Hypertension:

Treatment of hypertension.

Heart failure:

Treatment of symptomatic heart failure.

Stable coronary artery disease:

Reduction of risk of cardiac events in patients with a history of myocardial infarction and/or

revascularisation.

Posology The dose should be individualised according to the patient profile (see section 4.4) and blood pressure response. - Hypertension: Tenoryl  arginine may be used in monotherapy or in combination with other classes of antihypertensive therapy. The recommended starting dose is 5 mg given once daily in the morning. Patients with a strongly activated renin-angiotensin-aldosterone system (in particular, renovascular hypertension, salt and/or volume depletion, cardiac decompensation or severe hypertension) may experience an excessive drop in blood pressure following the initial dose. A starting dose of 2.5 mg is recommended in such patients and the initiation of treatment should take place under medical supervision. The dose may be increased to 10 mg once daily after one month of treatment. Symptomatic hypotension may occur following initiation of therapy with Tenoryl  arginine; this is more likely in patients who are being treated concurrently with diuretics. Caution is therefore recommended since these patients may be volume and/or salt depleted. If possible, the diuretic should be discontinued 2 to 3 days before beginning therapy with Tenoryl  arginine (see section 4.4). In hypertensive patients in whom the diuretic cannot be discontinued, therapy with Tenoryl  arginine should be initiated with a 2.5 mg dose. Renal function and serum potassium should be monitored. The subsequent dosage of Tenoryl  arginine should be adjusted according to blood pressure response. If required, diuretic therapy may be resumed. In elderly patients treatment should be initiated at a dose of 2.5 mg which may be progressively increased to 5 mg after one month then to 10 mg if necessary depending on renal function (see table below). Symptomatic heart failure: It is recommended that Tenoryl  arginine, generally associated with a non-potassium-sparing diuretic and/or digoxin and/or a beta-blocker, be introduced under close medical supervision with a recommended starting dose of 2.5 mg taken in the morning. This dose may be increased after 2 weeks to 5 mg once daily if tolerated. The dose adjustment should be based on the clinical response of the individual patient. In severe heart failure and in other patients considered to be at high risk (patients with impaired renal function and a tendency to have electrolyte disturbances, patients receiving simultaneous treatment with diuretics and/or treatment with vasodilating agents), treatment should be initiated under careful supervision (see section 4.4). Patients at high risk of symptomatic hypotension e.g. patients with salt depletion with or without hyponatraemia, patients with hypovolaemia or patients who have been receiving vigorous diuretic therapy should have these conditions corrected, if possible, prior to therapy with Tenoryl  arginine. Blood pressure, renal function and serum potassium should be monitored closely, both before and during treatment with Tenoryl  arginine (see section 4.4). - Stable coronary artery disease: Tenoryl  arginine should be introduced at a dose of 5 mg once daily for two weeks, then increased to 10 mg once daily, depending on renal function and provided that the 5 mg dose is well tolerated. Elderly patients should receive 2.5 mg once daily for one week, then 5 mg once daily the next week, before increasing the dose up to 10 mg once daily depending on renal function (see Table 1 “Dosage adjustment in renal impairment”). The dose should be increased only if the previous lower dose is well tolerated. Special population: Patients with renal impairment: Dosage in patients with renal impairment should be based on creatinine clearance as outlined in table 1 below: Table 1: dosage adjustment in renal impairment Creatinine clearance (ml/min) Recommended dose ClCR ≥ 60 5 mg per day 30 < ClCR < 60 2.5 mg per day 15 < ClCR < 30 2.5 mg every other day Haemodialysed patients * ClCR < 15 2.5 mg on the day of dialysis * Dialysis clearance of perindoprilat is 70 ml/min. For patients on haemodialysis, the dose should be taken after dialysis. Patients with hepatic impairment: No dosage adjustment is necessary in patients with hepatic impairment (see sections 4.4 and 5.2). Paediatric population: The efficacy and safety of use in children and adolescents (less than 18 years) have not been established. Therefore, use in children and adolescents is not recommended. Method of administration For oral use. Tenoryl  arginine is recommended to be taken once daily in the morning before a meal.

Hypersensitivity to the active substance, to any of the excipients or to any other ACE inhibitor; • History of angioedema associated with previous ACE inhibitor therapy; • Hereditary or idiopathic angioedema; • Second and third trimesters of pregnancy (see sections 4.4 and 4.6); • Concomitant use with Aliskiren in patients with diabetes mellitus or renal impairment (GFR < 60 ml/min/1.73m²) (see sections 4.4 and 4.5).

Stable coronary artery disease:

If an episode of unstable angina pectoris (major or not) occurs during the first month of perindopril

treatment, a careful appraisal of the benefit/risk should be performed before treatment continuation.

Hypotension:

ACE inhibitors may cause a fall in blood pressure. Symptomatic hypotension is seen rarely inuncomplicated hypertensive patients and is more likely to occur in patients who have been volumedepleted

e.g. by diuretic therapy, dietary salt restriction, dialysis, diarrhoea or vomiting, or who have severe renin-dependent hypertension (see sections 4.5 and 4.8). In patients with symptomatic heart

failure, with or without associated renal insufficiency, symptomatic hypotension has been observed.

This is most likely to occur in those patients with more severe degrees of heart failure, as reflected by the use of high doses of loop diuretics, hyponatraemia or functional renal impairment. In patients at increased risk of symptomatic hypotension, initiation of therapy and dose adjustment should be closely monitored (see sections 4.2 and 4.8). Similar considerations apply to patients with ischaemic heart or

cerebrovascular disease in whom an excessive fall in blood pressure could result in a myocardial infarction or cerebrovascular accident.

If hypotension occurs, the patient should be placed in the supine position and, if necessary, should receive an intravenous infusion of sodium chloride 9 mg/ml (0.9%) solution. A transient hypotensive

response is not a contraindication to further doses, which can be given usually without difficulty once the blood pressure has increased after volume expansion.

In some patients with congestive heart failure who have normal or low blood pressure, additional lowering of systemic blood pressure may occur with Tenoryl arginine. This effect is anticipated and is

usually not a reason to discontinue treatment. If hypotension becomes symptomatic, a reduction of dose or discontinuation of Tenoryl arginine may be necessary.

Aortic and mitral valve stenosis / hypertrophic cardiomyopathy:

As with other ACE inhibitors, Tenoryl arginine should be given with caution to patients with mitralvalve stenosis and obstruction in the outflow of the left ventricle such as aortic stenosis or hypertrophic cardiomyopathy.

Renal impairment:

In cases of renal impairment (creatinine clearance < 60 ml/min) the initial perindopril dosage should beadjusted according to the patient's creatinine clearance (see section 4.2) and then as a function of the

patient's response to treatment. Routine monitoring of potassium and creatinine are part of normalmedical practice for these patients (see section 4.8).

In patients with symptomatic heart failure, hypotension following the initiation of therapy with ACEinhibitors may lead to some further impairment in renal function. Acute renal failure, usually reversible,

has been reported in this situation.

In some patients with bilateral renal artery stenosis or stenosis of the artery to a solitary kidney, who have been treated with ACE inhibitors, increases in blood urea and serum creatinine, usually reversible

upon discontinuation of therapy, have been seen. This is especially likely in patients with renal insufficiency. If renovascular hypertension is also present there is an increased risk of severe

hypotension and renal insufficiency. In these patients, treatment should be started under close medical supervision with low doses and careful dose titration. 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 Tenoryl arginine therapy.

Some hypertensive patients with no apparent pre-existing renal vascular disease have developed increases in blood urea and serum creatinine, usually minor and transient, especially when Tenoryl

arginine has been given concomitantly with a diuretic. This is more likely to occur in patients with preexisting renal impairment. Dosage reduction and/or discontinuation of the diuretic and/or Tenoryl

arginine may be required.

Haemodialysis patients:

Anaphylactoid reactions have been reported in patients dialysed with high flux membranes, and treated concomitantly with an ACE inhibitor. In these patients consideration should be given to using a

different type of dialysis membrane or different class of antihypertensive agent.

Kidney transplantation:

There is no experience regarding the administration of Tenoryl arginine in patients with a recent kidney transplantation.

Hypersensitivity/Angioedema:

Angioedema of the face, extremities, lips, mucous membranes, tongue, glottis and/or larynx has been reported rarely in patients treated with ACE inhibitors, including Tenoryl arginine (see section 4.8).

This may occur at any time during therapy. In such cases, Tenoryl arginine should promptly be discontinued and appropriate monitoring should be initiated and continued until complete resolution of

symptoms has occurred. In those instances where swelling was confined to the face and lips the condition generally resolved without treatment, although antihistamines have been useful in relieving

symptoms.

Angioedema associated with laryngeal oedema may be fatal. Where there is involvement of the tongue, glottis or larynx, likely to cause airway obstruction, emergency therapy should be administered

promptly. This may include the administration of adrenaline and/or the maintenance of a patent airway. The patient should be under close medical supervision until complete and sustained resolution of

symptoms has occurred.

Patients with a history of angioedema unrelated to ACE inhibitor therapy may be at increased risk of angioedema while receiving an ACE inhibitor (see section 4.3).

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.

Anaphylactoid reactions during low-density lipoproteins (LDL) apheresis:

Rarely, patients receiving ACE inhibitors during low-density lipoprotein (LDL) apheresis with dextran sulphate have experienced life-threatening anaphylactoid reactions. These reactions were avoided by

temporarily withholding ACE inhibitor therapy prior to each apheresis.

Anaphylactic reactions during desensitisation:

Patients receiving 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. Hepatic failure:

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 receiving 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).

Neutropenia/Agranulocytosis/Thrombocytopenia/Anaemia:

Neutropenia/agranulocytosis, thrombocytopenia and anaemia have been reported in patients receiving ACE inhibitors. In patients with normal renal function and no other complicating factors, neutropenia

occurs rarely. Perindopril should be used with extreme caution in patients with collagen vascular disease, immunosuppressant therapy, treatment with allopurinol or procainamide, or a combination of these complicating factors, especially if there is pre-existing impaired renal function. Some of these patients developed serious infections, which in a few instances did not respond to intensive antibiotic therapy. If perindopril 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).

Race:

ACE inhibitors cause a higher rate of angioedema in black patients than in non-black patients.

As with other ACE inhibitors, perindopril may be less effective in lowering blood pressure in black people than in non-blacks, possibly because of a higher prevalence of low-renin states in the black

hypertensive population.

Cough:

Cough has been reported with the use of ACE inhibitors. Characteristically, the cough is nonproductive, persistent and resolves after discontinuation of therapy. ACE inhibitor-induced cough

should be considered as part of the differential diagnosis of cough.

Surgery/Anaesthesia:

In patients undergoing major surgery or during anaesthesia with agents that produce hypotension, Tenoryl arginine may block angiotensin II formation secondary to compensatory renin release. The

treatment should be discontinued one day prior to the surgery. If hypotension occurs and is considered to be due to this mechanism, it can be corrected by volume expansion.

Hyperkalaemia:

Elevations in serum potassium have been observed in some patients treated with ACE inhibitors, including perindopril. Risk factors for the development of hyperkalaemia include those with renal

insufficiency, worsening of renal function, age (> 70 years), diabetes mellitus, intercurrent events, in particular dehydration, acute cardiac decompensation, metabolic acidosis and concomitant use of

potassium-sparing diuretics (e.g. spironolactone, eplerenone, triamterene, or amiloride), potassium supplements or potassium-containing salt substitutes; or those patients taking other drugs associated with increases in serum potassium (e.g. heparin). 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. If concomitant use of the above-mentioned agents is deemed appropriate, they should

be used with caution and with frequent monitoring of serum potassium (see section 4.5).

Diabetic patients:

In diabetic patients treated with oral antidiabetic agents or insulin, glycaemic control should be closely monitored during the first month of treatment with an ACE inhibitor (see section 4.5).

Lithium:

The combination of lithium and perindopril is generally not recommended (see section 4.5).

Potassium-sparing drugs, potassium supplements or potassium-containing salt substitutes:

The combination of perindopril and potassium-sparing drugs, potassium supplements or potassiumcontaining salt substitutes is generally not recommended (see section 4.5).

Dual blockade of the renin-angiotensin-aldosterone system (RAAS):

Hypotension, syncope, stroke, hyperkalaemia, and changes in renal function (including acute renal failure) have been reported in susceptible individuals, especially if combining medicinal products that

affect this system. Dual blockade of the renin-angiotensin-aldosterone system by combining an angiotensin converting enzyme inhibitor (ACEI) with an angiotensin II receptor blocker (ARB) or

aliskiren is therefore not recommended.

Combination with aliskiren is contraindicated in patients with diabetes mellitus or renal impairment (GFR < 60 ml/min/1.73 m2) (see sections 4.3 and 4.5).

Pregnancy:

ACE inhibitors should not be initiated during pregnancy. Unless continued ACE inhibitor therapy is considered essential, patients planning pregnancy should be changed to alternative anti-hypertensive

treatments which have an established safety profile for use in pregnancy. When pregnancy is diagnosed,

treatment with ACE inhibitors should be stopped immediately, and, if appropriate, alternative therapy should be started (see sections 4.3 and 4.6).

Drugs inducing hyperkalaemia

Some drugs or therapeutic classes may increase the occurrence of hyperkalaemia: aliskiren, potassium salts,potassium-sparing diuretics, ACE inhibitors, angiotensin-II receptors antagonists, NSAIDs, heparins,immunosuppressant agents such as ciclosporin or tacrolimus, trimethoprim. The combination of these drugs increases the risk of hyperkalaemia.

Concomitant use contra-indicated (see section 4.3):

Aliskiren:

In diabetic or impaired renal patients, risk of hyperkalaemia, worsening of renal function and

cardiovascular morbidity and mortality increase.

Concomitant use not recommended (see section 4.4):

Aliskiren:

In patients other than diabetic or impaired renal patients, risk of hyperkalaemia, worsening of renal function

and cardiovascular morbidity and mortality increase.

Concomitant therapy with ACE inhibitor and angiotensin-receptor blocker:

It has been reported in the literature that in patients with established atherosclerotic disease, heart failure, or with diabetes with end organ damage, concomitant therapy with ACE inhibitor and 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 renin-angiotensin-aldosterone system agent. Dual blockade (e.g., by combining an ACE-inhibitor with an angiotensin II receptor antagonist) should be limited to individually defined cases with close monitoring of renal function, potassium levels,and blood pressure.

Estramustine:

Risk of increased adverse effects such as angioneurotic oedema (angioedema).

Potassium-sparing diuretics (e.g. triamterene, amiloride...), potassium salts:

Hyperkalaemia (potentially lethal), especially in conjunction with renal impairment (additive

hyperkalaemic effects).

The combination of perindopril with the above-mentioned drugs is not recommended (see section 4.4). If concomitant use is nonetheless indicated, they should be used with caution and with frequent monitoring of  serum potassium. For use of spironolactone in heart failure, see below.

Lithium:

Reversible increases in serum lithium concentrations and toxicity have been reported during concomitant administration of lithium with ACE inhibitors. Use of perindopril with lithium is not recommended, but if the combination proves necessary, careful monitoring of serum lithium levels should be performed (see section 4.4).

Concomitant use which requires special care:

Antidiabetic agents (insulins, oral hypoglycaemic agents):

Epidemiological studies have suggested that concomitant administration of ACE inhibitors and antidiabetic medicines (insulins, oral hypoglycaemic agents) may cause an increased blood-glucose lowering effect with risk of hypoglycaemia. This phenomenon appeared to be more likely to occur during the first weeks of combined treatment and in patients with renal impairment.

Baclofen:

Increased antihypertensive effect. Monitor blood pressure and adapt antihypertensive dosage if necessary.

Non-potassium-sparing diuretics:

Patients on diuretics, and especially those who are volume and/or salt depleted, may experience excessive reduction in blood pressure after initiation of therapy with an ACE inhibitor. The possibility of hypotensive effects can be reduced by discontinuation of the diuretic, by increasing volume or salt intake prior to initiating therapy with low and progressive doses of perindopril.

In arterial hypertension, when prior diuretic therapy can have caused salt/volume depletion, either the diuretic must be discontinued before initiating the ACE inhibitor, in which case a non-potassium-sparing diuretic can be thereafter reintroduced or the ACE inhibitor must be initiated with a low dosage and progressively increased.

In diuretic-treated congestive heart failure, the ACE inhibitor should be initiated at a very low dosage, possibly after reducing the dosage of the associated non-potassium-sparing diuretic.

In all cases, renal function (creatinine levels) must be monitored during the first few weeks of ACEinhibitor therapy.

Potassium-sparing diuretics (eplerenone, spironolactone):

With eplerenone or spironolactone at doses between 12.5 mg to 50 mg by day and with low doses of ACE inhibitors:

In the treatment of class II-IV heart failure (NYHA) with an ejection fraction < 40%, and previously treated with ACE inhibitors and loop diuretics, risk of hyperkalaemia, potentially lethal, especially in case of nonobservance of the prescription recommendations on this combination.

Before initiating the combination, check the absence of hyperkalaemia and renal impairment.

A close monitoring of the kalaemia and creatinaemia is recommended in the first month of the treatment once a week at the beginning and, monthly thereafter.

Non-steroidal anti-inflammatory medicinal products (NSAIDs) including aspirin ≥ 3 g/day:

When ACE-inhibitors are administered simultaneously with non-steroidal anti-inflammatory drugs (i.e. acetylsalicylic acid at anti-inflammatory dosage regimens, COX-2 inhibitors and non-selective NSAIDs), attenuation of the antihypertensive effect may occur. Concomitant 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 initiation of concomitant therapy, and periodically thereafter.

Concomitant use which requires some care:

Antihypertensive agents and vasodilators:

Concomitant use of these agents may increase the hypotensive effects of perindopril. Concomitant use with

nitroglycerin and other nitrates, or other vasodilators, may further reduce blood pressure.

Gliptins (linagliptin, saxagliptin, sitagliptin, vildagliptin):

Increased risk of angio-oedema, due to dipeptidyl peptidase IV (DPP-IV) decreased activity by the gliptin, in patients co-treated with an ACE inhibitor.

Tricyclic antidepressants/Antipsychotics/Anaesthetics:

Concomitant use of certain anaesthetic medicinal products, tricyclic antidepressants and antipsychotics with ACE inhibitors may result in further reduction of blood pressure (see section 4.4).

Sympathomimetics:

Sympathomimetics may reduce the antihypertensive effects of ACE inhibitors.

Gold:

Nitritoid reactions (symptoms include facial flushing, nausea, vomiting and hypotension) have been reported rarely in patients on therapy with injectable gold (sodium aurothiomalate) and concomitant ACE inhibitor therapy including perindopril.

Pregnancy:

The use of ACE inhibitors is not recommended during the first trimester of pregnancy (see section 4.4). The use of ACE inhibitors is contra-indicated during the 2nd and 3rd trimester of pregnancy (see sections 4.3 and 4.4).

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. Unless continued ACE inhibitor therapy is considered essential, patients planning pregnancy should be changed to alternative antihypertensive treatments which have an established safety profile for use in pregnancy. When pregnancy is diagnosed, treatment with ACE inhibitors should be stopped immediately, and, if appropriate, alternative therapy should be started.

Exposure to ACE inhibitor therapy during the second and third trimesters is known to induce human foetotoxicity (decreased renal function, oligohydramnios, skull ossification retardation) and neonatal toxicity (renal failure, hypotension, hyperkalaemia) (see section 5.3). Should exposure to ACE inhibitor have occurred from the second trimester of pregnancy, ultrasound check of renal function and skull is recommended. Infants whose mothers have taken ACE inhibitors should be closely observed for hypotension (see also sections 4.3 and 4.4).

Lactation:

Because no information is available regarding the use of Tenoryl  arginine during breast-feeding, Tenoryl  arginine is not recommended and alternative treatments with better established safety profiles during breast-feeding are preferable, especially while nursing a newborn or preterm infant.

Fertility:

There was no effect on reproductive performance or fertility.

Tenoryl  arginine has no direct influence on the ability to drive and use machines but individual reactions related to low blood pressure may occur in some patients, particularly at the start of treatment or in combination with another antihypertensive medication.

As a result the ability to drive or operate machinery may be impaired.

a. Summary of safety profile

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.

b. Tabulated list of adverse reactions

The following undesirable effects 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); not known (cannot be estimated from the available data).

MedDRA System Organ Class	Undesirable Effects	Frequency
Blood and the lymphatic System Disorders	Eosinophilia	Uncommon*
	Agranulocytosis or pancytopenia	Very rare
	Haemoglobin decreased and haematocrit decreased	Very rare
	Leucopenia/neutropenia	Very rare
	Haemolytic anaemia in patients with a congenital deficiency of G-6PDH (see section 4.4)	Very rare
	Thrombocytopenia	Very rare
Metabolism and Nutrition Disorders	Hypoglycaemia (see sections 4.4 and 4.5)	Uncommon*
	Hyperkalaemia, reversible on discontinuation (see section 4.4)	Uncommon*
	Hyponatraemia	Uncommon*
Psychiatric disorders	Mood disturbances	Uncommon
	Sleep disorder	Uncommon
Nervous System disorders	Dizziness	Common
	Headache	Common
	Paraesthesia	Common
	Vertigo	Common
	Somnolence	Uncommon*
	Syncope	Uncommon*
	Confusion	Very rare
Eye Disorders	Visual disturbances	Common
Ear and labyrinth disorders	Tinnitus	Common
Cardiac Disorders	Palpitations	Uncommon*
	Tachycardia	Uncommon*
	Angina pectoris (see section 4.4)	Very rare
	Arrhythmia	Very rare
	Myocardial infarction, possibly secondary to excessive hypotension in high risk patients (see section 4.4)	Very rare
Vascular Disorders	Hypotension (and effects related to hypotension)	Common
	Vasculitis	Uncommon*
	Stroke possibly secondary to excessive hypotension in high-risk patients (see section 4.4)	Very rare
Respiratory, Thoracic and Mediastinal Disorders	Cough	Common
	Dyspnoea	Common
	Bronchospasm	Uncommon
	Eosinophilic pneumonia	Very rare
	Rhinitis	Very rare
Gastro-intestinal 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)	Very rare
Skin and Subcutaneous Tissue Disorders	Pruritis	Common
	Rash	Common
	Urticaria (see section 4.4)	Uncommon
	Angioedema of face, extremities, lips, mucous membranes, tongue, glottis and/or larynx (see section 4.4)	Uncommon
	Photosensitivity reactions	Uncommon*
	Pemphigoid	Uncommon*
	Hyperhidrosis	Uncommon
	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	Very rare
Reproductive System and Breast Disorders	Erectile dysfunction	Uncommon
General Disorders and Administration Site Condition	Asthenia	Common
	Chest pain	Uncommon*
	Malaise	Uncommon*
	Oedema peripheral	Uncommon*
	Pyrexia	Uncommon*
Investigations	Blood urea increased	Uncommon*
	Blood creatinine increased	Uncommon*
	Blood bilirubin increased	Rare
	Hepatic enzyme increased	Rare
Injury, poisoning and procedural complications	Fall	Uncommon*

* Frequency calculated from clinical trials for adverse events detected from spontaneous report

Clinical trials:

During the randomised period of the EUROPA study, only serious adverse events were collected. Few patients experienced serious adverse events: 16 (0.3%) of the 6122 perindopril patients and 12 (0.2%) of the 6107 placebo patients. In perindopril-treated patients, hypotension was observed in 6 patients, angioedema in 3 patients and sudden cardiac arrest in 1 patient. More patients withdrew for cough, hypotension or other intolerance on perindopril than on placebo, 6.0% (n=366) versus 2.1% (n=129) respectively.

 

Please report adverse drug events to:

• Saudi Arabia

The National Pharmacovigilance Center (NPC):

Fax: +966-11-205-7662

SFDA Call Center: 19999

E-mail: npc.drug@sfda.gov.sa

Website: https://ade.sfda.gov.sa

• Other GCC States:

Please contact the relevant competent authority

Limited data are available for overdosage in humans. Symptoms associated with overdosage of ACEinhibitors may include hypotension, circulatory shock, electrolyte disturbances, renal failure,

hyperventilation, tachycardia, palpitations, bradycardia, dizziness, anxiety, and cough.

The recommended treatment of overdosage is intravenous infusion of sodium chloride 9 mg/ml (0.9%)solution. If hypotension occurs, the patient should be placed in the shock position. If available, treatment with angiotensin II infusion and/or intravenous catecholamines may also be considered. Perindopril may be removed from the general circulation by haemodialysis (see section 4.4). Pacemaker therapy is indicated for therapy-resistant bradycardia. Vital signs, serum electrolytes and creatinine concentrations should be monitored continuously.

Pharmacotherapeutic group: ACE inhibitor, plain, ATC code: C09A A04

Mechanism of action

Perindopril is an inhibitor of the enzyme that converts angiotensin I into angiotensin II (Angiotensin Converting Enzyme ACE). The converting enzyme, or kinase, is an exopeptidase that allows conversion of angiotensin I into the vasoconstrictor angiotensin II as well as causing the degradation of the vasodilator bradykinin into an inactive heptapeptide. Inhibition of ACE results in a reduction of angiotensin II in the plasma, which leads to increased plasma renin activity (by inhibition of the negative feedback of renin release) and reduced secretion of aldosterone. Since ACE inactivates bradykinin, inhibition of ACE also results in an increased activity of circulating and local kallikrein-kinin systems (and thus also activation of the prostaglandin system). It is possible that this mechanism contributes to the blood pressure-lowering action of ACE inhibitors and is partially responsible for certain of their side effects (e.g. cough).

Perindopril acts through its active metabolite, perindoprilat. The other metabolites show no inhibition of  ACE activity in vitro.

Clinical efficacy and safety

Hypertension:

Perindopril is active in all grades of hypertension: mild, moderate, severe; a reduction in systolic and diastolic blood pressures in both supine and standing positions is observed.

Perindopril reduces peripheral vascular resistance, leading to blood pressure reduction. As a consequence, peripheral blood flow increases, with no effect on heart rate.

Renal blood flow increases as a rule, while the glomerular filtration rate (GFR) is usually unchanged.

The antihypertensive activity is maximal between 4 and 6 hours after a single dose and is sustained for at least 24 hours: trough effects are about 87-100 % of peak effects.

The decrease in blood pressure occurs rapidly. In responding patients, normalisation is achieved within a month and persists without the occurrence of tachyphylaxis.

Discontinuation of treatment does not lead to a rebound effect.

Perindopril reduces left ventricular hypertrophy.

In man, perindopril has been confirmed to demonstrate vasodilatory properties. It improves large artery elasticity and decreases the media: lumen ratio of small arteries.

An adjunctive therapy with a thiazide diuretic produces an additive-type of synergy. The combination of an ACE inhibitor and a thiazide also decreases the risk of hypokalaemia induced by the diuretic treatment.

Heart failure:

Perindopril reduces cardiac work by a decrease in pre-load and after-load.

Studies in patients with heart failure have demonstrated:

- decreased left and right ventricular filling pressures,

- reduced total peripheral vascular resistance,

- increased cardiac output and improved cardiac index.

In comparative studies, the first administration of 2.5 mg of perindopril arginine to patients with mild to moderate heart failure was not associated with any significant reduction of blood pressure as compared to placebo.

Patients with stable coronary artery disease:

The EUROPA study was a multicentre, international, randomised, double-blind, placebo-controlled clinical trial lasting 4 years.

Twelve thousand two hundred and eighteen (12218) patients aged over 18 were randomised to 8 mg perindopril tert-butylamine (equivalent to 10 mg perindopril arginine) (n=6110) or placebo (n=6108).

The trial population had evidence of coronary artery disease with no evidence of clinical signs of heart failure. Overall, 90% of the patients had a previous myocardial infarction and/or a previous coronary revascularisation. Most of the patients received the study medication on top of conventional therapy including platelet inhibitors, lipid lowering agents and beta-blockers.

The main efficacy criterion was the composite of cardiovascular mortality, non-fatal myocardial infarction and/or cardiac arrest with successful resuscitation. The treatment with 8 mg perindopril tert-butylamine (equivalent to 10 mg perindopril arginine) once daily resulted in a significant absolute reduction in the primary endpoint of 1.9% (relative risk reduction of 20%, 95%CI [9.4; 28.6] – p<0.001).

In patients with a history of myocardial infarction and/or revascularisation, an absolute reduction of 2.2% corresponding to a RRR of 22.4% (95%CI [12.0; 31.6] – p<0.001) in the primary endpoint was observed by comparison to placebo.

Absorption

After oral administration, the absorption of perindopril is rapid and the peak concentration is achieved within 1 hour. The plasma half-life of perindopril is equal to 1 hour.

Perindopril is a prodrug. Twenty seven percent of the administered perindopril dose reaches the

bloodstream as the active metabolite perindoprilat. In addition to active perindoprilat, perindopril yields five metabolites, all inactive. The peak plasma concentration of perindoprilat is achieved within 3 to 4 hours.

As ingestion of food decreases conversion to perindoprilat, hence bioavailability, perindopril arginine should be administered orally in a single daily dose in the morning before a meal.

It has been demonstrated a linear relationship between the dose of perindopril and its plasma exposure.

Distribution

The volume of distribution is approximately 0.2 l/kg for unbound perindoprilat. Protein binding of

perindoprilat to plasma proteins is 20%, principally to angiotensin converting enzyme, but is

concentration-dependent.

Elimination

Perindoprilat is eliminated in the urine and the terminal half-life of the unbound fraction is

approximately 17 hours, resulting in steady-state within 4 days.

Special population

Elimination of perindoprilat is decreased in the elderly, and also in patients with heart or renal failure.

Dosage adjustment in renal insufficiency is desirable depending on the degree of impairment (creatinine clearance).

Dialysis clearance of perindoprilat is equal to 70 ml/min.

Perindopril kinetics are modified in patients with cirrhosis: hepatic clearance of the parent molecule is reduced by half. However, the quantity of perindoprilat formed is not reduced and therefore no dosage adjustment is required (see sections 4.2 and 4.4).

In the chronic oral toxicity studies (rats and monkeys), the target organ is the kidney, with reversible damage.

No mutagenicity has been observed in in vitro or in vivo studies.

Reproduction toxicology studies (rats, mice, rabbits and monkeys) showed no sign of embryotoxicity or teratogenicity. However, angiotensin converting enzyme inhibitors, as a class, have been shown to induce adverse effects on late foetal development, resulting in foetal death and congenital effects in rodents and rabbits: renal lesions and an increase in peri- and postnatal mortality have been observed.

Fertility was not impaired either in male or in female rats.

No carcinogenicity has been observed in long term studies in rats and mice.

Mannitol

Sodium Starch Glycolate

Talc

Colloidal Silicone Dioxide

Magnesium Stearate Simethicone Emulsion

Lake of Brilliant Blue

Ferric Oxide Yellow Opadry

Not applicable.

3 years (36 months)

Store below 30°C.
After opening, it should be used within 3 months. 
Store the tablets in the original container.
Do not use beyond the expiry date or if the product shows any sign of deterioration.

30 tablets packed in HDPE bottles with PP silicated cap, in printed carton with folded leaflet.

No special requirements.