A Rare Adverse Drug Reaction of Amlodipine Presenting as Epistaxis: A Case Report

Abstract

Epistaxis is a frequently encountered clinical condition with multifactorial etiology, including local nasal pathology, systemic diseases, and pharmacological agents. Calcium channel blockers such as amlodipine are widely prescribed for hypertension and are generally well tolerated. However, rare adverse drug reactions (ADRs) may occur. This case report describes a 50-year-old hypertensive female who developed recurrent epistaxis while receiving amlodipine therapy. Despite maintaining controlled blood pressure and receiving symptomatic treatment with tranexamic acid, the bleeding persisted. Amlodipine was suspected as the causative agent and replaced with cilnidipine, leading to complete resolution of symptoms. Causality assessment suggests a probable ADR. This case highlights the need for vigilance regarding rare but clinically significant adverse effects of commonly used antihypertensive agents.

Keywords

Introduction

Epistaxis, or nasal bleeding, is a common clinical presentation affecting up to 60% of the population at least once in their lifetime, with approximately 6% requiring medical attention¹. While most cases are idiopathic or related to local causes such as trauma or infection, systemic conditions including hypertension, coagulopathies, and drug-induced effects are also significant contributors².Amlodipine, a long-acting dihydropyridine calcium channel blocker (CCB), is extensively used in the management of hypertension and angina pectoris³. It exerts its action by inhibiting L-type calcium channels, leading to peripheral vasodilation and reduced vascular resistance. Although generally safe, known adverse effects include peripheral edema, headache, dizziness, and flushing?. Reports of epistaxis associated with amlodipine are extremely rare and sparsely documented in literature.

CASE PRESENTATION

A 50-year-old female presented with recurrent episodes of spontaneous nasal bleeding over a period of several weeks. She had a known history of hypertension for the past 7 years and was under regular treatment. Her past medical history included angiographic evaluation and episodes of hypoglycemia.

Medication History

Amlodipine 5 mg once daily

Telmisartan 40 mg once daily

The patient reported that epistaxis episodes occurred intermittently without any identifiable local triggers such as trauma, nasal dryness, or infection. Each episode lasted several minutes and required medical attention.

Clinical Findings

Blood pressure: Within normal limits during episodes

No signs of nasal infection, trauma, or structural abnormalities

No history of bleeding disorders

Routine laboratory investigations including complete blood count, coagulation profile, and renal function tests were within normal limits.

MANAGEMENT AND INTERVENTION

Initially, the patient was managed symptomatically with tranexamic acid, which resulted in delayed and incomplete control of bleeding.Given the persistence of symptoms and absence of other identifiable causes, a drug-induced etiology was suspected. Amlodipine was considered the probable offending agent.

Therapeutic Intervention

Amlodipine was discontinued

Telmisartan 40 mg was continued

Cilnidipine 10 mg was initiated as a replacement

OUTCOME AND FOLLOW-UP

Following the discontinuation of amlodipine and initiation of cilnidipine:

Epistaxis resolved completely

No further bleeding episodes were reported

Blood pressure remained well controlled

No new adverse effects were observed

DISCUSSION

Adverse drug reactions involving mucosal bleeding are uncommon with calcium channel blockers. However, the vasodilatory effect of amlodipine may contribute to increased capillary permeability and fragility, particularly in susceptible individuals?.

Possible Mechanisms

Peripheral Vasodilation

Capillary Fragility

Platelet Function Modulation

Cilnidipine, a newer generation calcium channel blocker, blocks both L-type and N-type calcium channels. Its additional N-type blocking action reduces sympathetic nerve activity, potentially offering better vascular stability and fewer adverse vascular effects.

Causality Assessment

Using WHO-UMC scale, this ADR can be classified as “Probable” based on:

Temporal relationship

Dechallenge

Lack of alternative causes

CONCLUSION

This case report demonstrates that epistaxis may occur as a rare adverse effect of amlodipine. Early recognition and prompt substitution with an alternative antihypertensive such as cilnidipine can lead to complete resolution of symptoms while maintaining adequate blood pressure control.

REFERENCES

1. Messerli FH, Grossman E. Calcium antagonists.
2. World Health Organization. WHO-UMC causality assessment system.
3. Kaur S, et al. Drug-induced epistaxis.
4. Burnier M. Cilnidipine: pharmacological profile and clinical use.
5. Kaplan NM. Systemic hypertension