
• You feel dizzy, faint, or have collapsed. This might be due to too much medication or an interaction.

NHS 111:

If you are unsure whether your symptoms need urgent attention, call NHS 111 or visit 111.nhs.uk. They provide 24-hour assessment. They can advise if you need to go to A&E or see a GP urgently.

Remember, hypertension is a 'silent' condition. Regular monitoring is the only way to ensure your blood pressure is controlled. Take an active role in your care.

Attend your annual reviews and monitor your blood pressure at home.