From the Guidelines
For patients with hypertension and heart failure, perindopril treatment typically starts at 2 mg once daily, preferably in the morning before food, as recommended by the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1. After two weeks, the dose can be increased to 4 mg once daily if tolerated. For severe heart failure patients, a lower starting dose of 1 mg is recommended with close monitoring. The maximum recommended dose is 8 mg daily, though most benefit is achieved at 4 mg daily. Dose adjustments are necessary for elderly patients and those with renal impairment (creatinine clearance <30 ml/min). Perindopril works by inhibiting the angiotensin-converting enzyme, reducing the formation of angiotensin II, a potent vasoconstrictor. This leads to decreased peripheral resistance, reduced sodium and water retention, and improved cardiac output. Common side effects include dry cough, hypotension, and rarely angioedema. Renal function and potassium levels should be monitored regularly, especially when initiating therapy or adjusting doses. Perindopril is contraindicated during pregnancy and should not be combined with aliskiren in patients with diabetes or renal impairment. The use of ACE inhibitors, such as perindopril, is beneficial for patients with prior or current symptoms of chronic HFrEF to reduce morbidity and mortality, as stated in the 2016 ACC/AHA/HFSA focused update on new pharmacological therapy for heart failure 1. Additionally, the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure recommend the use of ACE inhibitors, such as perindopril, in patients with HFrEF to reduce morbidity and mortality 1. It is essential to note that perindopril should be used with caution in patients with low systemic blood pressure, renal insufficiency, or elevated serum potassium (>5.0 mEq/L), and patients should be monitored closely for potential side effects. In patients who are intolerant to ACE inhibitors, ARBs may be considered as an alternative, as recommended by the 2016 ACC/AHA/HFSA focused update on new pharmacological therapy for heart failure 1. However, the most recent and highest quality study, the 2022 AHA/ACC/HFSA guideline for the management of heart failure, recommends perindopril as a first-line treatment for patients with hypertension and heart failure 1. Therefore, perindopril is the recommended treatment regimen for patients with hypertension and heart failure, with a starting dose of 2 mg once daily and a maximum dose of 8 mg daily, as supported by the most recent and highest quality evidence 1.
From the FDA Drug Label
DOSAGE AND ADMINISTRATION Hypertension Use in Uncomplicated Hypertensive Patients: In patients with essential hypertension, the recommended initial dose is 4 mg once a day 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 usual maintenance dose range is 4 to 8 mg administered as a single daily dose.
The recommended treatment regimen for Perindopril in patients with hypertension is an initial dose of 4 mg once a day, with a maintenance dose range of 4 to 8 mg administered as a single daily dose. However, for patients with heart failure, there is no direct information in the provided drug label. 2
From the Research
Recommended Treatment Regimen for Perindopril
The recommended treatment regimen for Perindopril in patients with hypertension and heart failure is as follows:
- The initial dose of Perindopril is 4mg once daily, which can be increased to 8mg once daily if necessary 3, 4, 5.
- Perindopril has been shown to be effective in reducing blood pressure and improving symptoms of heart failure in patients with mild to moderate essential hypertension and congestive heart failure 3, 4, 5.
- The antihypertensive efficacy of Perindopril 4-8 mg once daily is comparable to that of other ACE inhibitors, such as captopril and enalapril, and calcium-channel antagonists 3, 4.
- Combination treatment with Perindopril and an antihypertensive agent from another treatment class, such as a diuretic or beta-blocker, can provide additional benefits in patients who do not respond to monotherapy 3, 4, 6.
Dosage Adjustments
- Dosage adjustments may be necessary in elderly patients and those with renal impairment, as they may experience greater blood pressure reductions and increased risk of adverse effects 7.
- The dose of Perindopril should be reduced in patients with renal impairment, as they may experience decreased clearance of the drug 7.
Adverse Effects
- The most common adverse effect of Perindopril is cough, which can lead to treatment withdrawal in some patients 3, 4, 5.
- Other adverse effects of Perindopril include dizziness, headache, and fatigue, which are generally mild and transient 3, 4, 5.
- Perindopril has a similar adverse effect profile to that of other ACE inhibitors, and is generally well tolerated in patients with hypertension and heart failure 3, 4, 5.