What is the dose range for perindopril (Angiotensin-Converting Enzyme Inhibitor)?

From the Guidelines

Perindopril is typically prescribed at a dose range of 4-16 mg daily in 1-2 divided doses, with a starting dose of 4 mg daily, as recommended by the most recent guidelines 1. The dose of perindopril can be adjusted based on blood pressure response and tolerability.

• For most adults, the recommended dose range is 4-16 mg daily in 1-2 divided doses.
• The starting dose is usually 4 mg daily, which can be gradually increased based on blood pressure response and tolerability.
• For elderly patients or those with renal impairment, a starting dose of 4 mg daily is recommended.
• The maximum recommended daily dose is 16 mg for hypertension, though some patients with heart failure or following a myocardial infarction may be maintained on a lower dose. Perindopril should be taken in the morning before food for optimal absorption.
• Dose adjustments should be made at intervals of at least 2-4 weeks to allow full effect of each dose level.
• This gradual titration approach helps minimize side effects such as first-dose hypotension, which can occur particularly in patients who are volume-depleted from diuretic therapy. As an ACE inhibitor, perindopril works by preventing the conversion of angiotensin I to angiotensin II, thereby reducing peripheral vascular resistance and blood pressure, as supported by studies such as ADVANCE 1 and SPRINT 1. The use of perindopril in patients with diabetes has been shown to reduce cardiovascular event rates, as demonstrated in the ADVANCE trial 1, which found that treatment with perindopril and indapamide reduced the risk of major macrovascular and microvascular events by 9%. Overall, perindopril is an effective treatment for hypertension and heart failure, and its dose should be individualized based on patient response and tolerability, with a goal of achieving a blood pressure of <130/80 mmHg, as recommended by current guidelines 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION The usual maintenance dose range is 4 to 8 mg administered as a single daily dose. The dosage may be titrated upward until blood pressure, when measured just before the next dose, is controlled or to a maximum of 16 mg per day.

The perindopril dose range is:

• Initial dose: 4 mg once daily
• Maintenance dose: 4 to 8 mg once daily
• Maximum dose: 16 mg per day 2 Key points to consider:
• The dose may be titrated upward until blood pressure is controlled
• Dosages above 8 mg should be administered with caution and under close medical supervision, especially in elderly patients.

From the Research

Perindopril Dose Range

• The recommended dose range for perindopril is 4 to 8 mg once daily 3, 4.
• Studies have shown that perindopril 4 to 8 mg once daily significantly reduces supine systolic blood pressure (SBP) and diastolic blood pressure (DBP) from baseline values in hypertensive patients 3.
• The maximum antihypertensive effect was seen with perindopril 8 mg, with the 16 mg dose providing no additional response 4.
• Uptitration to high-dose perindopril (8 mg) may be required in patients with multiple risk factors to achieve blood pressure control 5.
• Perindopril has been shown to be effective and well-tolerated in patients with mild to moderate essential hypertension, with a similar adverse event profile to other ACE inhibitors 3, 6.

Dose-Response Characteristics

• A dose-response study of perindopril in hypertension found that all doses of perindopril (2,4,8, and 16 mg) significantly lowered diastolic blood pressure compared with placebo 4.
• The ratio of changes in placebo-corrected diastolic blood pressure at 24 versus 6 h for perindopril 2,4, and 8 mg was similar, indicating a consistent antihypertensive effect throughout the day 4.

Clinical Outcomes

• The treatment effect of an ACE-inhibitor based regimen with perindopril in relation to beta-blocker use has been evaluated in a combined analysis of individual data from the ADVANCE, EUROPA, and PROGRESS trials 7.
• The results showed that adding perindopril to existing beta-blocker treatment reduced the relative risk of cardiovascular mortality, non-fatal myocardial infarction, and stroke by 20% 7.