Perindopril Starting Dose
For hypertension, start perindopril at 4 mg once daily, then increase to 8 mg once daily after 2 weeks if blood pressure remains uncontrolled. 1, 2, 3
Standard Hypertension Dosing
- Initial dose: 4 mg once daily for most adults with mild-to-moderate hypertension 2, 3, 4
- Titration: Increase to 8 mg once daily after 2 weeks if blood pressure target (<130/80 mmHg) is not achieved 1, 5
- Adequate 24-hour blood pressure control is obtained with once-daily dosing at these doses 2, 6
Heart Failure with Reduced Ejection Fraction (HFrEF)
- Initial dose: 2 mg once daily (lower than hypertension dosing) 1
- Target dose: 8-16 mg once daily, with minimum effective target of at least 4 mg daily 1
- Increase dose gradually, reassessing blood pressure, renal function, and potassium within 1-2 weeks after each increment 1, 5
Elderly Patients (≥70 years)
- Start at 2 mg once daily due to pharmacokinetic differences that result in greater blood pressure reductions 6, 7
- Dose reduction is required because elderly patients achieve higher drug concentrations and more pronounced ACE inhibition 6
- After 1 month, if diastolic blood pressure remains >90 mmHg, double the dose to 4 mg daily 7
- Further titration to 8 mg daily may be needed, or add a diuretic if 8 mg is reached without adequate control 7
Renal Impairment
- Dose reduction is required when creatinine clearance <40 mL/min 5, 6
- Start at lower doses (similar to elderly dosing at 2 mg daily) and titrate cautiously 6
- Monitor renal function and potassium within 1-2 weeks of initiation and after each dose increase 1, 5
Combination Therapy Strategy
- If monotherapy with perindopril 8 mg fails to achieve blood pressure <130/80 mmHg, add a thiazide-like diuretic or calcium channel blocker rather than further increasing ACE inhibitor dose 8, 5
- The 2024 ESC guidelines recommend combination therapy as initial treatment for most patients with confirmed hypertension (BP ≥140/90 mmHg), preferably using a single-pill combination of an ACE inhibitor with either a calcium channel blocker or diuretic 8
- Patients with more cardiovascular risk factors are more likely to require higher doses (8 mg) or combination therapy 3
Critical Monitoring Parameters
- Check blood pressure, renal function, and potassium before initiation 1, 5
- Recheck within 1-2 weeks after starting or changing dose 1, 5
- Monitor at 3-6 month intervals during chronic therapy 1
- Achieve blood pressure control within 3 months of initiating therapy 8
Absolute Contraindications Requiring Immediate Discontinuation
Common Pitfalls to Avoid
- Do not combine perindopril with ARBs - this provides no added benefit and increases adverse events 8, 5
- Do not underdose - patients with multiple cardiovascular risk factors often require the full 8 mg dose for adequate control 3
- Do not delay titration - if blood pressure remains uncontrolled after 2 weeks at 4 mg, increase to 8 mg rather than waiting longer 1, 3
- Cough is the most common adverse effect (8.9% incidence) and the most common reason for discontinuation (3.4% of patients) 7