Adult: To reduce risk of cardiac events in patients with history of MI and/or revascularisation: As perindopril erbumine: Initially, 4 mg once daily for 2 weeks, then increase to 8 mg once daily, if tolerated. As perindopril arginine: Initially, 5 mg once daily for 2 weeks, then increase to 10 mg once daily, if tolerated. Elderly: As perindopril erbumine: 2 mg once daily for 1 week, followed by 4 mg once daily for another 1 week, then may increase to 8 mg once daily, if tolerated. As perindopril arginine: 2.5 mg once daily for 1 week, followed by 5 mg once daily for 1 week, then may increase to 10 mg once daily, if tolerated.
Oral Heart failure
Adult: As perindopril erbumine: Initially, 2 mg once daily, may be increased to 4 mg once daily after 2 weeks, if tolerated. As perindopril arginine: Initially, 2.5 mg once daily, may be increased to 5 mg once daily after 2 weeks, if tolerated.
Oral Hypertension
Adult: As monotherapy or in combination with other antihypertensive agents: As perindopril erbumine: Initially, 4 mg once daily. In patients with renovascular hypertension, salt and/or volume depletion, cardiac decompensation or severe hypertension: Initially, 2 mg once daily. Doses may be increased to 8 mg once daily after 1 month. As perindopril arginine: Initially, 5 mg once daily. In patients with renovascular hypertension, salt and/or volume depletion, cardiac decompensation or severe hypertension: Initially, 2.5 mg once daily. Doses may be increased to 10 mg once daily after 1 month. Dosage recommendations may vary among countries and between individual products (refer to local or country-specific product guidelines). Elderly: As perindopril erbumine: Initially, 2 mg once daily, may be increased to 4 mg once daily after 1 month, and then 8 mg once daily, if necessary. As perindopril arginine: Initially, 2.5 mg once daily, may be increased to 5 mg once daily after 1 month, and then 10 mg once daily, if necessary. Dosage recommendations may vary among countries and between individual products (refer to local or country-specific product guidelines).
What are the brands available for Perindopril in Malaysia?
Hypertension:
Patients taking diuretics: As perindopril erbumine: Initially, 2 mg once daily. As perindopril arginine: Initially, 2.5 mg once daily. Doses may be adjusted according to blood pressure response.
Renal Impairment
CrCl (mL/min)
Dosage
<15
As perindopril erbumine: 2 mg on dialysis days. As perindopril arginine: 2.5 mg on dialysis days.
15-<30
As perindopril erbumine: 2 mg on alternate days. As perindopril arginine: 2.5 mg on alternate days.
30-<60
As perindopril erbumine: 2 mg daily. As perindopril arginine: 2.5 mg daily.
Administration
Perindopril Should be taken on an empty stomach.
Contraindications
History of angioedema related to previous ACE inhibitor treatment; hereditary or idiopathic angioedema, significant bilateral or unilateral renal artery stenosis. Extracorporeal treatments leading to contact of blood with negatively charged surfaces. Pregnancy. Concomitant use with aliskiren in patients with diabetes mellitus or renal impairment (eGFR <60 mL/min/1.73 m2). Concomitant use with or within 36 hours of switching from or to sacubitril/valsartan.
Special Precautions
Patient with history of angioedema unrelated to ACE inhibitor treatment; hypertrophic cardiomyopathy with left ventricular outflow tract obstruction, severe aortic or mitral valve stenosis, renovascular hypertension, salt or volume depletion, collagen vascular disease (e.g. SLE, scleroderma), risk factors for hyperkalaemia (e.g. worsening renal function, metabolic acidosis, concomitant use of K-sparing diuretics, K supplements or K-containing salt substitutes), diabetes mellitus, ascites due to cirrhosis, ischaemic heart disease, cerebrovascular disease, primary aldosteronism. Patient undergoing major surgery, desensitisation treatment (e.g. hymenoptera venom), or receiving anaesthesia that may produce hypotension. Patient taking diuretics. Black race. Renal impairment. Elderly. Lactation.
Adverse Reactions
Significant: Symptomatic hypotension with or without syncope; neutropenia, agranulocytosis, thrombocytopenia, anaemia, persistent non-productive cough, hyperkalaemia; risk of impaired renal function. Rarely, angioedema of the face, extremities, lips and intestine. Ear and labyrinth disorders: Tinnitus, vertigo. Eye disorders: Visual disturbances. Gastrointestinal disorders: Nausea, constipation, diarrhoea, dyspepsia, vomiting, abdominal pain, dysgeusia. General disorders and administration site conditions: Asthenia. Investigations: Increased BUN and serum creatinine (transient). Musculoskeletal and connective tissue disorders: Muscle cramps, back pain. Nervous system disorders: Headache, paraesthesia, dizziness. Respiratory, thoracic and mediastinal disorders: Dyspnoea. Skin and subcutaneous tissue disorders: Pruritus, rash. Potentially Fatal: Rarely, angioedema of the tongue, glottis or larynx; cholestatic jaundice which may lead to fulminant hepatic necrosis.
Monitor renal function and electrolytes before treatment initiation and during treatment; blood pressure; CBC with differential (periodically in patients with collagen vascular disease and renal impairment). Assess for signs and symptoms of angioedema or cough.
Overdosage
Symptoms: Hypotension, palpitations, dizziness, anxiety, cough, bradycardia, tachycardia, renal failure, hyperventilation, electrolyte disturbances, and circulatory shock. Management: Administer IV infusion of NaCl 0.9% solution. In case of hypotension, place the patient in shock position. Administration of angiotensin II infusion and/or IV catecholamines may also be considered, if available. Haemodialysis may be beneficial. For treatment-resistant bradycardia, pacemaker therapy may be used. Continuously monitor vital signs, serum electrolytes, and creatinine levels.
Drug Interactions
Increased hypotensive effect with other antihypertensive agents, diuretics, vasodilators, baclofen, certain anaesthetics, TCAs and antipsychotics. May increase the risk of hyperkalaemia with K-sparing diuretics (e.g. spironolactone, eplerenone), K supplements, or other agents associated with increases in serum K (e.g. trimethoprim, ciclosporin, heparin). May increase the risk of hypoglycaemia with insulin and oral hypoglycaemic agents. May increase the risk of angioedema with racecadotril, estramustine, mTOR inhibitors (e.g. temsirolimus, sirolimus, everolimus), and gliptins (e.g. sitagliptin, linagliptin). Concomitant use with NSAIDs, including selective COX-2 inhibitors, may result in renal function deterioration and reduced antihypertensive effect. May increase the serum levels and toxicity of lithium. May reduce antihypertensive effect with sympathomimetic agents. Concomitant use with parenteral gold (e.g. sodium aurothiomalate) may cause nitritoid reactions characterised by facial flushing, nausea, vomiting, and hypotension. May cause anaphylactoid reactions with hymenoptera venom. Potentially Fatal: Concomitant use with aliskiren increases the risk of hyperkalaemia, worsening renal renal function, and CV morbidity and mortality, particularly in patients with diabetes or renal impairment. Increased risk of angioedema with sacubitril/valsartan.
Food Interaction
Conversion to perindoprilat is reduced with food.
Lab Interference
May give false-negative aldosterone/renin ratio (ARR).
Action
Description: Mechanism of Action: Perindopril is a prodrug for perindoprilat, which inhibits the angiotensin-converting enzyme (ACE) that converts angiotensin I into the vasoconstrictor angiotensin II. Reduction in plasma angiotensin II leads to reduced vasoconstriction, increased plasma renin activity and reduced aldosterone secretion. Onset: 1 hour. Pharmacokinetics: Absorption: Rapidly absorbed (perindopril). Food reduces conversion to perindoprilat. Bioavailability: Perindopril: Approx 65-75%. Perindoprilat: Approx 25%; approx 16% with food. Time to peak plasma concentration: Approx 1 hour (perindopril); 3-7 hours (perindoprilat). Distribution: Enters breast milk (perindopril and perindoprilat). Volume of distribution: Approx 0.2 L/kg (perindoprilat). Plasma protein binding: Approx 60% (perindopril); 10-20% (perindoprilat). Metabolism: Extensively metabolised in the liver via hydrolysis to perindoprilat (active metabolite) and inactive metabolites, including glucuronides. Excretion: Via urine (75%, 4-12% as unchanged drug). Elimination half-life: 1.5-3 hours (perindopril); 25-30 hours or longer (perindoprilat).
Chemical Structure
Perindopril Source: National Center for Biotechnology Information. PubChem Compound Summary for CID 107807, Perindopril. https://pubchem.ncbi.nlm.nih.gov/compound/Perindopril. Accessed Apr. 29, 2025.
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