Equivalent Dose Conversion: Perindopril 8 mg to Telmisartan
Start telmisartan 80 mg once daily when converting from perindopril (Coversyl) 8 mg, as this represents the maximum recommended dose of both agents and maintains equivalent renin-angiotensin system blockade.
Dosing Rationale
- Perindopril 8 mg represents the maximum recommended daily dose for hypertension, placing the patient at the upper end of ACE inhibitor therapy 1
- Telmisartan 80 mg is the maximum recommended dose and provides optimal blood pressure control with sustained 24-hour efficacy 1, 2
- The ONTARGET trial demonstrated equivalence between telmisartan 80 mg and ramipril 10 mg (another maximal-dose ACE inhibitor) for cardiovascular outcomes in high-risk patients 1
- Maximum blood pressure reduction with telmisartan occurs at 40-80 mg/day, with 80 mg providing superior end-of-dosing-interval control compared to submaximal ARB doses 2, 3
Critical Conversion Protocol
Transition directly on the same day - discontinue perindopril 8 mg and start telmisartan 80 mg immediately to maintain continuous renin-angiotensin system blockade without a gap in therapy 4
Mandatory Monitoring Within 1-2 Weeks
- Check blood pressure to assess adequacy of telmisartan dose 4, 5
- Measure serum creatinine and potassium as both ACE inhibitors and ARBs carry risk of hyperkalemia and renal dysfunction 1, 4
- Studies show both agents have similar safety profiles regarding renal function when used at therapeutic doses 6
Special Precaution for Angioedema History
If the patient has any history of angioedema with perindopril or other ACE inhibitors, wait at least 6 weeks after discontinuing perindopril before starting telmisartan 1, 4
Common Pitfalls to Avoid
- Never combine telmisartan with ACE inhibitors - this increases risk of hyperkalemia, syncope, and acute kidney injury without additional cardiovascular benefit 1, 4, 5
- Do not start at a lower telmisartan dose (such as 40 mg) when converting from maximal perindopril 8 mg, as this may result in inadequate blood pressure control during the transition period 2, 3
- Avoid abrupt discontinuation of perindopril without immediate ARB replacement, as this creates a gap in renin-angiotensin system blockade 4
If Blood Pressure Remains Uncontrolled on Telmisartan 80 mg
Add hydrochlorothiazide 12.5-25 mg once daily rather than attempting to exceed the maximum telmisartan dose 1, 4, 7
- Telmisartan/hydrochlorothiazide combination provides significantly greater blood pressure reductions than monotherapy and increases the percentage of patients achieving target blood pressure 7
- The fixed-dose combination of telmisartan 80 mg/hydrochlorothiazide 12.5 mg is well-established and provides 24-hour blood pressure control 7