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Amlodipine Substitute

Amlodipine is the most commonly prescribed drug in the United Kingdom and the most commonly prescribed high blood pressure (BP) medication. Amlodipine may be the first choice when a patient is diagnosed with high blood pressure, and a drug is prescribed, but this is not always the case.
Taking any medication carries the risk of side effects, with Amlodipine being associated with a few common ones. Patients may eventually be prescribed an Amlodipine substitute medication.


Today, we will discuss alternative amlodipine drugs based on treatment guidelines. The most important message is that alternative amlodipine drug(s) will be influenced by national blood pressure guidelines, which state recommended treatment for different patient groups.

Classification of Amlodipine

Amlodipine is known as a calcium channel blocker (CCB). As the name implies, Amlodipine inhibits calcium movement into cells in blood vessels, the heart, and the pancreas. Smooth muscle contractions are caused by calcium. As a result, Amlodipine causes blood vessel dilation, which aids in the reduction of blood pressure.

Amlodipine is a Beta-Blocker?

Many patients wonder whether Amlodipine is a beta-blocker. No, it does not, and calcium channel blockers work differently than beta-blockers.

Why is Amlodipine the Most Prevalent Blood Pressure Drug in the United Kingdom?

In the United Kingdom, high blood pressure is treated in stages. Three major patient factors that influence blood pressure medication selection are:

  • The age
  • Ethnicity
  • Diabetes condition

Calcium channel blockers, such as Amlodipine, are the first-line treatment in non-diabetic patients over 55 and patients of Caribbean or African descent (any age).
High blood pressure prevalence rises with age; for example, in England, 58 percent of men and women aged 65 to 74 have high blood pressure (GOV.UK, 2017), contributing to Amlodipine’s popularity.
If treatment does not produce satisfactory results or patients experience side effects, the high blood pressure medication is changed, or an additional drug is prescribed.

Amlodipine and Ankle Swelling (Oedema), as well as Other Adverse Effects:

Amlodipine and other calcium channel blockers have several common side effects, including (BNF, 2021):

  • Headaches,
  • Flushing,
  • Dizziness,
  • Palpitations,
  • Tachycardia (fast heart rate)
  • Oedema (swellings)
  • Muscle cramps
  • Constipation

One of the most common side effects of Amlodipine use is ankle swelling (oedema). The most troublesome side effect of Amlodipine is ankle swelling, which usually necessitates switching from Amlodipine to an alternative treatment.

Do All Calcium Channel Blockers Cause Ankle Swelling (Oedema)?

Compared to first-generation calcium channel blockers, available data suggests that lercanidipine may be associated with a lower frequency of edema.
(for example, nifedipine, verapamil, and diltiazem), but not when compared to a second-generation CCB, as confirmed by meta-analysis (review of many clinical studies) (Amlodipine).
Verapamil and diltiazem are primarily used to treat angina rather than high blood pressure in the United Kingdom. They discovered other side effects (headache and flushing) common among calcium channel blockers.
The same review concluded that calcium channel blockers under investigation are equally effective in terms of blood pressure reduction.

Can Lifestyle Changes Replace Amlodipine?

This post primarily focuses on amlodipine alternatives.
Typically, patients are advised by their doctor about lifestyle factors that may contribute to high blood pressure.
The topic of lifestyle and its effect on blood pressure deserves discussion. However, the topic’s significance should not be overlooked.
Changes in lifestyle, such as diet and exercise, significantly impact blood pressure, and physical activity is a critical component of lifestyle changes. There is a mountain of evidence demonstrating the benefits of exercise in preventing and treating hypertension.
Physical activity lowers both systolic and diastolic blood pressure. Furthermore, the effect of exercise on blood pressure is immediate, with a lowering effect lasting for more than 24 hours. Regular exercise helps maintain a stable blood pressure level (Hegde et al., 2015).

Alternatives to Amlodipine: Diuretics

When Amlodipine is not tolerated, for example, due to oedema, diuretics (thiazide-type) are given to patients over the age of 55 or patients of the Caribbean or African origin (no diabetes).

Diuretics, also known as “water tablets,” increase the amount of urine produced. Increased water excretion from the body reduces blood volume, lowering blood pressure.
Common Adverse Effects of Diuretics (NICE, 2021)

  • Diarrhea
  • Constipation
  • Dry mouth
  • Dizziness
  • Erectile dysfunction
  • Fatigue
  • Headaches
  • Hyperglycaemia (increased sugar level)
  • Hyperuricaemia; nausea
  • Postural hypotension (drop in blood pressure when standing up)
  • Skin reactions (rashes)

Indapamide

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Indapamide is the second most commonly prescribed thiazide-type diuretic. According to the hypertension management guide, indapamide is the preferred diuretic in the treatment of hypertension.

Chlorthalidone

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Chlortalidone, a diuretic, is not commonly prescribed in the UK to treat high blood pressure.

Bendroflumethiazide

In the United Kingdom, bendroflumethiazide is the most commonly prescribed diuretic. However, bendroflumethiazide is no longer recommended as a diuretic for treating high blood pressure in the United Kingdom. In treating high blood pressure, indapamide and chlorthalidone are preferred diuretics.

Alternatives to Amlodipine: ACE Inhibitors

Another popular class of antihypertensive drugs is ACE inhibitors. All diabetic patients (regardless of ethnicity) and patients under 55 who do not have diabetes would be given ACE inhibitors as first-line treatment for high blood pressure.

Over ten drugs are licensed to treat high blood pressure on the list of ACE inhibitors.

What are the Most Common Adverse Effects of ACE Inhibitors?

The following are common ACE inhibitor side effects:

  • Headaches
  • dizziness
  • Tickling,
  • dry cough which does not go away
  • Abdominal discomfort
  • dyspepsia
  • diarrhea
  •  nausea
  • vomiting
  • Rash
  • Fatigue

Fatigue ACE inhibitors are typically started at a low dose and titrated up based on the response, resulting in the availability of various tablet and capsule strengths.

Ramipril

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Ramipril is the most commonly prescribed ACE inhibitor and the second most commonly prescribed high blood pressure medication in the United Kingdom.

There are no specific recommendations for prescribing ramipril as a first-line treatment for high blood pressure. For people who have had a heart attack or heart failure, ramipril, lisinopril, and perindopril may be preferred (NICE, 2020).

Ramipril is available in capsules and tablets. The strength of ramipril ranges from 1.25mg to 10mg.

Lisinopril

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In the United Kingdom, lisinopril is the second most commonly prescribed ACE inhibitor to treat high blood pressure. Lisinopril is only available in tablet form, with doses ranging from 2.5mg to 20mg per tablet.

Enalapril

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The number of prescriptions for enalapril and the second most popular ACE inhibitor, lisinopril, differs significantly. Enalapril is still a popular drug for treating high blood pressure, with over 1.5 million prescriptions written last year (OpenPrescribing.net, 2021).

The strength of enalapril ranges from 2.5mg to 20mg per tablet.

Amlodipine Alternatives Using Angiotensin II Receptor Antagonists:

Angiotensin II receptor antagonists (blockers) treat the same conditions as ACE inhibitors, including hypertension.

Angiotensin II receptor blockers work differently than calcium channel blockers (AmlodipineAmlodipine) or ACE inhibitors. Angiotensin II receptor antagonists, as the name implies, block angiotensin II (a ‘compound’) and thus relax smooth muscle and lower blood pressure.

Angiotensin II receptor blockers, unlike ACE inhibitors, do not cause coughing or oedema.

The following are the most commonly used angiotensin II receptor blockers in the United Kingdom:

Losartan

Candesartan

Angiotensin II Receptor Blockers: Common Side Effects

  • Dizziness
  • Vertigo
  • Hyperkalaemia (low level of potassium)
  • Abdominal pain, nausea, and vomiting
  • Headaches
  • Postural hypotension (drop in blood pressure when standing up)

Can Amlodipine be Replaced with Angiotensin II Receptor Antagonists?

Examining the high blood pressure management guidelines.

ACE inhibitors can be replaced with angiotensin II receptor antagonists (ramipril)
when starting treatment, especially for patients who:

Have Diabetes at Any Age or from Any Family?

They are under 55 and are not of black African or African–Caribbean descent.

Losartan

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With over ten million prescriptions issued last year, losartan is the most commonly prescribed angiotensin II receptor blocker (OpenPrescribing.net, 2021).

Candesartan

Atacand

The effectiveness of the second most commonly prescribed angiotensin II receptor blocker does not differ from that of losartan.
There is insufficient evidence to show that one angiotensin II receptor blocker is more effective than others in lowering blood pressure (Tsoi et al., 2018).

What are Some Natural Substitutes for Amlodipine?

There are no approved herbal or dietary supplements to treat high blood pressure, and healthcare providers rarely recommend anything other than prescription medications and lifestyle changes. However, some research suggests that certain supplements may help maintain healthy blood pressure.

Limit your sodium intake

The American Heart Association (AHA) recommends keeping sodium intake to 2,300 mg per day, ideally 1,500 mg. To be more specific, 2,300 mg of sodium is equivalent to about one teaspoon of table salt. Some people may require even less sodium to keep their blood pressure under control.

Exercise

Obesity and overweight are associated with an increased risk of high blood pressure. Controlling your blood pressure is recommended by losing weight and exercising. Aerobic exercise at least three times per week (or ideally, most days of the week) has been shown to help lower systolic and diastolic blood pressure.

Diet

To help lower blood pressure, healthcare providers frequently recommend the DASH (Dietary Approaches to Stop Hypertension) diet. This diet includes more fruits, vegetables, whole grains, and lean protein sources like fish and chicken. The DASH diet restricts the consumption of red meat, full-fat dairy products, and foods high in saturated fats, sugar, and sodium.

Stop smoking

Nicotine, which is found in cigarettes and other tobacco products, can constrict blood vessels and raise blood pressure. Quitting smoking can help to normalize blood pressure and reduce heat stress.

We should avoid caffeine and alcohol.

In the long run, excessive alcohol consumption may result in high blood pressure. Try to limit your alcohol consumption to no more than two drinks per day for men and one drink per day for women. While not entirely significant, caffeine can cause short-term increases in blood pressure. Caffeine consumption should be limited, especially if you have uncontrolled high blood pressure.

Supplements

Potassium, magnesium, and dietary fiber may aid in blood pressure control. In addition to prescription medications, a healthcare provider may recommend potassium, magnesium, and a dietary fiber-rich diet. Other supplements that may aid in blood pressure reduction include:

  • Coenzyme Q10
  • Garlic
  • Fish oil
  • Ginger
  • Flaxseed
  • Vitamin C
  • Probiotics

More conclusive research is needed to determine the effect of these supplements on hypertension. Before taking a supplement to treat high blood pressure, consult with your doctor.

How to Make the Transition to an Amlodipine Alternative?

The procedure for changing blood pressure medications will differ depending on your blood pressure and overall health. The primary reason for changing antihypertensive medications is uncontrolled blood pressure.
If your blood pressure is uncontrolled, your healthcare provider may recommend increasing your amlodipine dose. If that doesn’t work, they may add another blood pressure medication to your treatment plan. Combination therapy is usually recommended for people with difficult-to-treat high blood pressure and other medical conditions. People who are allergic to Amlodipine or have intolerable side effects may be switched to another CCB or blood pressure medication.
Seek medical advice from your healthcare provider before switching to an amlodipine substitute. Before switching you to a different medication, your healthcare provider will want to assess your overall medical condition. If you have other medical conditions and are taking other medications, it is also important to consider potential side effects and drug interactions when switching medications.

Conclusion

The above list was created using STAGE 1 blood pressure management (initiating the treatment). Further blood pressure treatment combines the use of two, three, or even four drugs.
At STAGE 2, for example, a calcium channel blocker (Amlodipine) and an ACE inhibitor (ramipril) or angiotensin II receptor blocker (losartan), or diuretic could be used. STAGE 3 patients are treated with three different drugs, while STAGE 4 patients are treated with four antihypertensive drugs.
We have listed the most commonly used antihypertensive drugs in the United Kingdom, considered first-line treatment for high blood pressure. Although the purpose of this post was to provide a list of alternative amlodipine drugs, it is clear that choosing alternative amlodipine medicines is dependent on individual patients and any other underlying conditions they may have.