Asian Journal of Pharmaceutical and Clinical Research

Vol. 4, Issue 2, 2011

ISSN - 0974-2441

ResearchArticle

CASEREPORTOFAMLODIPINEINDUCEDGINGIVALHYPERPLASIALATEONSETATALOWDOSE

JIMMYJOSE1,SANTHOSHYL1,NAVEENMR1,VIJAYKUMAR2
DepartmentofPharmacypractice,SACCollegeofPharamcy,B.G.NagaraDepartmentofMedicine,AH&RCB.G.Nagara.India
Email:santosh.kvc@gmail.com

ABSTRACT
Drug induced gingival hyperplasia is reported with three main group of drugs like calcium channel blockers (CCBs), immunosuppressants and
anticonvulsants. Among the CCBs, the incidence of nifedipine induced gingival hyperplaisa is reported to be about 10%. Amlodipine, a third
generationcalciumchannelblockershasbeenshowntopromotegingivalhyperplasiaalthoughinverylimitedcasesreported.Therearelessdata
on reports of hyperplasia with amlodipine at a dose of 5 mg, even after taking for more than 6 months. Clinical manifestation of gingival
enlargementfrequentlyappearswithin1to3monthsafterinitiationoftreatmentwiththeassociatedmedication.Thiscasereportdescribesthe
druginducedgingivalhyperplasiaanditsmanagementinahypertensivepatienttakingamlodipineatadoseof5mg.
Keywords:Gingivalhyperplasia,Amlodipine.

INTRODUCTION
An increasing number of medications are associated with gingival
enlargement. Currently,morethan20prescriptionmedicationsare
associatedwithgingivalenlargement.1Amlodipineaneweragentof
dihydropyridine, used for treatment of hypertension and angina,
wasfirstreportedforcausinggingivalovergrowthassideeffect,by
Seymour et al in 1994.2 Recently, Lazy et al. had reported rapidly
developedgingivalhyperplasiainpatientreceived10mgperdayof
amlodipinewithintwomonthsofonset.3
Clinical manifestation of gingival enlargement frequently appears
within1to3monthsafterinitiationoftreatmentwiththeassociated
medication.4 There are less data on reports of hyperplasia with
amlodipine at a dose of 5 mg, even after taking for more than 6
months.5But,inthe present casethe gingival hyperplasia occurred
atadoseof5mgafter7monthsofuse.
Casereport
A 47 year old hypertensive female visited the hospital with chief
complaintsofswellingandbleedingofgumsfromlast2months.Her
past medication history included use of amlodipine from 7 months
for high bloodpressure.There wasmassiveinflamation of gums of
upperand lower jaw(Figure 1). Therewasnohistory of intakeof
any other drugs. Amlodipine induced gingival hyperplasia was
suspectedandthedrugwaswithdrawn.Patientwasswitchedonto
enalapril for the treatment of hypertension. The patient was
adviced for regular follow ups. Biopsy was done and a highly
vascular connective tissue is observed histologically with focal
accumulation of inflammatory cells, primarily plasma cells. At the
susbequentfollowupsafter2weeksfortwovisits,shewasexamined
and interviewed. Her symtoms like pain and hyperplasia was
observedtobereduced.

ACTH level and upregulation of keratinocyte growth factor.

Alternatively, inflammation may develop as a result of direct toxic
effects of concentrated drug in crevicular gingival fliud and/ or
bacterial plagues. This inflammation could lead to theupregulation
ofseveralcytokinefactorssuchasTGF1.6,7
Many studies have reported gingival hyperplasia caused by 10mg
OD of amlodipine. 2,8,9 Jorgensen et al conducted a study where a
series of 150 cardiac patients were followed up. It was found that
amlodipineatadoseof5mg/daycannotinducegingivalhyperplasia
eveniftakenformorethan6months.5Butinthepresentcasea5mg
doseofamlodipinehasdevelopedthegingivalhyperplasia.
Drugwithdrawalresultedinimprovementwhichisthefirstlinestep
formanagementofdruginducedhyperplasia.Howeverrechallenge
of drug was not done. The patient was counselled about the oral
hygenic importance. We conclude that the hyperplasia could occur
withamlodipineevenatasmalldose(5mg)anditcouldoccureven
after 7 months of drug adminsitration. Hence the possibility of
amlodipineinducedhyperplasiashouldbeconsideredforalowdose
aswellasalatepresentation.

DISCUSSION
Even though there are previous reports of Amlodipine induced
hyperplasia,thepresentcaseisinterestingasitoccurredwithalow
dose of amlodipine (5 mg) and appeared only on long term
administration (7 months).Several factors may influence the
relationship between the drugs and gingival hyperplasia. Those
factors includes age, genetic predisposition, pharmacokinetic
variables,poororalhygiene,periodontaldisease,periodontalpocket
depth,gingivalinflammation,degreeofdentalplaque,durationand
doseofadrug,histopathology,ultrastructuralfactors,inflammatory
changes and drug action on growth factors. The underlying
mechanism behind drug induced gingival hyperplasia involves
inflammatory and non inflammatory pathways. The proposed non
inflammatory mechanisms include defective collagenase activity
due to decreased uptake of folic acid, blockage of aldosterone
synthesis in adrenal cortex and consequent feedback increase in

Fig.1:Suspectedamlodipineinducedgingivalhyperplasia

Santoshetal.
AsianJPharmClinRes,Vol4,Issue2,2011,6566
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