⚠️ First-dose hypotension can be significant (especially in heart failure, volume depletion, or on high-dose diuretics).
🛏️ Start low, consider first dose at night, and ensure the patient can lie down.
🩺 If symptomatic hypotension occurs: lie flat + raise legs 🦵⬆️, check volume status, and give IV fluids if appropriate (after senior review in HF).
ℹ️ About
- 📚 Always check the BNF for:
Perindopril arginine or
Perindopril erbumine.
- 🧬 ACE inhibitor → reduces conversion of angiotensin I to angiotensin II.
- 🫀 ↓ Ang II → ↓ vasoconstriction and ↓ aldosterone → natriuresis and lower BP (often without reflex tachycardia).
- 🧪 ↑ bradykinin (reduced breakdown) → contributes to cough and angioedema (but also vasodilatory benefit).
Mode of action (why it helps clinically)
- 🫀 Heart failure: reduces afterload and maladaptive RAAS activation → improves symptoms and outcomes; helps reverse/remodel the ventricle over time.
- 🩸 Hypertension: lowers systemic vascular resistance.
- 🫘 Diabetic nephropathy/CKD with albuminuria: reduces intraglomerular pressure → reduces proteinuria and slows progression (watch creatinine/K+).
- 🧱 Post-MI: reduces adverse remodelling and recurrent events in appropriate patients.
Indications
- 🩸 Hypertension
- 🫀 Heart failure (start low, titrate to highest tolerated dose)
- 🫘 Diabetic nephropathy / CKD with albuminuria (as per local/NICE pathways)
- ❤️ Secondary prevention post-MI / LV dysfunction (where indicated)
⚖️ Dosing (always verify exact product and local formulary)
🧾 Important: perindopril comes as erbumine and arginine salts (different mg strengths).
Do not “swap mg-for-mg” without checking the BNF.
- 🧪 Before starting: document baseline BP, check U&Es/creatinine/eGFR, and review potassium.
- 💧 If on high-dose diuretics, dehydrated, or vomiting/diarrhoea: consider correcting volume depletion first to reduce first-dose hypotension.
| Preparation |
Typical adult dose range (BNF-check) |
Frequency |
Route |
Notes |
| Perindopril erbumine |
🔹 Often 2–8 mg (indication-dependent) |
OD |
PO |
🫀 HF: start lower and uptitrate; HTN often starts higher than HF. |
| Perindopril arginine |
🔹 Often 2.5–10 mg (indication-dependent) |
OD |
PO |
⚠️ Not equivalent mg-to-mg with erbumine — check product carefully. |
🧓 Practical initiation tips (ward-friendly)
- 🛏️ First dose at night can reduce symptomatic hypotension (especially HF/frail).
- 🩺 Review co-meds: nitrates, alpha-blockers, diuretics, and dehydration amplify BP drop.
- 🎯 Titrate every 1–2 weeks (or per HF protocol) toward target/highest tolerated dose.
- 🧾 Provide “sick day rules” in at-risk patients (vomiting/diarrhoea/sepsis → temporary hold to reduce AKI risk, per local policy).
Interactions
- 💊 NSAIDs (esp. with diuretic) → ↑ AKI risk (“triple whammy”) 🚫
- 🧂 Potassium supplements / potassium-sparing diuretics (e.g. spironolactone) → ↑ hyperkalaemia risk ⚠️
- 🫁 Thrombolysis (alteplase) may increase risk of angioedema in patients on ACE inhibitors (stroke setting) ⚠️
- 🧪 Lithium levels can rise with ACE inhibitors (toxicity risk) ⚠️
Cautions
- 🧓 Older/frail patients (falls risk from hypotension) — slow titration and careful monitoring.
- 🫀 Aortic stenosis / HOCM: can precipitate hypotension/syncope (specialist input) ⚠️
- 🧾 Afro-Caribbean patients: ACE inhibitors can be less effective as monotherapy for HTN; often used in combination depending on comorbidity (CKD/proteinuria/HF) 🧩
Contraindications
- 🤰 Pregnancy (teratogenic) and generally avoid in breastfeeding — switch to pregnancy-safe alternatives.
- 😮💨 Prior ACE inhibitor–associated angioedema (absolute contraindication) 🚨
- 🩸 Bilateral renal artery stenosis (or stenosis to a solitary kidney) → risk of severe renal failure.
- 🧂 Hyperkalaemia (significant) — correct/seek specialist advice first.
Side effects
- 📉 First-dose/postural hypotension (esp. HF/diuretics/dehydration) 🛏️
- 😮💨 Cough (bradykinin-mediated); can occur days to months after starting.
- 🫁 Angioedema (rare but life-threatening) 🚨 — facial/tongue swelling, stridor → emergency care and stop permanently.
- 🧪 Rise in creatinine (acceptable mild rise is common); significant AKI suggests renal artery stenosis, dehydration, NSAIDs, or sepsis.
- 🧂 Hyperkalaemia (risk increased with CKD, diabetes, K-sparing drugs).
- 👅 Taste disturbance, rash/urticaria (uncommon).
Monitoring
- 🧪 Check U&Es/creatinine/eGFR and K+ at baseline, then again at ~1–2 weeks after initiation and after each dose increase (earlier if high risk).
- 📈 In HF pathways, monitoring may be tighter (e.g. within 1 week) — follow local protocol.
- 🩺 Monitor BP (including postural if symptomatic) and ask about cough, dizziness, swelling, and reduced urine output.
