Source: Pharmaceutical Benefits Scheme (AU) Revision Year: 2022 Publisher: Servier Laboratories (Aust.) Pty. Ltd., www.servier.com.au, Level 4, Building 9, 588A Swan Street, Burnley, 3121, Victoria
PREXUM is contraindicated:
Since ACE inhibitors reduce angiotensin II formation resulting in decreased production of aldosterone, increases in serum potassium have been observed in some patients treated with ACE inhibitors including perindopril. The effect is usually not significant in patients with normal renal function. Serum electrolytes (including sodium potassium and urea) should be measured from time to time when ACE inhibitors are given and especially in combination with diuretics.
Hyperkalaemia can cause serious, sometimes fatal, arrhythmias. Risk factors for the development of hyperkalaemia include those with renal insufficiency, worsening of renal function, age (>70 years), diabetes, intercurrent events, in particular dehydration, acute cardiac decompensation, metabolic acidosis and combined use of potassium-sparing diuretics (e.g. spironolactone, eplerenone, triamterene or amiloride), potassium supplements or potassium-containing salt substitutes; or those patients taking other medicines associated with increases in serum potassium (e.g. heparin, other ACE-inhibitors, angiotensin receptor blocker, acetylsalicylic acid ≥3 g/day, COX-2 inhibitors and other non-selective NSAIDS, immunosuppressant agents such as ciclosporin or tacromilus, cotrimoxazole also known as trimethoprim/sulfamethoxazole). The use of potassium supplements, potassium-sparing diuretics, or potassium-containing salt substitutes particularly in patients with impaired renal function may lead to a significant increase in serum potassium. Hyperkalaemia can cause serious, sometimes fatal arrhythmias. Potassium-sparing diuretics and angiotensin-receptor blockers should be used with caution in patients receiving ACE inhibitors, and serum potassium and renal function should be monitored. Combined use of the above-mentioned medicines should be used with caution in combination with ACE inhibitors. Frequent monitoring of serum potassium is needed (see section 4.5 – Interactions with other medicines and other forms of interactions). In some patients hyponatraemia may co-exist with hyperkalaemia.
Glycaemic control should be closely monitored during the first month of treatment with an ACE inhibitor in patients with diabetes treated with oral medicines or insulin (see section 4.5 – Interactions with other medicines and other forms of interactions).
The combination of lithium and perindopril is generally not recommended (see section 4.5 – Interactions with other medicines and other forms of interactions).
The combination of perindopril and potassium sparing medicines, potassium supplements or potassium-containing salt substitutes is generally not recommended (see section 4.5 – Interactions with other medicines and other forms of interactions).
Patients with a history of angioedema unrelated to ACE inhibitor treatment may be at increased risk of angioedema while treated with an ACE inhibitor (see section 4.3 – Contraindications).
Life-threatening angioedema has been reported with most ACE inhibitors. The overall incidence is approximately 0.1-0.2%. The aetiology is thought to be non-immunogenic and may be related to accentuated bradykinin activity. Usually the angioedema is non-pitting oedema of the skin mucous membrane and subcutaneous tissue.
Angioedema of the face, extremities, lips, tongue, mucous membranes, glottis and/or larynx has been reported in patients treated with ACE inhibitors and has been reported uncommonly with PREXUM (see section 4.8 – Adverse effects (Undesirable effects)). This may occur at any time during treatment. In such cases PREXUM should be promptly discontinued and the patient carefully observed until the swelling disappears. Where such cases have been described with other ACE inhibitors and swelling has been confined to the face and lips, the condition has generally resolved without treatment although antihistamines have been useful in relieving symptoms. Angioedema associated with laryngeal oedema may be fatal or near fatal. In most cases symptoms occurred during the first week of treatment and the incidence appears to be similar in both sexes or those with heart failure or hypertension.
Where there is involvement of the tongue, glottis or larynx likely to cause airway obstruction, appropriate treatment (e.g. adrenaline (epinephrine) and oxygen) should be given promptly. Treatment of progressive angioedema should be aggressive and failing a rapid response to medical treatment, mechanical methods to secure an airway should be undertaken before massive oedema complicates oral or nasal intubation.
Patients who respond to medical treatment should be observed carefully for a possible rebound phenomenon.
The onset of angioedema associated with use of ACE inhibitors may be delayed for weeks or months. Patients may have multiple episodes of angioedema with long symptom-free intervals.
Angioedema may occur with or without urticaria.
Intestinal angioedema has been reported rarely in patients treated with ACE inhibitors. These patients presented with abdominal pain (with or without nausea or vomiting); in some cases there was no prior facial angioedema and C-1 esterase levels were normal. The angioedema was diagnosed by procedures including abdominal CT scan, or ultrasound or at surgery and symptoms resolved after stopping the ACE inhibitor. Intestinal angioedema should be included in the differential diagnosis of patients on ACE inhibitors presenting with abdominal pain.
ACE inhibitors should not be reintroduced in patients who have a history of angioedema due to rare reports of recurrence.
The combined use of PREXUM with sacubitril/valsartan fixed dose combinations is contraindicated due to the increased risk of angioedema (see section 4.3 – Contraindications). Sacubitril/valsartan fixed dose combinations must not be initiated until 36 hours after taking the last dose of PREXUM. If treatment with sacubitril/valsartan fixed dose combinations is stopped, PREXUM must not be initiated until 36 hours after the last dose of sacubitril/valsartan fixed dose combination (see section 4.3 – Contraindications and section 4.5 – Interactions with other medicines and other forms of interactions).
The combined use of PREXUM with NEP inhibitors, mammalian target of rapamycin (mTOR) inhibitors (e.g. sirolimus, everolimus, temsirolimus) and gliptins (e.g. linagliptin, saxagliptin, sitagliptin, vildagliptin, alogliptin) may lead to an increased risk of angioedema (e.g. swelling of the airways or tongue, with or without respiratory impairment) (see section 4.5- Interactions with other medicines and other forms of interactions). Caution should be used when commencing treatment with these above-mentioned medicines in a patient already taking an ACE inhibitor.
Rarely, patients treated with ACE inhibitors during LDL apheresis with dextran sulfate have experienced life-threatening anaphylactoid reactions. These reactions were avoided by temporarily withholding ACE inhibitor treatment prior to each apheresis. Anaphylactoid reactions have been reported in patients dialysed with high flux membranes, who are treated with an ACE inhibitor. Extracorporeal treatments leading to contact of blood with negatively charged surfaces (e.g. polyacrylonitril membranes such as “AN69”) are contraindicated. If such treatment is required, consideration should be given to using a different type of dialysis membrane (e.g. cuprophane or polysulfone (PSF)) or a different class of antihypertensive medicines (see section 4.3 – Contraindications and section 4.5 – Interactions with other medicines and other forms of interactions).
Patients treated with ACE inhibitors during desensitisation treatment (e.g. hymenoptera venom) have experienced anaphylactoid reactions. In the same patients, these reactions have been avoided when the ACE inhibitors were temporarily withheld, but they reappeared upon inadvertent rechallenge.
Hypotension has been reported in patients commencing treatment with ACE inhibitors. Symptomatic hypotension is rarely seen in uncomplicated hypertension but is a potential consequence of PREXUM use in patients with salt/volume depletion, for example, in patients vigorously treated with diuretics, in patients on dialysis, with impaired renal function, following severe diarrhoea or vomiting, in patients on dietary restrictions, or in those with severe renin-dependent hypertension (see section 4.4 – Special warnings and precautions for use and section 4.8 – Adverse effects (Undesirable effects)).
Administration of PREXUM 2.5 to patients with mild-moderate heart failure was not associated with any significant reduction in blood pressure. In patients with symptomatic heart failure, with or without associated renal insufficiency, symptomatic hypotension has been observed. This is more likely to occur in those patients with severe heart failure, as reflected by the use of high doses of loop diuretics, hyponatraemia or functional renal impairment. This may be associated with syncope, neurological deficits, oliguria and/or progressive increase in blood nitrogen, and rarely with acute renal failure and/or death. Because of the potential fall in blood pressure in these patients, treatment should be started at low doses under very close supervision. Such patients should be followed closely for the first two weeks of treatment and whenever the dose is increased, or diuretic treatment is commenced or increased.
Patients with ischaemic heart or cerebrovascular disease in whom an excessive fall in blood pressure could result in myocardial infarction or cerebrovascular accident should be closely followed for the first two weeks of treatment and whenever the dose of PREXUM and/or the diuretic is increased. In all high-risk patients it is advisable to initiate treatment with one PREXUM 2.5 tablet once daily.
In some patients with congestive heart failure who have normal or low blood pressure, additional lowering of systemic blood pressure may occur with PREXUM. This is anticipated and is usually not a reason to discontinue treatment. If symptomatic hypotension occurs, a reduction of dose or discontinuation of PREXUM may be necessary.
If hypotension occurs, the patient should be placed in a supine position and if necessary infused with normal saline. A transient hypotensive response is not a contraindication to further doses, which can usually be given without difficulty when blood pressure has increased following volume expansion.
If renovascular hypertension is also present treatment should be started under close medical supervision with low doses and careful dose titration. There is an increased risk of severe hypotension and renal insufficiency. Since treatment with diuretics may be a contributory factor to the above, they should be discontinued and renal function should be monitored during the first weeks of perindopril treatment. Loss of renal function may occur with only minor changes in serum creatinine even in patients with unilateral renal artery stenosis.
There is no experience regarding the administration of PREXUM in patients with a recent kidney transplantation.
Rarely, ACE inhibitors have been associated with a syndrome that starts with cholestatic jaundice and progresses to fulminant hepatic necrosis and sometimes death. The mechanism of this syndrome is not understood. Patients treated with ACE inhibitors who develop jaundice or marked elevations of hepatic enzymes should discontinue the ACE inhibitor and receive appropriate medical follow-up (see section 4.8 – Adverse effects (Undesirable effects)).
ACE inhibitors cause a higher rate of angioedema in patients of indigenous African origin than in patients of other racial origin. As with other ACE inhibitors, perindopril may be less effective in lowering blood pressure in people of indigenous African origin than in people of other racial origin, possibly because of a higher prevalence of low-renin states in this population. It is unknown if the same observations have been made in patients of indigenous Australian origin.
A persistent dry (non-productive) irritating cough has been reported with most of the ACE inhibitors. The frequency of reports has been increasing since cough was first recognised as a class-effect of ACE inhibitor treatment with the incidence of cough varying between 2-15% depending upon the medicine, dose and duration of use. The cough is often worse when lying down or at night, and has been reported more frequently in women (who account for two thirds of the reported cases). Patients who cough may have increased bronchial reactivity compared with those who do not. The observed higher frequency of this side-effect in non-smokers may be due to a higher level of tolerance of smokers to cough. The cough is most likely due to stimulation of the pulmonary cough reflex by kinins (bradykinin) and/or prostaglandins, which accumulate because of ACE inhibition. Once a patient has developed intolerable cough, an attempt may be made to switch the patient to another ACE inhibitor; the reaction may recur but this is not invariably the case. A change to another class of medicines may be required in severe cases.
PREXUM treatment has occasionally been associated with mild or transient proteinuria (<1 gram/per 24 hours). However in the majority of patients with pre-existing proteinuria treated with PREXUM, proteinuria disappeared or remained stable. ACE inhibitors have potential to delay the progression of nephropathy in patients with diabetes or hypertension.
Neutropaenia/agranulocytosis, thrombocytopenia and anaemia have been reported in patients treated with an ACE inhibitor. In patients with normal renal function and no other complicating factors, neutropaenia occurs rarely. PREXUM should be used with extreme caution in patients with collagen vascular disease, immunosuppressant treatment, treatment with allopurinol or procainamide, or a combination of these complicating factors, especially if there is pre-existing renal impairment. Some of these patients developed serious infections, which in a few instances did not respond to intensive antibiotic treatment. If PREXUM is used in such patients, periodic monitoring of white blood cell counts is advised and patients should be instructed to report any sign of infection (e.g. sore throat, fever).
Dermatological reactions characterised by maculo-papular pruritic rashes and sometimes photosensitivity have been reported with another ACE inhibitor. Rare and sometimes severe skin reactions (lichenoid eruptions, psoriasis, pemphigus like rash, rosacea, Stevens-Johnson syndrome etc) have been reported following administration of perindopril and may therefore occur. A causal relationship is difficult to assess. Patients who develop a cutaneous reaction with one ACE inhibitor might not when switched to another medicine of the same class, but there are reports of crossreactivity.
Taste disturbances were reported to be common (prevalence up to 12.5%) with high doses of one ACE inhibitor. The actual incidence of taste disturbance is probably low (<0.5%) but data are scarce and difficult to interpret. Taste disturbances with ACE inhibitors have been described as suppression of taste or a metallic sensation in the mouth. Dysgeusia usually occurs in the first weeks of treatment and may disappear in most cases within one to three months.
The effects of perindopril may be enhanced by concomitant administration of antihypertensive medicines which cause renin release.
As a consequence of inhibiting the RAAS, hypotension, syncope, stroke, hyperkalaemia, and changes in renal function (including acute renal failure) have been reported in susceptible individuals, especially if combining medicines that affect this system. Dual blockade of the RAAS through the combined use of ACE-inhibitors, angiotensin II receptor blockers or aliskiren is therefore not recommended (see section 4.3 – Contraindications and section 4.5 – Interactions with other medicines and other forms of interactions). If dual blockade therapy is considered absolutely necessary, this should be limited to individually defined cases under specialist supervision with frequent close monitoring of renal function, electrolytes and blood pressure. The combination of PREXUM with aliskiren is contraindicated in patients with diabetes or renal impairment (GFR < 60 mL/min/1.73 m²) (see section 4.3 – Contraindications and section 4.5 – Interactions with other medicines and other forms of interactions). ACE inhibitors and angiotensin receptor blockers should not be used in combination in patients with diabetic nephropathy.
PREXUM may block angiotensin II formation secondary to compensatory renin release in patients undergoing major surgery or during anaesthesia with agents that produce hypotension and cause further reduction in blood pressure. Treatment should be discontinued one day prior to the surgery. Perioperative hypotension can be corrected with volume expansion.
There has been some concern on theoretical grounds that patients with mitral valve stenosis and obstruction in the outflow of the left ventricle such as aortic stenosis or with hypertrophic cardiomyopathy might be at particular risk of decreased coronary perfusion when treated with vasodilators, including ACE inhibitors. Vasodilators may tend to drop diastolic pressure, and hence coronary perfusion pressure, without producing the concomitant reduction in myocardial oxygen demand that normally accompanies vasodilatation. The true clinical importance of this concern is uncertain.
If an episode of unstable angina pectoris, regardless of severity, occurs during the first month of perindopril treatment, a careful appraisal of the benefits/risks of continuing treatment should be performed.
PREXUM tablets contain lactose. Patients with an intolerance to lactose, rare hereditary problems of galactose intolerance, total lactase deficiency or glucose-galactose malabsorption should not take this medicine.
Patients with primary hyperaldosteronism will generally not respond to antihypertensive medicines acting through inhibition of the renin-angiotensin system. Therefore, treatment with PREXUM is not recommended.
Biotransformation of perindopril to perindoprilat mainly occurs in the liver. Studies in patients with hepatic impairment have shown that kinetic parameters of perindopril were not modified by hepatic failure. With the exception of bioavailability, which was increased, kinetic parameters of perindoprilat (including Tmax) were also unchanged. The increase in bioavailability could be due to inhibition of the formation of perindopril metabolites other than perindoprilat (see section 5.2 – Pharmacokinetic properties). The administration of perindopril leads to the formation of a glucuronoconjugate derivative of perindoprilat by a hepatic first-pass effect. The kinetic parameters of perindoprilat glucuronide are not modified by hepatic failure. The small changes in the kinetics of perindoprilat do not justify the need to change the usual dose in most patients with hepatic failure.
As a consequence of inhibiting the RAAS, changes in renal function may be anticipated in susceptible individuals. In patients with severe congestive heart failure whose renal function may depend on RAAS activity, treatment with ACE inhibitors may be associated with oliguria and/or progressive increase in blood nitrogen, and rarely with acute renal failure and/or death.
In patients with symptomatic heart failure, hypotension following the initiation of treatment with ACE inhibitors may lead to further impairment in renal function. Acute renal failure, usually reversible, has been reported in this situation.
ACE inhibitors should be avoided in patients with known or suspected renal artery stenosis (see section 4.3 – Contraindications).
In clinical studies in patients with hypertension with unilateral or bilateral renal artery stenosis, increases in blood urea, nitrogen and serum creatinine were observed in 20% of patients. Acute renal insufficiency may also occur. These increases are usually reversible upon discontinuation. Renal function may also be reduced in patients with stenosis of the artery supplying a transplanted kidney. It is believed that renal artery stenosis reduces the pressure in the afferent glomerular arteriole, and transglomerular hydrostatic pressure is then maintained by angiotensin II-induced constriction of the efferent arteriole. When an ACE inhibitor is given, the efferent arteriole relaxes, glomerular filtration pressure falls, and renal failure may result. ACE inhibitors can lead to the thrombotic occlusion of a stenosed renal artery.
Some patients with hypertension and with no apparent pre-existing renovascular disease have developed increases in blood urea, nitrogen and serum creatinine, which are usually minor and transient, particularly when PREXUM has been given in combination with a diuretic. However, increases in blood, urea nitrogen and serum creatinine are more likely to occur in patients with preexisting renal impairment or in those on diuretics. Dose reduction of the ACE inhibitor and/or discontinuation of the diuretic may be required.
Renal function should always be assessed (see section 4.2 – Dose and method of administration). In the case of renal impairment, the initial PREXUM dose should be adjusted according to the patient’s creatinine clearance (see section 4.2 – Dose and method of administration). Routine monitoring of potassium and creatinine are part of normal medical practice for these patients (see section 4.2 Dose and Method of Administration). If a deterioration in renal function has occurred after treatment with one ACE inhibitor, then it is likely to be precipitated by another and in these patients use of another class of antihypertensive agent would be preferable. Patients with unilateral renal artery disease present a special problem as deterioration of function may not be apparent from measurement of blood urea and serum creatinine.
Some ACE inhibitors have been associated with the occurrence of proteinuria (up to 0.7%) and/or decline in renal function in patients with one or more of the following characteristics: old age, preexisting renal disease, combined use with potassium-sparing diuretics or high doses of other diuretics, limited cardiac reserve or treatment with a non-steroidal anti-inflammatory medicine (NSAID).
Perindopril is dialysable with a clearance of 70 mL/min.
Renal insufficiency is commonly observed in elderly people. Care should therefore be taken when prescribing PREXUM to elderly patients. The initial dose of PREXUM should always be one PREXUM 2.5 tablet once daily and patients should be monitored closely during the initial stages of treatment (see section 4.2 – Dose and method of administration). In a study of 91 elderly patients with a mean age of 71.9 years, a 6% increase in serum potassium occurred in the first month of treatment and subsequently remained stable. There was no change in the group in blood urea, creatinine or creatinine clearance. Particular care should be taken in elderly patients with congestive heart failure who have renal and/or hepatic insufficiency.
Use of PREXUM in children is not recommended as no data establishing safety or effectiveness in children are available.
Increases in blood urea and plasma creatinine, hyperkalaemia reversible on discontinuation may occur, especially in the presence of renal insufficiency, severe heart failure and renovascular hypertension. Elevation of liver enzymes and serum bilirubin have been reported rarely.
Clinical trial data has shown that dual blockade of the renin-angiotensin-aldosterone-system (RAAS) through the combined use of ACE-inhibitors, angiotensin II receptor blockers or aliskiren is associated with higher frequency of adverse events such as hypotension, hyperkalaemia and decreased renal function (including acute renal failure) compared to the use of a single RAAS-acting agent (see section 4.3 – Contraindications, section 4.4 – Special warnings and precautions for use and section 5.1 – Pharmacodynamic properties).
Patients with diabetes or renal impairment (GFR <60 mL/min/1.73 m²), may be at risk of hypotension, syncope, stroke, hyperkalaemia and changes in renal function (including acute renal failure).
Extracorporeal treatments leading to contact of blood with negatively charged surfaces such as dialysis or haemofiltration with certain high-flux membranes (e.g. polyacrylonitril membranes such as “AN69”) and low density lipoprotein apheresis with dextran sulfate are contraindicated due to increased risk of severe anaphylactoid reactions (see section 4.3 – Contraindications and section 4.4 – Special warnings and precautions for use). If such treatment is required, consideration should be given to using a different type of dialysis membrane (e.g. cuprophane or polysulfone (PSF)) or a different class of antihypertensive agent.
The combined use of PREXUM with sacubitril/valsartan fixed dose combinations is contraindicated as the concomitant inhibition of neprilysin and ACE may increase the risk of angioedema. Sacubitril/valsartan fixed dose combinations must not be started until 36 hours after taking the last dose of PREXUM. PREXUM must not be started until 36 hours after the last dose of sacubitril/valsartan fixed dose combination (see section 4.3 – Contraindications and section 4.4 – Special warnings and precautions for use).
Patients other than those with diabetes or renal impairment may be at risk of hyperkalaemia, worsening of renal function and cardiovascular morbidity, and an increase in mortality (see section 4.3 – Contraindications).
It is reported in the literature that in patients with established atherosclerosis, heart failure, or diabetes with end organ damage, combined use with an ACE inhibitor and an angiotensin-receptor blocker is associated with a higher frequency of hypotension, syncope, hyperkalaemia, and worsening renal function (including acute renal failure) as compared to use of a single RAAS agent.
Dual blockade (e.g, by combining an ACE inhibitor with an angiotensin receptor blocker) should be limited to individually defined cases with close monitoring of renal function, serum potassium, and blood pressure.
Patients on combined treatment with co-trimoxazole (trimethoprim/sulfamethoxazole) may be at increased risk of hyperkalaemia (see section 4.4 – Special warnings and precautions for use).
Reversible increases in serum lithium concentrations and toxicity have been reported during the combined use of lithium with ACE inhibitors. Combined use of thiazide diuretics may increase the risk of lithium toxicity and enhance the already increased risk of lithium toxicity with ACE inhibitors. Use of perindopril with lithium is not recommended, but if the combination is necessary, careful monitoring of serum lithium levels should be performed (see section 4.4 – Special warnings and precautions for use).
The combined use of PREXUM and potassium sparing diuretics may result in potentially lethal hyperkalaemia especially in patients with renal impairment (additive hyperkalaemic effects). The combination of perindopril with the above-mentioned medicines is not recommended (see section 4.4 – Special warnings and precautions for use). If the combination is required, it should be used with caution and with frequent monitoring of serum potassium. For use of spironolactone and eplerenone in heart failure, see paragraph under ‘Combined medicines which require SPECIAL CARE’.
Reported with captopril and enalapril. ACE inhibitors may add to the glucose lowering effect, with risk of hypoglycaemia, in patients with diabetes who are treated with insulin or with oral hypoglycaemic medicines. Hypoglycaemia is very rare and appears to be more likely to occur during the first weeks of combined treatment and in patients with renal impairment.
Baclofen may increase the antihypertensive effect of PREXUM. Monitor blood pressure and adjust the dose of PREXUM if necessary.
Patients treated with diuretics, especially those who are volume and/or salt depleted, may experience excessive reduction in blood pressure after initiation of treatment with an ACE inhibitor. The possibility of hypotensive effects can be reduced by discontinuation of the diuretic, or by increasing volume or salt intake prior to commencing treatment with low and progressive doses of PREXUM. If it is not possible to discontinue the diuretic, the starting dose of the ACE inhibitor should be reduced. The patient should be closely observed for several hours following the initial dose of the ACE inhibitor and until the blood pressure has stabilised. In arterial hypertension, when prior diuretic treatment has caused salt/volume depletion, the diuretic must be discontinued before commencing treatment with the ACE inhibitor. A non-potassium-sparing diuretic can then be reintroduced, or the ACE inhibitor be commenced at a low dose and progressively increased. In diuretic-treated congestive heart failure, the ACE inhibitor should be initiated at a very low dose, possibly after reducing the dose of the associated non-potassium-sparing diuretic.
In all cases, renal function (creatinine levels) must be monitored during the first few weeks of ACE inhibitor treatment.
As the combination of perindopril and potassium sparing medicines (e.g eplerenone and spironolactone), potassium supplements or potassium-containing salt substitutes is general not recommended:
Medicines with prostaglandin synthetase inhibitor properties (e.g. indometacin) or an NSAID (i.e. acetylsalicylic acid at anti-inflammatory dose regimens, non-selective NSAIDs or COX-2 inhibitors) may diminish the antihypertensive efficacy of concomitantly administered ACE inhibitors. However, clinical studies have not demonstrated any interaction between PREXUM and indometacin or other NSAIDs. Combination use of ACE inhibitors and NSAIDs may lead to an increased risk of worsening of renal function, including possible acute renal failure, and an increase in serum potassium, especially in patients with poor pre-existing renal function. The combination should be administered with caution, especially in the elderly. Patients should be adequately hydrated and consideration should be given to monitoring renal function after commencing treatment with the combination, and periodically thereafter.
Hyperkalaemia may occur during the combined use of ACE inhibitors with ciclosporin. Frequent monitoring of serum potassium is recommended.
Hyperkalaemia may occur during the combined use of ACE inhibitors with heparin. Frequent monitoring of serum potassium is recommended.
The combined use of an ACE inhibiting medicine (ACE inhibitor or angiotensin receptor blocker), an anti-inflammatory medicine (NSAID or COX-2 inhibitor) and a thiazide diuretic increases the risk of renal impairment. This includes use in fixed-combination products. The combination of medicines from these three classes should be used with caution particularly in elderly patients or those with pre-existing renal impairment. Combined use of these medications should be accompanied by increased monitoring of serum creatinine, particularly at initiation.
Patients on combined treatment with an ACE inhibitor and an mTOR inhibitor may be at increased risk of angioedema (see section 4.4 – Special warnings and precautions for use).
When an ACE inhibitor and a gliptin are used in combination, there is an increased risk of angioedema due to the decreased activity of the dipeptidyl peptidase IV (DPP-IV).
Nitritoid reactions (symptoms include facial flushing, nausea, vomiting and hypotension) have been reported rarely in patients treated with injectable gold (sodium aurothiomalate) and combined ACE inhibitor treatment including perindopril.
Combined use of these medicines may increase the hypotensive effects of perindopril. Combined use with nitroglycerin and other nitrates, or other vasodilators, may further reduce blood pressure.
The simultaneous administration of tetracycline with an ACE inhibitor may significantly reduce the absorption of tetracycline, possibly due to the magnesium content in the ACE inhibitor tablets. This interaction should be considered if co-prescribing an ACE inhibitor and tetracycline or other medicines that interact with magnesium.
As the sympathetic nervous system plays an important part in physiological blood pressure regulation, caution should be exercised with combined administration of a medicine with sympathetic activity and PREXUM. Sympathomimetics may reduce the antihypertensive effects of ACE inhibitors.
Combined use of certain anaesthetics, tricyclic antidepressants and antipsychotics with ACE inhibitors may result in further reduction of blood pressure (see section 4.4 – Special warnings and precautions for use).
The effects of perindopril arginine on fertility have not been investigated. Studies in rats showed no impairment of male or female fertility at oral perindopril erbumine doses up to 10 mg/kg/day.
Australian Pregnancy Categorisation: D.
The use of ACE inhibitors is contraindicated during pregnancy (see section 4.3 – Contraindications).
As with all ACE inhibitors, PREXUM should not be taken during pregnancy. Pregnancy should be excluded before starting treatment with PREXUM and avoided during the treatment. Unless continued treatment with an ACE inhibitor is considered essential, patients planning pregnancy should be changed to alternative anti-hypertensive treatments which have an established safety profile for use in pregnancy. If a patient intends to become pregnant, treatment with ACE inhibitors must be discontinued and replaced by another form of treatment. If a patient becomes pregnant while on ACE inhibitors, she must immediately inform her doctor to discuss a change in medication and further management.
Perindopril or its metabolites have been shown to cross the placenta and distribute to the foetus in pregnant animals. There are no adequate and well-controlled studies of ACE inhibitors in pregnant women, but foetotoxicity is well documented in animal models. Data, however, show that ACE inhibitors cross the human placenta. Post-marketing experience with all ACE inhibitors suggests that exposure in utero may be associated with hypotension and decreased renal perfusion in the foetus.
The ACE inhibitor class has also been associated with foetal death in utero.
Epidemiological evidence regarding the risk of teratogenicity following exposure to ACE inhibitors during the first trimester of pregnancy has not been conclusive; however a small increase in risk cannot be excluded.
A historical cohort study in over 29,000 infants born to mothers without diabetes has shown 2.7 times higher risk for congenital malformations in infants exposed to ACE inhibitors during the first trimester compared to no exposure. The risk ratios for cardiovascular and central nervous system malformations were 3.7 times (95% confidence interval 1.89 to 7.3) and 4.4 times (95% confidence interval 1.37 to 14.02) respectively, compared to no exposure.
When ACE inhibitors have been used during the second and third trimesters of pregnancy, there have been reports of foetal and neonatal toxicity: hypotension, hyperkalaemia, renal failure, skull hypoplasia, oligohydramnios and death.
Oligohydramnios has been reported, presumably resulting from decreased foetal renal function; oligohydramnios has been associated with foetal limb contractures, craniofacial deformities, hypoplastic lung development and intra-uterine growth retardation. Prematurity and patent ductus arteriosus have been reported, however it is not clear whether these events were due to ACE inhibitor exposure or to the mother’s underlying disease.
Infants exposed in utero to ACE inhibitors should be closely observed for hypotension, oliguria, and hyperkalaemia. Should exposure to ACE inhibitors have occurred from the second trimester of pregnancy, ultrasound check of renal function and skull is recommended. If such complications arise, appropriate medical treatment should be initiated to support blood pressure and renal perfusion.
Animal studies have shown that perindopril and its metabolites are excreted in milk during lactation, but there are no human data. It is therefore recommended that PREXUM should not be given to lactating women as the possible effect on the newborn is unknown. Alternative treatments with better established safety profiles during breast-feeding are preferable, especially while nursing a newborn or preterm infant.
The antihypertensive effect in individual cases may be symptomatic. Treatment with any blood pressure lowering agent may, therefore, affect the ability to drive, cross the road safely or operate machinery, especially at the start of treatment or when changing over from other preparations, or during combined use of alcohol.
Reporting suspected adverse reactions after registration of the medicinal product is important. It allows continued monitoring of the benefit-risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions at http://www.tga.gov.au/reporting-problems.
The safety profile of perindopril is consistent with the safety profile of ACE inhibitors. The most frequent adverse events reported in clinical trials and observed with perindopril are: dizziness, headache, paraesthesia, vertigo, visual disturbances, tinnitus, hypotension, cough, dyspnoea, abdominal pain, constipation, diarrhoea, dysgeusia, dyspepsia, nausea, vomiting, pruritis, rash, muscle cramps, and asthenia. The following adverse effects (see Table 2) have been observed during clinical trials and/or post-marketing use with perindopril and ranked under the following frequency: very common (>1/10); common (>1/100, <1/10); uncommon (>1/1000, <1/100); rare (>1/10000, <1/1000); very rare (<1/10000 and including isolated reports).
Table 2. Adverse effects observed during clinical trials and/or post-marketing use with perindopril:
| ADVERSE EFFECTS MedDRA System organ class | Frequency |
|---|---|
| Blood and lymphatic system disorders | |
| Eosinophilia | Uncommon# |
| Agranulocytosis or pancytopenia | Very rare |
| Decreases in haemoglobin and haematocrit | Very rare |
| Leucopenia/neutropenia | Very rare |
| An unexplained change in prothrombin ratio was reported in one patient | Very rare |
| Haemolytic anaemia has been reported in patients with congenital G6PDH deficiency (see section 4.4 – Special warnings and precautions for use) | Very rare |
| Blood and lymphatic system disorders continued | |
| Thrombocytopenia | Very rare |
| Endocrine disorders | |
| Syndrome of inappropriate antidiuretic hormone secretion (SIADH) | Rare |
| Metabolism and nutrition disorders | |
| Hypoglycaemia (see section 4.4 – Special warnings and precautions for use and section 4.5 – Interactions with other medicines and other forms of interactions) | Uncommon# |
| Hyperkalaemia, reversible on discontinuation (see section 4.4 – Special warnings and precautions for use) | Uncommon# |
| Hyponatraemia | Uncommon# |
| Psychiatric disorders | |
| Depression | Uncommon# |
| Mood disturbances | Uncommon |
| Sleep disorder (insomnia, dream abnormality) | Uncommon |
| Nervous system disorders | |
| Dizziness | Common |
| Headache | Common |
| Paresthaesia | Common |
| Vertigo | Common |
| Drowsiness | Common |
| Somnolence | Uncommon# |
| Syncope | Uncommon# |
| Confusion | Very rare |
| Hallucinations | Very rare |
| Eye disorders | |
| Visual disturbance | Common |
| Ear and Labyrinth disorders | |
| Tinnitus | Common |
| Cardiac disorders | |
| Palpitations | Common |
| Tachycardia | Uncommon# |
| Angina pectoris (see section 4.4 – Special warnings and precautions for use) | Very rare |
| Arrhythmia | Very rare |
| Myocardial infarction possibly secondary to excessive hypotension in high-risk patients (see section 4.4 – Special warnings and precautions for use) | Very rare |
| Vascular disorders | |
| Hypotension (and effects related to hypotension) | Common |
| Vasculitis | Common |
| Flushing | Common |
| Impaired peripheral circulation | Common |
| Stroke – possibly secondary to excessive hypotension in high-risk patients (see section 4.4 – Special warnings and precautions for use) | Very rare |
| Vascular disorders continued | |
| Raynaud’s phenomenon | Not known |
| Respiratory, thoracic and mediastinal disorders | |
| Cough | Common |
| Dyspnoea | Common |
| Epistaxis | Common |
| Discomfort on exertion | Common |
| Bronchospasm | Uncommon |
| Eosinophilic pneumonia | Very rare |
| Rhinitis | Very rare |
| Gastrointestinal disorders | |
| Abdominal pain | Common |
| Constipation | Common |
| Diarrhoea | Common |
| Dysgeusia | Common |
| Dyspepsia | Common |
| Nausea | Common |
| Vomiting | Common |
| Dry mouth | Uncommon |
| Pancreatitis | Very rare |
| Hepato-biliary disorders | |
| Hepatitis, either cytolytic or cholestatic (see section 4.4 – Special warnings and precautions for use) | Very rare |
| Skin and subcutaneous tissue disorders | |
| Pruritus | Common |
| Rash | Common |
| Urticaria (see section 4.4 – Special warnings and precautions for use) | Uncommon |
| Angioedema of face, extremities, lips, mucous membranes, tongue, glottis and/or larynx (see section 4.4 – Special warnings and precautions for use) | Uncommon |
| Hyperhidrosis | Uncommon |
| Photosensitivity reactions | Uncommon# |
| Pemphigoid | Uncommon# |
| Eczema | Uncommon# |
| Psoriasis aggravation | Rare# |
| Erythema multiforme | Very rare |
| Musculoskeletal and Connective tissue disorders | |
| Muscle cramps | Common |
| Arthralgia | Uncommon# |
| Myalgia | Uncommon# |
| Renal and urinary disorders | |
| Renal insufficiency | Uncommon |
| Acute renal failure | Rare# |
| Anuria/Oliguria | Rare# |
| Reproductive system and Breast disorders | |
| Erectile dysfunction | Uncommon |
| General disorders and administration site conditions | |
| Asthenia | Common |
| Chest pain | Uncommon# |
| Malaise | Uncommon# |
| Oedema peripheral | Uncommon# |
| Pyrexia | Uncommon# |
| Sweating | Uncommon |
| Atypical chest pain | Uncommon |
| Investigations | |
| Blood urea increased | Uncommon# |
| Blood creatinine increased | Uncommon# |
| Blood bilirubin elevation | Rare |
| Hepatic enzyme increases | Rare |
| Injury, Poisoning and Procedural Complications | |
| Fall | Uncommon# |
# Frequency of these adverse events detected from spontaneous reports is calculated from clinical trial data.
In total, 56 of 1,275 patients (4.4%) studied stopped treatment because of adverse reactions. In a specific study of 632 patients, in which 36 patients (5.7%) withdrew because of adverse events, a plausible or probable relationship with perindopril treatment was considered to exist in 19 cases (3%).
Incompatibilities were either not assessed or not identified as part of the registration of this medicine.
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