Amlodipine: Do You Still Need It? | Dr Dan Reardon

Amlodipine. Do you still need it?

Amlodipine is the most prescribed blood pressure tablet in England, and one of the easiest to leave running unquestioned for years. This page is what I, Dr Dan Reardon, consider when someone on it sits opposite me in Sutton Coldfield.

Around 41 million prescriptions a year in England, three quarters of all calcium-channel blocker prescriptions

Usually started for blood pressure, sometimes for angina, sometimes hidden inside a combination tablet

No withdrawal syndrome when it is stopped, so the question is never the taper. It is whether you still need it

Why it was started, and why it is still there.

Amlodipine is usually the first or second blood pressure tablet a person is given. It is cheap, it works, and it needs no blood tests. It gets added, the dose gets adjusted once, and then it is carried unchanged through the years in which you get older, lose or gain weight, become fitter or frailer, and collect other tablets.

The problem is rarely that amlodipine has stopped working. It is that the person it was prescribed for has changed and the prescription has not. The blood pressure target that was right for you at 58 may not be the right target at 78. The dose that was right at one weight may not be right at another. And nobody is paid to notice.

I am not against amlodipine. In the right person it is preventing strokes, and I would not take it away from them. The question I ask is whether you are still that person.

The four questions, asked of amlodipine.

Why was it started?

Nearly always for blood pressure. Occasionally for angina, which changes everything that follows. And sometimes it is there twice: once on its own and once inside a combination tablet with another blood pressure medicine, which nobody has noticed because the combination has a different name.

What I want to see: the original reason, in writing, and every tablet on the list that contains it.

Is the problem it treated still there?

High blood pressure rarely goes away on its own, so for amlodipine this question has a different shape. It is not whether you still have high blood pressure. It is whether the target you are being treated to is still the right target for you now, and whether amlodipine is still the right way to reach it.

What I want to see: your readings at home, not in a clinic, because the two are not the same number.

Has your physiology changed since?

Weight lost or gained. Fitness built. Kidneys older. A fall, a dizzy spell, a blood pressure that drops when you stand. In a frail older person on two or more blood pressure medicines, treated to a number set for a robust 60-year-old, reducing one of them has been studied properly and is often safe. In a 70-year-old whose top number is high and who is otherwise well, the same tablet may be the thing standing between them and a stroke.

What I want to see: how you have changed since it was started, and what your blood pressure does when you stand up.

Is one medicine treating another's side effect?

This is the amlodipine question. Amlodipine swells ankles, and the higher the dose the more often: a small minority at starting doses, around a quarter of people at the top dose. The swelling is not fluid overload. It comes from pressure changes in the small vessels of the legs. So when it is read as heart failure and a water tablet is added, the water tablet cannot work, and now there are two tablets where there should be a different decision.

If you take amlodipine, your ankles swell, and someone has added a water tablet for it, I would like to see you.

What changing or stopping amlodipine involves.

Unlike some blood pressure medicines, amlodipine does not cause a rebound when it is stopped. There is no withdrawal syndrome and no taper for its own sake. What happens is simpler and still needs watching: your blood pressure drifts back towards where it was, over days to weeks, and the only way to know whether that matters is to measure it at home against a target that is right for you, with an agreed point at which it goes back on.

Often the right answer is not to stop at all. It is to reduce the dose, or to change to a medicine in the same family that swells ankles less, or to a different kind of blood pressure medicine that actually reduces the swelling. Which of those applies is the plan, and the plan is written for one person.

One exception matters. If the medicine on your list is diltiazem or verapamil rather than amlodipine, it may be there to control a heart rhythm, not blood pressure, and the whole question changes. Never stop or change a blood pressure medicine without talking to a doctor.

When amlodipine should stay.

When it is preventing strokes. In older people with a high top number, this family of medicines has been shown to cut strokes by close to half. Age alone is never a reason to stop.

When your blood pressure is not controlled, or you have had a heart attack or stroke recently. Deprescribing is for over-treatment, not under-treatment.

When it is doing a job other than blood pressure, such as angina.

When it is the only thing controlling a real need. Then the answer is to substitute, not to stop, and sometimes it is simply to continue, with the reason written down.

What the review does for someone on amlodipine.

I am Dr Dan Reardon, an NHS A&E doctor, GMC 6098984, and a CQC-registered independent doctor provider. In private practice I do one thing: the Independent Medication Review, in person at Sutton Medical Consulting in Sutton Coldfield.

For someone on amlodipine, the review goes through the whole list, because amlodipine is rarely the only thing on it and the decision about it depends on what else is there. I take the history, I read your home readings, I ask the four questions of every medicine, and I write you a plan: what to keep and why, what to change and how, and at what point we check. If the plan involves reducing or stopping something, I can manage that with you, month by month, until it is done.

Sometimes the plan says the amlodipine stays exactly as it is. That is a good outcome too. You will know why.

MB ChB · BSc · MSc Mental Health · GMC 6098984 · CQC registered

Questions people ask about amlodipine.

Can I just stop taking amlodipine?

Not without a doctor. Amlodipine does not cause a withdrawal syndrome when it is stopped, but your blood pressure goes back towards where it was, and whether that matters depends on why it was started and what it is protecting you from. The decision needs your readings, your history and someone taking responsibility for it.

Does amlodipine cause swollen ankles?

Yes, and the higher the dose the more likely it is. The swelling comes from pressure changes in the small blood vessels of the legs, not from fluid overload, which is why water tablets do not fix it. If you take amlodipine and have been given a water tablet for swollen ankles, that is worth a doctor looking at properly.

Is it dangerous to come off amlodipine?

For some people it would be. In older people with high systolic blood pressure, this family of medicines prevents strokes, and nobody should stop it for age alone. For a frail person on several blood pressure medicines treated to a target set for someone younger, reducing one is often safe and sensible. Which of those you are is a question about you, not about amlodipine.

What about the rest of my blood pressure medication?

The review covers all of it. Ramipril, losartan, bisoprolol, indapamide and the others each have their own questions, and the decision about one depends on the others. The blood pressure page sets out what the review considers across the class.