: Amlodipine is a calcium ion influx inhibitor (slow channel blocker or calcium ion antagonist) and inhibits the transmembrane influx of calcium ions into cardiac and vascular smooth muscle.
The mechanism of the antihypertensive action of amlodipine is due to a direct relaxant effect on vascular smooth muscle. The precise mechanism by which amlodipine relieves angina has not been fully determined, but amlodipine reduces total ischemic burden by the following two actions: Amlodipine dilates peripheral arterioles and thus reduces the total peripheral resistance (afterload) against which the heart works. Since the heart rate remains stable, this unloading of the heart reduces myocardial energy consumption and oxygen requirements.
The mechanism of action of amlodipine also probably involves dilatation of the main coronary arteries and coronary arterioles, both in normal and ischemic regions. This dilatation increases myocardial oxygen delivery in patients with coronary artery spasm (Prinzmetal's or variant angina) and blunts smoking-induced coronary vasoconstriction.
In patients with hypertension, once-daily dosing provides clinically significant reductions in blood pressure in both the supine and standing positions throughout the 24-hour interval. Due to the slow onset of action, acute hypotension is not a feature of amlodipine administration.
In patients with angina, once-daily administration of amlodipine increases total exercise time, time to angina onset, and time to 1 mm ST segment depression, and decreases both angina attack frequency and nitroglycerine tablet consumption.
Amlodipine has not been associated with any adverse metabolic effects or changes in plasma lipids and is suitable for use in patients with asthma, diabetes, and gout.
Use in Patients with Coronary Artery Disease
: The effects of amlodipine on cardiovascular morbidity and mortality, the progression of coronary atherosclerosis, and carotid atherosclerosis were studied in the Prospective Randomized Evaluation of the Vascular Effects of Amlodipine Trial (PREVENT). This multicenter, randomized, double-blind, placebo-controlled study followed 825 patients with angiographically defined CAD for 3 years. The population included patients with previous MI (45%), percutaneous transluminal coronary angioplasty (PTCA) at baseline (42%), or history of angina (69%). The severity of CAD ranged from 1-vessel disease (45%) to 3+vessel disease (21%). Patients with uncontrolled hypertension (diastolic blood pressure [DBP] >95 mmHg) were excluded from the study. Major cardiovascular events were adjudicated by a blinded endpoint committee. Although there were no demonstrable effects on the rate of progression of coronary artery lesions, amlodipine arrested the progression of carotid intima-media thickening. A significant reduction (-31%) was observed in amlodipine-treated patients in the combined endpoint of cardiovascular death, MI, stroke, PTCA, coronary artery bypass graft (CABG), hospitalization for unstable angina, and worsening congestive heart failure (CHF).
A significant reduction (-42%) in revascularization procedures (PTCA and CABG) was also seen in amlodipine-treated patients. Fewer hospitalizations (-33%) were seen for unstable angina in amlodipine-treated patients than in the placebo group.
CAMELOT enrolled 1997 patients with CAD recently documented by angiography, without left main coronary disease and without heart failure or an ejection fraction <40%. Patients (76% males, 89% Caucasian, 93% enrolled at US sites, 89% with a history of angina, 52% without PCI, 4% with PCI and no stent, and 44% with a stent) were randomized to double-blind treatment with either amlodipine besylate tablets (5 mg to 10 mg once daily) or placebo in addition to standard care that included aspirin (89%), statins (83%), beta-blockers (74%), nitroglycerine (50%), anti-coagulants (40%), and diuretics (32%), but excluded other calcium channel blockers, for 2 years. The primary endpoint was the time to first occurrence of one of the following events: hospitalization for angina pectoris, coronary revascularization, MI, cardiovascular death, resuscitated cardiac arrest, hospitalization for heart failure, stroke/transient ischemic attack (TIA), or peripheral vascular disease (PVD).
The outcome of this study was largely derived from the prevention of hospitalizations for angina and the prevention of revascularization procedures (see table). The other components of the primary endpoint including cardiovascular death, resuscitated cardiac arrest, MI, hospitalization for heart failure, stroke/TIA, or PVD did not demonstrate a significant difference between amlodipine besylate and placebo. (See table.)
Click on icon to see table/diagram/image
Treatment to Prevent Heart Attack Trial (ALLHAT)
: A randomized double-blind morbidity-mortality study called the Antihypertensive and Lipid-lowering-treatment to Prevent Heart Attack Trial (ALLHAT) was performed to compare newer drug therapies: amlodipine 2.5 mg/day to 10 mg/day (calcium channel blocker) or lisinopril 10 mg/day to 40 mg/day (ACE-inhibitor) as first-line therapies to that of the thiazide-diuretic chlorthalidone 12.5 mg/day to 25 mg/day in mild to moderate hypertension.
A total of 33,357 hypertensive patients aged 55 or older were randomized and followed up for a mean of 4.9 years. The patients had at least one additional CHD risk factor, including MI or stroke for >6 months or documentation of other atherosclerotic CVD (overall 51.5%), type 2 diabetes (36.1%), high-density lipoprotein-C (HDL-C) <35 mg/dL (11.6%), left ventricular hypertrophy diagnosed by electrocardiogram or echocardiography (20.9%), or current cigarette smoking (21.9%).
The primary endpoint was a composite of fatal CHD or non-fatal MI. There was no significant difference in the primary endpoint between amlodipine-based therapy and chlorthalidone-based therapy: RR 0.98, 95% CI [0.90-1.07], p=0.65. Among Secondary Endpoints, the incidence of heart failure (component of a composite combined cardiovascular endpoint) was significantly higher in the amlodipine group as compared to the chlorthalidone group (10.2% vs. 7.7%, RR 1.38, 95% CI [1.25-1.52], p<0.001).
However, there was no significant difference in all-cause mortality between amlodipine-based therapy and chlorthalidone-based therapy: RR 0.96, 95% CI [0.89-1.02], p=0.20.
Use in Patients with Heart Failure
: Hemodynamic studies and exercise-based controlled clinical trials in NYHA Class II-IV heart failure patients have shown that amlodipine did not lead to clinical deterioration, as measured by exercise tolerance, left ventricular ejection fraction, and clinical symptomatology.
A placebo controlled study (PRAISE) designed to evaluate patients in NYHA Class III-IV heart failure receiving digoxin, diuretics, and ACE inhibitors has shown that amlodipine did not lead to an increase in risk of mortality or combined mortality and morbidity in patients with heart failure.
In a follow-up, long-term, placebo-controlled study (PRAISE-2) of amlodipine in patients with NYHA class III and IV heart failure without clinical symptoms or objective findings suggestive of underlying ischemic disease, on stable doses of ACE inhibitors, digitalis, and diuretics, amlodipine had no effect on total or cardiovascular mortality. In this same population, amlodipine was associated with increased reports of pulmonary edema despite no significant difference in the incidence of worsening heart failure compared to placebo.
After oral administration of therapeutic doses, amlodipine is well absorbed with peak blood levels between 6 and 12 hours post-dose. Absolute bioavailability has been estimated to be between 64% and 80%. The volume of distribution is approximately 21 L/kg. Absorption of amlodipine is unaffected by consumption of food.
studies have shown that approximately 97.5% of circulating amlodipine is bound to plasma proteins.
: The terminal plasma elimination half-life is about 35 to 50 hours and is consistent with once-daily dosing. Steady-state plasma levels are reached after 7 to 8 days of consecutive dosing. Amlodipine is extensively metabolized by the liver to inactive metabolites, with 10% of the parent compound and 60% of metabolites excreted in the urine.
Use in the Elderly
: The time to reach peak plasma concentrations of amlodipine is similar in elderly and younger subjects. Amlodipine clearance tends to be decreased with resulting increases in AUC and elimination half-life in elderly patients. Increases in AUC and elimination half-life in patients with CHF were as expected for the patient age group studied.
: Preclinical safety data
: Carcinogenesis: Rats and mice treated with amlodipine in the diet for 2 years, at concentrations calculated to provide daily dosage levels of 0.5, 1.25, and 2.5 mg/kg/day showed no evidence of carcinogenicity. The highest dose (for mice, similar to, and for rats twice* the maximum recommended clinical dose of 10 mg, on a mg/m2
basis) was close to the maximum tolerated dose for mice but not for rats.
Mutagenesis: Mutagenicity studies revealed no drug-related effects at either the gene or chromosome levels.
Impairment of Fertility: There was no effect on the fertility of rats treated with amlodipine (males for 64 days and females for 14 days prior to mating) at doses up to 10 mg/kg/day (8 times* the maximum recommended human dose of 10 mg, on a mg/m2
*Based on patient weight of 50 kg.