Perindopril

About Perindopril

The body converts perindopril to perindoprilat, which blocks the angiotensin-converting enzyme (ACE) that makes angiotensin II, a hormone that narrows blood vessels and stimulates aldosterone. The label approves it for essential high blood pressure, alone or with other blood pressure medicines (especially thiazide diuretics), and for stable coronary artery disease, to reduce the risk of cardiovascular death or nonfatal heart attack; safety and effectiveness in children have not been established. For blood pressure it usually starts at 4 mg once a day, with a usual range of 4 to 8 mg a day as one dose or two divided doses and a maximum of 16 mg a day. For coronary artery disease it starts at 4 mg once a day for two weeks and is raised as tolerated to 8 mg once a day. It is not recommended when creatinine clearance is below 30 mL per minute; with milder kidney impairment it starts at 2 mg a day and does not exceed 8 mg.

The boxed warning is fetal toxicity: drugs that act directly on the renin-angiotensin system can injure and kill a developing baby, so perindopril is stopped as soon as pregnancy is detected. Angioedema, swelling that involves the tongue, glottis or larynx, can be fatal; it occurs more often in Black patients, can also affect the intestine, and is more likely with an mTOR inhibitor or a neprilysin inhibitor. Perindopril must not be taken after angioedema or another allergic reaction to any ACE inhibitor, with hereditary or idiopathic angioedema, with aliskiren in diabetes, or with sacubitril, including within 36 hours of switching to or from sacubitril-valsartan. Blood pressure can drop too far, especially after the first dose in people already on a diuretic, so patients are followed closely for the first two weeks and after dose increases. A persistent dry cough can occur with any ACE inhibitor and usually clears after stopping; cough, dizziness and back pain are the most common side effects.

ACE inhibitors have been linked to agranulocytosis, a severe fall in white blood cells, most often in people with kidney impairment, especially with a collagen vascular disease, and, rarely, to cholestatic jaundice that can progress to liver failure; jaundice or a marked rise in liver enzymes means stopping the drug. Kidney function and potassium are checked periodically. Food reduces how much perindopril is converted to perindoprilat, although the label calls the effect on ACE inhibition probably not clinically significant. Aceon (approved in 1993) and Prestalia (perindopril arginine with amlodipine, approved in 2015) are both listed as discontinued.

Taking Perindopril

How to take it

Once or twice a day as prescribed, at about the same times each day, with a full glass of water, with or without food. Get up slowly from sitting or lying down, and call the prescriber about ongoing vomiting or diarrhea or unusual sweating, which can leave you dehydrated.

If you miss a dose

Take it as soon as you remember, unless it is almost time for the next dose; then skip the missed dose and carry on as usual. Do not take a double dose.

Storage

At room temperature, away from heat and moisture (not in the bathroom), out of reach of children. Use a take-back program rather than flushing.

Interactions to know about

Potassium supplements, potassium salt substitutes and potassium-sparing diuretics can raise potassium too high; ibuprofen, naproxen and other NSAIDs can strain the kidneys; it raises lithium levels; and starting it on top of a diuretic can drop blood pressure too far. Injectable gold has rarely caused flushing, nausea and low blood pressure with ACE inhibitors, and mTOR inhibitors and sacubitril add to the risk of angioedema.

This summarizes the official prescribing information. Your prescriber’s and pharmacist’s instructions, and the leaflet that comes with your medicine, take priority.

Why the cash price for Perindopril differs from pharmacy to pharmacy

With Aceon discontinued, every fill is a generic, so quotes differ mainly in each pharmacy’s dispensing fee and markup and in whether perindopril is on its flat-price generic list. A pharmacy that rarely fills perindopril may need to order it in.

A dose split into two a day, or written as two tablets of a lower strength, raises the count where a pharmacy prices per tablet, and each new strength while the dose is raised is a separate fill with its own fee. Prestalia is discontinued, so a prescription written for it has to be rewritten by the prescriber.

Ways to pay less for Perindopril without insurance

• Ask whether perindopril is on the pharmacy’s flat-price generic list, and compare more than one pharmacy.
• Once your dose is settled, ask for a ninety-day supply.
• If your dose is 8 mg once a day, check that it is written as one 8 mg tablet rather than two 4 mg tablets.
• If it is quoted high, ask the prescriber whether another generic ACE inhibitor, such as lisinopril or ramipril, would suit you.
• Upload the prescription to Script Unlock so licensed pharmacies can quote their cash price. You pay the pharmacy directly.

Questions to ask your pharmacist about Perindopril

1. 1.When will my potassium and kidney function be checked?
2. 2.What should I do if I get a dry cough, stomach pain, or swelling of my face, lips or tongue?
3. 3.What should I do if I become pregnant or plan to?
4. 4.Is it safe with my water pill, lithium, potassium supplement or salt substitute?

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