Recommended Dosing for Coversyl Plus (Perindopril/Indapamide) in Hypertension
The recommended initial dose of Coversyl Plus (perindopril/indapamide) for most hypertensive patients is 4mg/1.25mg once daily, which can be titrated up to 8mg/2.5mg once daily if blood pressure remains uncontrolled after 4 weeks. 1, 2
Initial Dosing Considerations
- For uncomplicated hypertension, start with perindopril/indapamide 4mg/1.25mg once daily, taken in the morning 1, 2
- In elderly patients (>65 years), a lower starting dose is recommended: perindopril/indapamide 2mg/0.625mg once daily for the first week, then increase to 4mg/1.25mg if tolerated 1, 3
- For patients with blood pressure ≥160/100 mmHg, consider starting with the higher dose of 8mg/2.5mg once daily for more effective blood pressure control 4, 5
Dose Titration
- If blood pressure is not adequately controlled after 4 weeks on the initial dose, increase to perindopril/indapamide 8mg/2.5mg once daily 1, 2
- The maximum recommended dose for hypertension is perindopril 8mg/indapamide 2.5mg once daily 6, 5
- If blood pressure remains uncontrolled on the maximum dose, adding a third agent (preferably a dihydropyridine calcium channel blocker like amlodipine) is recommended rather than further dose escalation 6, 7
Special Populations
- For patients with renal impairment, dose adjustment may be required; consider starting with perindopril/indapamide 2mg/0.625mg once daily or every other day 8
- In patients >70 years, start with perindopril 2mg/indapamide 0.625mg once daily for the first week, followed by 4mg/1.25mg once daily in the second week, and increase to 8mg/2.5mg for maintenance if tolerated 1
- For patients currently on diuretic therapy, if possible, discontinue the diuretic 2-3 days before starting perindopril/indapamide to reduce the risk of symptomatic hypotension 1
Monitoring and Follow-up
- Check blood pressure 2-4 weeks after initiation or dose adjustment 6
- Monitor serum creatinine, estimated glomerular filtration rate (eGFR), and serum potassium at least annually in all patients, and more frequently in those with risk factors for renal impairment 4
- Assess for potential side effects including hypotension, cough, electrolyte disturbances (particularly hypokalemia), and renal function changes 4, 1
Treatment Algorithm for Uncontrolled Hypertension
- Start with perindopril/indapamide 4mg/1.25mg once daily (or 2mg/0.625mg in elderly) 1, 2
- If BP remains ≥140/90 mmHg after 4 weeks, increase to perindopril/indapamide 8mg/2.5mg once daily 5
- If BP still uncontrolled after 4 weeks on maximum dose, add amlodipine 5-10mg daily (creating a triple therapy regimen) 6, 7
- For resistant hypertension (BP ≥140/90 mmHg despite triple therapy including a diuretic), consider adding a mineralocorticoid receptor antagonist 4
Clinical Efficacy
- The FORTISSIMO study demonstrated that perindopril/indapamide 10/2.5mg (equivalent to Coversyl Plus 8/2.5mg) effectively reduced blood pressure by 42/19 mmHg over 12 weeks in patients with previously uncontrolled hypertension 5
- Triple therapy with perindopril/indapamide/amlodipine has shown superior blood pressure reduction compared to dual therapy, with control rates exceeding 80% after appropriate up-titration 7
Common Pitfalls and Caveats
- Avoid combining perindopril/indapamide with another ACE inhibitor, ARB, or direct renin inhibitor due to increased risk of adverse events (hyperkalemia, syncope, acute kidney injury) without added cardiovascular benefit 4
- Monitor for hypotension, especially when initiating therapy in elderly patients, those on prior diuretic therapy, or those with volume depletion 1
- Be aware that indapamide can cause hypokalemia, which may be partially offset by the potassium-sparing effect of perindopril 3
- For patients with albuminuria (urine albumin-to-creatinine ratio ≥30 mg/g), perindopril/indapamide is particularly beneficial due to the renoprotective effects of ACE inhibitors 4