Amlodipine Nursing Considerations

Amlodipine Nursing Implications

Amlodipine Nursing Pharmacology

Amlodipine is a medication that is used to treat increased blood pressure. High blood pressure is a condition that if left untreated may cause damage to a person’s brain, heart, kidneys, blood vessels, and the person’s body parts.

Damage to the organs may cause many conditions such as heart attacks, kidney failure, heart failure, vision loss, and many other conditions. Decreased blood pressure will help a person prevent stroke, heart attacks, and problems with the kidneys.

Amlodipine is a long-acting calcium channel blocker drug that works by making the blood vessels relax so the blood may flow easily. Calcium channel blockers are the medications that work by preventing calcium to enter the cells of the heart and the arteries.

Amlodipine has antioxidant properties and the ability to increase the production of nitric oxide. Nitric oxide is an important vasodilator that helps to decrease blood pressure. This medication should be taken regularly even if the patient’s blood pressure level is within the normal range to achieve its full benefit unless stopped by the physician.

In addition to taking amlodipine, lifestyle modification will also help in controlling blood pressure such as eating foods that are low in fat and salt. Maintaining adequate weight, regular exercise, smoking cessation, and drinking alcohol in moderation should be done.

Amlodipine helps in controlling increased blood pressure, angina, and coronary artery disease but amlodipine does not cure these conditions. The patient should continue taking amlodipine even if the patient is feeling well.

Indications of Amlodipine

Amlodipine is used alone or combined with other drugs such as anti-hypertensive and anti-angina drugs for the treatment of the following conditions:

• Hypertension. Amlodipine is the first line of choice among other anti-hypertensive. It may be used alone or may be combined with other hypertensive drugs.
• Angiographically documented coronary artery disease patients. For patients with coronary artery disease, amlodipine is indicated to reduce the risk to be hospitalized from angina and may reduce the risk of having a coronary revascularization procedure.
• Chronic stable angina. Amlodipine is indicated for the treatment of a person with stable chronic angina. It can be taken alone or it may be taken with other anti-angina medications.

Amlodipine is used to avoid chest pain or angina, by increasing the ability to exercise and decreasing angina attacks. Amlodipine is a peripheral vasodilator that directly acts on the smooth vascular muscle that will be causing a reduction in peripheral vascular resistance and a decrease in blood pressure.

The precise mechanisms of amlodipine to relieve angina have not been fully defined, but thought may include the following:

• Exertional angina. Exertional angina usually happens during an activity or physical exertion, that goes away after rest or after taking angina medication. Amlodipine to patients with exertional angina reduces the peripheral resistance or afterload against which the heart works and decreases the rate of pressure product and myocardial oxygen demand, at any level of exercise.
• Vasospastic Angina. Vasospastic angina usually develops after the coronary artery supply of blood and oxygen to the heart becomes narrow and experienced spasm. Amlodipine helps to block constriction and restore blood flow in the coronary arteries and arterioles. This inhibition of coronary spasm is needed for the effectiveness of amlodipine in vasospastic angina.

Mechanism of Action of Amlodipine

Vascular smooth muscle contraction is initiated when the calcium enters the cell through voltage-dependent L-type calcium channels. The calcium binds with the intracellular calmodulin, which binds and activates myosin light-chain kinase.

Myosin light-chain kinase or MLCK  is responsible for the phosphorylation of myosin light-chain, which may lead to muscle contraction and vasoconstriction.

The smooth vascular muscle contraction is amplified by calcium-induced calcium release from the sarcoplasmic reticulum. This sequence leads to a decreased vascular cross-sectional area, increased vascular resistance, and blood pressure increase.

Amlodipine blocks the voltage-dependent L- type calcium channels, that inhibit the initial influx of calcium.

Decreased intracellular calcium leads to decreased vascular smooth muscle contractility and increased muscle relaxation and vasodilation. In addition, amlodipine has improved vascular endothelial function for hypertensive patients.

• Hypertension. Amlodipine is a peripheral arterial vasodilator that acts directly on the smooth vascular muscle leading to a decrease in blood pressure. Amlodipine act as a dihydropyridine calcium antagonist that stops calcium ions into the vascular smooth and cardiac muscle. Studies imply that amlodipine binds the dihydropyridine and non-dihydropyridine located on a cell membrane. The contractions of the cardiac and vascular smooth muscle depend on the movement of extracellular calcium ions into the cells by the ion channels. Amlodipine blocks the calcium ion across the cell membranes. The direct action of amlodipine on vascular smooth muscle is to reduce the person’s blood pressure.
• Angina. Amlodipine acts to dilate the peripheral arterioles that reduce peripheral resistance against the cardiac muscle function. The heart rate remains stable during the administration of amlodipine. The work of the heart is reduced as well as the myocardial energy use and requirement of oxygen.Amlodipine also makes the coronary arteries and coronary arteries to be dilated which helps to reduce blood pressure. The dilation may cause an increase in myocardial oxygen delivery to a person who is experiencing coronary artery spasms and will help to reduce coronary vasoconstriction because of smoking. Amlodipine’s role in relieving angina is lowering the afterload following its vasodilator and anti-hypertensive properties. When the afterload is reduced it may lead to low myocardial oxygen demand at any level of exertion as the heart doesn’t need to work as hard to pump the blood into the systemic circulation.
• Raynaud phenomenon. Amlodipine also helps the patients with Raynau’s phenomenon (RP), which is a condition of excessive vascular response to cold temperature manifested by changes in the color of the distal skin of the digits, toes, toes, and earlobes. Amlodipine induces the smooth muscles to relax and is effective for the treatment of Raynaud’s phenomenon.
• Diabetic nephropathy. ACE inhibitors and angiotensin receptor blockers are the first line of choice for patients with diabetic nephropathy. Clinical trials show that combined antihypertensive therapy with amlodipine and ace inhibitors and angiotensin receptors gives a greater anti-proteinuria effect to patients with diabetic nephropathy.

Pharmacokinetics of Amlodipine

Amlodipine is absorbed after oral administration with peak blood concentrations after 6 to 12 hours. The bioavailability of amlodipine is not changed by the food presence. Amlodipine is metabolized in the liver and is slowly cleared with the elimination of a half-life of 40 to 50 hours.

The pharmacokinetics of amlodipine does not significantly influence by renal impairment. Patients with renal impairment may receive the usual initial dose.

The elderly and the patient with hepatic insufficiency have a decreased clearance of amlodipine as a result of an increase in AUC and a lower initial dose may be required. There are some shreds of evidence that age, severe hepatic impairment, and some renal impairments may influence the pharmacokinetic profile of a person leading to higher plasma concentration.

Amlodipine may show linear dose-related pharmacokinetics features and there is relatively small fluctuation in the concentration of plasma across a dosage interval. In structural relation to other dihydropyridine derivatives, amlodipine shows significantly different pharmacokinetic characteristics and is suitable for a single daily dose administration.

Dosing Considerations when Prescribing and Administering Amlodipine

Amlodipine comes as a tablet or suspension that should be taken by mouth. The dosage of amlodipine varies depending on the patient’s age.

When giving amlodipine to adults,  the usual adult dose is 5mg/day and should be taken orally and the dosage may be increased by 2.5 mg/day every 7 to 14 days.

The dosage should not exceed 5 to 10 mg/day. For geriatric patients, 2.5 mg/day is given initially and should not increase from 5 to 10 mg/day.

For geriatric patients, it is usual to start with a lower dose because elderly patients have decreased renal frequency and decreased hepatic and cardiac function. Children 6 years and younger are given 0.05 to 0.2 mg/kg per day of amlodipine, with a maximum dose of 0.3 to 0.6 mg/kg per day.

Side Effects of Amlodipine

The side effects of amlodipine include the following:   

• Swelling
• Fatigue
• Palpitations
• Dizziness
• Nausea
• Flushing
• Abdominal pain
• Sleepiness
• Male sexual disorder
• Drowsiness
• Itching
• Skin rash
• Muscle cramps
• Muscle weakness

If the side effects are mild, side effects would probably go away within a few days or a couple of weeks after starting the medication. If the side effect becomes more severe and doesn’t go away, the patient should consult the physician.

Other serious side effects of amlodipine include:

• Extrapyramidal symptoms such as muscle spasm, restlessness, muscle rigidity, slow movement, jerky movement, and tremor.
• Low blood pressure
• Fainting
• Increased risk of chest pain or heart attack

If the patient had an allergic reaction after taking amlodipine the patient should discontinue taking the medication. Tell your physician right away if any serious side effects such as fast, irregular, pounding heartbeat, fainting, and an allergic reaction occur.

Adverse Reactions to Amlodipine

Although this medication is used to prevent chest pain, some people who have a previous history of severe heart disease may rarely develop worsening chest pain or heart attack after starting amlodipine or if the dose is increased.

Seek medical help right away if worsening chest pain and symptoms of heart attack occur.

The usual treatment of amlodipine was well tolerated up to 10 mg daily. Most adverse reactions reported for patients while taking amlodipine were mild and moderate.

Termination of taking amlodipine was required in only about 1.5%  of patients and was not significantly different from a placebo of about 1%. It is important to know that amlodipine may cause peripheral edema.

The following events may occur and should be reported to the physician immediately:

• Cardiovascular: Arrhythmia including ventricular tachycardia and atrial fibrillation, bradycardia, chest pain, decreased blood pressure, peripheral ischemia, syncope, tachycardia, postural dizziness, postural hypotension, and vasculitis.
• Central and peripheral nervous system: Occurrence of hypoesthesia, peripheral neuropathy, paresthesia, tremor, and vertigo.
• Gastrointestinal: Presence of anorexia, constipation, dyspepsia, difficulty swallowing, diarrhea, flatulence, pancreatitis, vomiting, and gingival hyperplasia.
• Musculoskeletal system: Presence of arthralgia, arthrosis, muscle cramps, and myalgia.
• Psychiatric: Sexual dysfunction, insomnia, nervousness, depressive behavior, abnormal dreams, anxiety, depersonalization.
• Respiratory system: Occurrence of dyspnea and epistaxis.
• Skin and appendages: Presence of angioedema, erythema multiform, pruritus, rash erythematous, and maculopapular rash.
• Special senses: abnormal vision, conjunctivitis, diplopia, painful eyes, and tinnitus.
• Urinary system: Nocturia and micturition disorder.
• Autonomic nervous system: increased sweating and dry mouth.
• Metabolic: Excessive thirst and hyperglycemia.
• Hematopoietic: Occurrence of leukopenia and purpura

The following events occurred in <0.1% of patients. Amlodipine therapy is not associated with clinically significant changes in the laboratory result of the patient.

Drug Interactions with Amlodipine

In vitro data of the human plasma, amlodipine does not affect the protein binding drugs. If the physician advised the patient to take amlodipine, the physician may already be aware of the possible drug interactions.

Amlodipine can potentially interact with other medications. It is important to tell the physician about all the medications, herbs, and supplements the patient is currently taking before taking amlodipine and any medicines.

An interaction happens when a substance changes how the drug works. This may prevent the drug from working well. Amlodipine may increase systemic exposure when co-administered with other medicines.

The following are medications that can cause drug interactions with amlodipine:

• Heart medications
• Anti-fungal medications
• Antibiotics
• Medication for patients with erection problems
• Cholesterol medications
• Drugs that control the immune system

Nursing Considerations for Patients on Amlodipine

Since amlodipine has a vasodilation effect that is gradual in onset, hypotension has been reported after oral administration. Caution should always be exercised before administering amlodipine as well as the other medication such as peripheral vasodilators particularly the patients with severe aortic stenosis.

During amlodipine therapy participation of the healthcare team is required. The Nurse should check for the patient’s adherence and offer to counsel on medication administration.

Before giving the patient amlodipine the nurse should ask the patient about allergies to medication, especially to amlodipine or any other ingredients that can be found in amlodipine tablets.

The FDA has emphasized some considerations that the nurse and the physician should be aware of before giving amlodipine if the patient is included in the following:

• Pregnancy and lactation. There are no adequate studies on pregnant women and there is a lack of research into the safety of pregnant women. Amlodipine should only be given to pregnant women only if the potential benefit justifies the possible risk to the fetus. It is also not known if amlodipine can be secreted in human milk. In the absence of the information, it is recommended to breastfeeding should be discontinued while taking amlodipine.
• Pediatric patients (children under 6 years old). The effect of amlodipine in children aged 6 years and below is not known due to a lack of studies.
• Geriatric patients. There is no clinical experience identified between the difference in the response of the elderly and younger patients when taking amlodipine. In general, the nurse should be cautious about the dosage for elderly patients. The nurse should start at the low end of the dosing range when giving amlodipine to the elderly because the elderly might have decreased hepatic, renal, and cardiac function.
• Patients with hepatic failure. Hepatic failure happens when the liver is not working well and cannot perform its function. The nurse should be cautious when administering amlodipine to patients with severe hepatic impairment because amlodipine is metabolized by the liver and plasma elimination is 56 hours in a patient with impaired hepatic function.

 Other nursing considerations  for patients on amlodipine also include:

• The nurse should know that amlodipine may cause gingival hyperplasia.  Gingival enlargement is one of the common side effects of certain drugs such as amlodipine, a calcium channel blocker. Amlodipine-induced gingival hyperplasia was managed by scaling and root planing.
• Grapefruit juice may elevate the drug level and drug effect. Grapefruit juice can affect some medications such as amlodipine. In most cases, grapefruit juices increase the level of the medicine in the patient’s blood.
• Monitoring the patient’s blood pressure before and after giving amlodipine. Monitoring the patient’s blood pressure is important because a sudden drop in blood pressure may occur when taking amlodipine. Amlodipine relaxes the blood vessels and lowers the blood pressure.
• Check and monitor the patient’s intake and output from time to time. Since amlodipine is an anti-hypertensive agent adverse side effects should be monitored. Intake and output should be closely monitored to detect or avoid peripheral edema.
• Monitor for the signs and symptoms of CHF.  Congestive heart failure is also known as chronic heart failure. The heart cannot pump blood through the body that ensures an adequate supply of oxygen. Signs of CHF may include; shortness of breath, fatigue, weakness, swelling of the legs, ankle, and feet, rapid and irregular heartbeat, swelling of the abdomen, reduced ability to exercise, and persistent coughing. If the patient shows signs of CHF the nurse should refer the patient to the physician immediately.
• Educate the patient about the interventions for hypertension and teach the patient how to take blood pressure. Educating the patient about the interventions and teaching the patient to take his or her blood pressure aims to give knowledge to the patient to avoid the risk of complications.

Nursing Diagnosis for Patients on Amlodipine

Possible Nursing Diagnoses

• Risk for Impaired Skin Integrity related to the possible side effect of amlodipine
• Impaired Sleep Pattern related to the possible side effect of amlodipine
• Nausea related to the side effect of amlodipine
• Deficient Knowledge related to a new drug prescription

Nursing Assessment

Nursing Planning and Intervention

Nursing Evaluation

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

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