Starting Dose of Perindopril for Hypertension
The recommended starting dose of perindopril for adults with hypertension is 4 mg once daily, with dose adjustments based on blood pressure response and patient characteristics. 1
Dosing Guidelines for Different Patient Populations
Standard Adult Dosing
- Initial dose: 4 mg once daily
- Maintenance dose range: 4-8 mg once daily
- Maximum dose: 16 mg per day 1
- Perindopril can be administered as a single daily dose or in two divided doses, though once-daily dosing is generally sufficient 1
Elderly Patients (>65 years)
- Initial dose: 4 mg once daily
- For very elderly patients (>70 years): Start with 2 mg once daily for the first week 1
- Maintenance dose: Generally not exceeding 8 mg daily
- Doses above 8 mg should be administered with caution and close medical supervision 1
Patients with Renal Impairment
- For creatinine clearance >30 mL/min: Initial dose of 2 mg/day
- Maximum dose should not exceed 8 mg/day 1
- For creatinine clearance <30 mL/min: Safety and efficacy not established
- During dialysis, perindopril is removed with the same clearance as in patients with normal renal function 1
Patients on Diuretics
- If possible, discontinue diuretic 2-3 days before starting perindopril to reduce risk of symptomatic hypotension 1
- If diuretic cannot be discontinued, start with a lower dose of 2-4 mg daily (in one or two divided doses) with careful medical supervision 1
Dosing for Specific Conditions
Stable Coronary Artery Disease
- Initial dose: 4 mg once daily for 2 weeks
- Maintenance dose: Increase to 8 mg once daily as tolerated 1
- For elderly patients (>70 years): 2 mg once daily in first week, 4 mg once daily in second week, then 8 mg once daily for maintenance if tolerated 1
Clinical Considerations
- The antihypertensive effect of perindopril is maintained for at least 24 hours, with trough/peak ratios of >50% 2
- Response rates with perindopril 4-8 mg once daily (67-80%) have been shown to be significantly higher than with captopril 25-50 mg twice daily (44-57%) 2
- Perindopril has been shown to improve arterial compliance and reduce left ventricular mass index 2
Common Pitfalls and Precautions
- Monitor for symptomatic hypotension after the first dose, especially in patients:
- Currently on diuretic therapy
- With volume depletion
- With severe renin-dependent hypertension 1
- Most common adverse effect is cough, which is also the most common reason for treatment discontinuation 2
- Contraindicated in patients with history of angioedema related to previous ACE inhibitor therapy 3
- Monitor renal function and potassium levels, especially in patients with renal artery stenosis 3
Perindopril is a prodrug that is hydrolyzed to the active metabolite perindoprilat after absorption, providing effective 24-hour blood pressure control with once-daily dosing 4, 5. The dose-response curve for blood pressure reduction tends to flatten after 8 mg per day 6.