Cardiovascular effects: Symptomatic hypotension may occur. Patients at particular risk include those with volume or salt depletion secondary to salt restriction, prolonged diuretic therapy, dialysis, diarrhea, or vomiting. Marked hypotension may occur in patients with congestive heart failure – potential for myocardial infarction or stroke in those with ischemic cardiovascular or cerebrovascular disease.
Renal effects: Deterioration of renal function, manifested as minor and transient increases in BUN and serum creatinine concentrations, may occur following administration of ACE inhibitor therapy, particularly in hypertensive patients with unilateral or bilateral renal artery stenosis, pre-existing renal impairment, or concomitant diuretic therapy. Dosage reduction and, in some cases, discontinuance of perindopril and/or the diuretic may be required.
Effects on potassium: Hyperkalemia can develop, especially in those with renal impairment or diabetes mellitus and those receiving drugs that can increase serum potassium concentration (e.g., potassiumsparing diuretics, potassium supplements, potassium-containing salt substitutes). The combination is generally not recommended.
Cough: Persistent and nonproductive; resolves after drug discontinuance.
Dual blockade of the renin-angiotensin-aldosterone system (RAAS): The concomitant use ofACE-inhibitors, angiotensin II receptor blockers or aliskiren increases the risk of hypotension, hyperkalaemia and decreased renal function (including acute renal failure).
Aortic and mitral valve stenosis/ hypertrophic cardiomyopathy: As with other ACE inhibitors, perindopril should be given with caution to patients with mitral valve stenosis and obstruction in the outflow of the left ventricle such as aortic stenosis or hypertrophic cardiomyopathy.
Renal impairment: In cases of renal impairment (creatinine clearance < 60 ml/min) the initial perindopril dosage should be adjusted according to the patient’s creatinine clearance and then as a function of the patient’s response to treatment. Routine monitoring of potassium and creatinine are part of normal medical practice for these patients.