How to switch from perindopril (ACE inhibitor) 2mg to telmisartan (angiotensin II receptor antagonist)?

Switching from Perindopril 2mg to Telmisartan

When switching from perindopril 2mg to telmisartan, start with telmisartan 40mg once daily after a 24-36 hour washout period between medications.

Rationale for Switching

Switching from an ACE inhibitor (perindopril) to an ARB (telmisartan) is commonly done due to:

• ACE inhibitor-induced cough (occurs in up to 20% of patients)
• Angioedema (occurs in <1% of patients, more frequently in Black patients)
• Other intolerance issues

Switching Protocol

1. Baseline Assessment:

   • Check renal function (serum creatinine, eGFR)
   • Measure serum potassium
   • Record baseline blood pressure

2. Discontinuation and Washout:

   • Stop perindopril 2mg
   • Allow a 24-36 hour washout period before starting telmisartan 1
   • This minimizes the risk of overlapping effects and potential adverse reactions

3. Initial Dosing:

   • Start telmisartan at 40mg once daily 2, 1
   • The starting dose of 40mg is appropriate when switching from a low dose of perindopril (2mg)
   • Perindopril 2mg is considered a low dose (standard dose range is 2-8mg)

4. Monitoring:

   • Check renal function and serum potassium within 1-2 weeks of initiating telmisartan 2, 1
   • Monitor blood pressure within 2-4 weeks of switching
   • Adjust dose if necessary based on blood pressure response

Dose Titration

• If blood pressure control is inadequate after 2-4 weeks, increase to telmisartan 80mg once daily
• Target dose of telmisartan is 80mg once daily for optimal cardiovascular benefits 3, 4
• Maximum dose should not exceed 80mg daily

Special Considerations

• Renal Impairment: Use caution if eGFR <30 mL/min/1.73m² or serum creatinine >2.5 mg/dL in men or >2.0 mg/dL in women 1
• Elderly Patients: Consider starting at a lower dose (20mg) and titrate more gradually 1
• Hypotension Risk: Monitor for symptoms of hypotension, especially in volume-depleted patients 4
• Potassium Levels: ARBs can cause hyperkalemia similar to ACE inhibitors, so continued monitoring is necessary 2

Potential Benefits of Switching

• Telmisartan has been shown to have similar efficacy to ACE inhibitors in blood pressure control 3, 4
• Lower incidence of cough (3% vs 7% with ACE inhibitors) 3
• Significantly lower risk of angioedema compared to ACE inhibitors 4
• Once-daily dosing promotes adherence

Common Pitfalls to Avoid

• Abrupt Switching: Always allow a washout period to prevent potential adverse effects
• Inadequate Monitoring: Failure to check renal function and electrolytes after switching
• Combination with Other RAS Blockers: Avoid concurrent use with other ACE inhibitors or ARBs 2, 1
• Suboptimal Dosing: Many patients are maintained on suboptimal doses, which may reduce clinical benefits 1

By following this protocol, the transition from perindopril 2mg to telmisartan should be safe and effective for blood pressure control while potentially reducing ACE inhibitor-specific side effects.