Indapamide/Perindopril-Teva, 0.625 mg+2, 5 mg 30 pcs

Pharmacotherapeutic group: hypertensive combined (diuretic + angiotensin-converting enzyme inhibitor)

Code ATX: C09BA04

Pharmacological properties.

Pharmacodynamics

Indapamide/Perindopril-Teva, a combined antihypertensive drug containing perindopril, angiotensin-converting enzyme (ACE) inhibitor and indapamide, thiazide-like diuretic. The synergistic action of perindopril and indapamide determines the pharmacological properties of the drug.

Indapamide with regard to the chemical structure belongs to the group of sulfonamides, and with regard to pharmacological properties is similar to thiazide diuretics. Indapamide inhibits sodium reabsorption in the cortical segment of the renal tubules, increasing renal excretion of sodium, chlorine and, to a lesser extent, potassium and magnesium, increasing diuresis and reducing blood pressure (BP).

Perindopril is an ACE inhibitor whose mechanism of action is associated with inhibition of ACE activity, resulting in reduction of angiotensin II, which has a vasoconstrictor effect, and which also breaks down bradykinin, which has a vasoconstrictor effect, to an inactive heptapeptide.

As a result, perindopril decreases aldosterone secretion and increases plasma renin activity by the principle of feedback; with long-term use it reduces total peripheral vascular resistance (PPR), which is mainly due to the effect on the vessels in the muscles and kidneys. These effects are not accompanied by retention of salts and fluids or development of reflex tachycardia.

Perindopril has therapeutic effects due to its active metabolite, perindoprilat. Its other metabolites are not active.

Perindopril normalizes heart function by promoting vein dilation (decreased preload) through changes in prostaglandin metabolism and decreased RPS (decreased postload).

In chronic heart failure (CHF), perindopril reduces filling pressures in the left and right ventricles of the heart, decreases PPS, increases cardiac output and increases cardiac index, and increases peripheral blood flow in the muscles.

Antihypertensive effect

. The indapamide/perindopril combination has dose-dependent antihypertensive effects on both diastolic and systolic BP in standing and lying positions. Antihypertensive effect is maintained for 24 hours. Stable therapeutic effect occurs in less than 1 month from the start of treatment and is not accompanied by tachyphylaxis. Discontinuation of treatment does not cause “withdrawal” syndrome. Moreover, combination indapamide/perindopril decreases degree of left ventricular hypertrophy (LVH), improves arterial elasticity, decreases RPS, does not influence lipid metabolism (total cholesterol, high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol (LDL-C), triglycerides).

In patients with type 2 diabetes mellitus (mean age 66 years, body mass index 28 kg/m², glycosylated hemoglobin (HbA1c) 7.5%, BP 145/81 mm Hg.) the effect of a fixed perindopril/indapamide combination on major micro- and macrovascular complications was studied in addition to both standard therapy for glycemic control and an intensive glycemic control (IGC) strategy (target HbA1c < 6.5%). At the same time, 83% of patients had arterial hypertension, 32% and 10% had macrovascular and microvascular complications, and 27% had microalbuminuria. Most patients were receiving hypoglycemic therapy at the time of inclusion in the study. As concomitant therapy, patients received hypotensive agents (75%), as well as hypolipidemic agents (28%) and antiplatelet agents (47%).

After a 6-week introductory period during which patients received indapamide/perindopril therapy, they were allocated to the standard glycemic control group or to the IGC group (gliclazide with the possibility of increasing the dose to a maximum of 120 mg/day or the addition of another hypoglycemic agent).

The IGC group (mean duration of follow-up 4.8 years, mean HbA1c 6.5%) compared with the standard control group (mean HbA1c 7.3%) showed a 10% significant reduction in the relative risk of combined incidence of macrovascular and microvascular complications. The benefit was achieved by a significant reduction in the relative risk of: major microvascular complications by 14%, the occurrence and progression of nephropathy by 21%, microalbuminuria by 9%, macroalbuminuria by 30%, and the development of renal complications by 11%. The benefits of hypotensive therapy were independent of the benefits achieved on IGC.

Indapamide in monotherapy has an antihypertensive effect within 24 hours at doses with minimal diuretic effect. Indapamide improves elasticity of large arteries, reduces PPS, reduces congestion. Increasing dose of indapamide does not increase antihypertensive effect, but increases risk of adverse events.

Indapamide has no effect on lipid metabolism (total cholesterol, HDL-C and LDL-C, triglycerides) and carbohydrate metabolism.

Perindopril is effective in the therapy of arterial hypertension of any severity. Antihypertensive effect reaches its maximum 4-6 hours after a single dose and lasts for 24 hours. 24 hours after perindopril administration there is a clear (about 80%) residual ACE inhibition. Perindopril shows antihypertensive effect both in patients with low and normal plasma renin activity.

Perindopril has a vasodilator effect, helps to restore elasticity of large vessels and the structure of the vascular wall of small arteries. It also reduces left ventricular hypertrophy.

The concomitant use of thiazide diuretics enhances the antihypertensive effect of perindopril.

Double blockade of the renin-angiotensin-aldosterone system (RAAS)

. There is evidence from clinical trials of combination therapy with ACE inhibitor with angiotensin II receptor antagonists (ARA II). There have been clinical studies involving patients with a history of cardiovascular or cerebrovascular disease, or type 2 diabetes with confirmed target organ damage, as well as studies involving patients with type 2 diabetes and diabetic nephropathy.

These studies found no significant positive effect on the occurrence of renal and/or cardiovascular events and mortality rates in patients receiving combination therapy, while the risk of hyperkalemia, acute renal failure and/or arterial hypotension increased compared to patients receiving monotherapy.

With consideration of the similar within-group pharmacodynamic properties of ACE inhibitors and ARA II, these results would be expected for any other drug interactions between ACE inhibitors and ARA II classes.

Therefore, ACE inhibitors and ARA II should not be used concomitantly in patients with diabetic nephropathy.

There are data from a clinical trial investigating the beneficial effects of adding the direct renin inhibitor drug aliskiren to standard therapy with an ACE inhibitor or ARA II in patients with type 2 diabetes and chronic kidney disease or cardiovascular disease, or with a combination of these conditions. The study was terminated early due to an increased risk of adverse outcomes. Cardiovascular death and stroke occurred more frequently in the group of patients receiving aliskiren compared to the placebo group. Also adverse events and serious adverse events (hyperkalemia, arterial hypotension and renal dysfunction) were reported more frequently in the aliskiren group than in the placebo group.

Pharmacokinetics

The combined use of perindopril and indapamide does not change the pharmacokinetic characteristics of these drugs compared to their separate administration.

Indapamide is rapidly and completely absorbed from the gastrointestinal tract. Maximum plasma concentration (C_max) of indapamide is reached after 1 hour. Binding to plasma proteins is 79%. The elimination half-life (T_1/2) is 14-24 hours (average 18 hours). Repeated administration of indapamide does not lead to its cumulation in the body. It is excreted mainly by the kidneys (70%) and through the intestine (22%) in the form of inactive metabolites.

The pharmacokinetics of indapamide is not altered in patients with renal insufficiency.

Perindopril after oral administration is rapidly absorbed in the gastrointestinal tract (GIT) and reaches maximum plasma concentration (C_max) within 1 hour. Perindopril has no pharmacological activity. Approximately 27% of the total amount of perindopril taken orally enters the bloodstream as the active metabolite perindoprilat. In addition to perindoprilat, 5 other metabolites without pharmacological activity are formed. C_max of perindoprilat is reached after 3-4 hours.

The intake of perindopril with meals is accompanied by a decrease in the conversion of perindopril to perindoprilate, and its bioavailability is correspondingly reduced. Therefore, perindopril should be taken once daily, before meals.

There is a linear dependence of plasma concentration of perindopril on its dose. The volume of distribution of free perindoprilat is 0.2 l/kg. Binding to plasma proteins is insignificant, the binding of perindoprilat, mainly to ACE, is less than 20% and depends on its concentration.

Perindopril is excreted by the kidneys. The “effective” half-life (T_1/2) of the free fraction is about 17 hours, so the equilibrium state is reached within 4 days.

The excretion of perindopril is slower in the elderly and in patients with cardiac and renal insufficiency.

The dialysis clearance of perindopril is 70 ml/min.

In patients with cirrhosis, the “hepatic” clearance of perindopril is reduced by half, while the total amount of perindoprilate produced is not reduced, and dosing adjustments are not required.

Indications

Essential hypertension.
In patients with arterial hypertension and type 2 diabetes mellitus to reduce the risk of developing microvascular complications (from the kidneys) and macrovascular complications from cardiovascular diseases.

Pharmacological effect

Pharmacotherapeutic group: combined antihypertensive drug (diuretic + angiotensin-converting enzyme inhibitor)

ATX code: C09BA04

Pharmacological properties

Pharmacodynamics

The drug Indapamide/Perindopril-Teva, a combination antihypertensive drug containing perindopril, an angiotensin-converting enzyme (ACE) inhibitor and indapamide, a thiazide-like diuretic. The synergistic effect of perindopril and indapamide determines the pharmacological properties of the drug.

Indapamide, according to its chemical structure, belongs to the group of sulfonamides, and according to its pharmacological properties it is close to thiazide diuretics. Indapamide inhibits sodium reabsorption in the cortical segment of the renal tubules, increasing the renal excretion of sodium, chloride and, to a lesser extent, potassium and magnesium, increasing diuresis and reducing blood pressure (BP).

Perindopril is an ACE inhibitor, the mechanism of action of which is associated with inhibition of ACE activity, leading to a decrease in the formation of angiotensin II, which has a vasoconstrictor effect, and also destroys bradykinin, which has a vasodilator effect, to an inactive heptapeptide.

As a result, perindopril reduces the secretion of aldosterone and increases the activity of renin in the blood plasma according to the feedback principle; with long-term use, it reduces total peripheral vascular resistance (TPVR), which is mainly due to the effect on the vessels in the muscles and kidneys. These effects are not accompanied by salt and fluid retention or the development of reflex tachycardia.

Perindopril has a therapeutic effect due to its active metabolite – perindoprilat. Its other metabolites are not active.

Perindopril normalizes heart function, promoting the dilation of veins (reducing preload) by changing the metabolism of prostaglandins and reducing peripheral vascular resistance (reducing afterload).

In chronic heart failure (CHF), perindopril reduces filling pressure in the left and right ventricles of the heart, reduces peripheral vascular resistance, increases cardiac output and cardiac index, and increases peripheral blood flow in the muscles.

Antihypertensive effect

The combination of indapamide/perindopril has a dose-dependent antihypertensive effect on both diastolic and systolic blood pressure in the standing and lying position. The antihypertensive effect lasts for 24 hours. A stable therapeutic effect occurs in less than 1 month from the start of treatment and is not accompanied by tachyphylaxis. Stopping treatment does not cause withdrawal syndrome. In addition, the combination of indapamide/perindopril reduces the degree of left ventricular hypertrophy (LVH), improves arterial elasticity, reduces peripheral vascular resistance, and does not affect lipid metabolism (total cholesterol, high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol (LDL-C), triglycerides).

In patients with type 2 diabetes mellitus (mean age 66 years, body mass index 28 kg/m2, glycosylated hemoglobin (HbA1c) 7.5%, blood pressure 145/81 mmHg), the effect of a fixed combination of perindopril/indapamide on major micro- and macrovascular complications was studied in addition to both standard therapy for glycemic control and an intensive strategy. glycemic control (GCC) (target HbA1c < 6.5%). At the same time, 83% of patients had arterial hypertension, 32% and 10% had macro- and microvascular complications, and 27% had microalbuminuria. Most patients were receiving hypoglycemic therapy at the time of inclusion in the study. As concomitant therapy, patients received antihypertensive drugs (75%), as well as lipid-lowering drugs (28%) and antiplatelet drugs (47%).

After a 6-week run-in period during which patients received indapamide/perindopril therapy, they were allocated to either standard glycemic control or an IGC group (gliclazide with the option of increasing the dose to a maximum of 120 mg/day or adding another hypoglycemic agent).

The IHC group (mean follow-up 4.8 years, mean HbA1c 6.5%) compared with the standard control group (mean HbA1c 7.3%) showed a significant 10% reduction in the relative risk of the combined incidence of macro- and microvascular complications. The benefit was achieved due to a significant reduction in the relative risk of: major microvascular complications by 14%, the occurrence and progression of nephropathy by 21%, microalbuminuria by 9%, macroalbuminuria by 30% and the development of renal complications by 11%. The benefits of antihypertensive therapy were independent of the benefits achieved with IGCs.

Indapamide, when used alone, has an antihypertensive effect for 24 hours in doses that have a minimal diuretic effect. Indapamide improves the elasticity of large arteries, reduces peripheral vascular resistance, and reduces LVH. Increasing the dose of indapamide does not entail an increase in the antihypertensive effect, but increases the risk of developing adverse events.

Indapamide does not affect lipid metabolism (total cholesterol, HDL-C and LDL-C, triglycerides) and carbohydrate metabolism.

Perindopril is effective in the treatment of arterial hypertension of any severity. The antihypertensive effect reaches its maximum 4-6 hours after a single dose and continues for 24 hours. 24 hours after taking perindopril, a clear (about 80%) residual ACE inhibition is observed. Perindopril exhibits an antihypertensive effect in both patients with low and normal plasma renin activity.

Perindopril has a vasodilating effect, helps restore the elasticity of large vessels and the structure of the vascular wall of small arteries. It also reduces left ventricular hypertrophy.

Concomitant use of thiazide diuretics enhances the antihypertensive effect of perindopril.

Dual blockade of the renin-angiotensin-aldosterone system (RAAS)

There are data from clinical studies of combination therapy using an ACE inhibitor with angiotensin II receptor antagonists (ARA II). Clinical studies were conducted in patients with a history of cardiovascular or cerebrovascular disease, or type 2 diabetes mellitus accompanied by confirmed target organ damage, as well as studies in patients with type 2 diabetes mellitus and diabetic nephropathy.

These studies did not reveal a significant positive effect on renal and/or cardiovascular events and mortality in patients receiving combination therapy, while the risk of hyperkalemia, acute renal failure and/or hypotension increased compared with patients receiving monotherapy.

Taking into account the similar intragroup pharmacodynamic properties of ACE inhibitors and ARA II, these results can be expected for the interaction of any other drugs – representatives of the classes of ACE inhibitors and ARA II.

Therefore, ACE inhibitors and ARB II should not be used simultaneously in patients with diabetic nephropathy.

There is evidence from a clinical trial examining the beneficial effects of adding a direct renin inhibitor, aliskiren, to standard therapy with an ACE inhibitor or angiotensin-converting enzyme II inhibitor in patients with type 2 diabetes mellitus and chronic kidney disease or cardiovascular disease, or a combination of these diseases. The study was stopped early due to an increased risk of adverse outcomes. Cardiovascular death and stroke occurred more frequently in the aliskiren group compared to the placebo group. Also, adverse events and serious adverse events (hyperkalemia, hypotension, and renal dysfunction) were reported more frequently in the aliskiren group than in the placebo group.

Pharmacokinetics

The combined use of perindopril and indapamide does not change the pharmacokinetic characteristics of these drugs compared to their separate administration.

Indapamide is quickly and completely absorbed from the gastrointestinal tract. The maximum plasma concentration (Cmax) of indapamide is achieved after 1 hour. Plasma protein binding 79%. The half-life (T1/2) is 14-24 hours (average 18 hours). Repeated administration of indapamide does not lead to its accumulation in the body. It is excreted mainly by the kidneys (70%) and through the intestines (22%) in the form of inactive metabolites.

The pharmacokinetics of indapamide do not change in patients with renal failure.

Perindopril, after oral administration, is rapidly absorbed from the gastrointestinal tract (GIT) and reaches its maximum plasma concentration (Cmax) within 1 hour. Perindopril has no pharmacological activity. Approximately 27% of the total amount of perindopril ingested enters the bloodstream in the form of the active metabolite perindoprilate. In addition to perindoprilate, 5 more metabolites are formed that do not have pharmacological activity. Cmax of perindoprilat is achieved after 3-4 hours.

Taking perindopril during meals is accompanied by a decrease in the conversion of perindopril to perindoprilat, and its bioavailability is correspondingly reduced. Therefore, perindopril should be taken once a day, before meals.

There is a linear relationship between the concentration of perindopril in the blood plasma and its dose. The volume of distribution of free perindoprilate is 0.2 l/kg. The association with plasma proteins is insignificant; the association of perindoprilate, mainly with ACE, is less than 20% and depends on its concentration.

Perindopril is excreted by the kidneys. The “effective” half-life (T1/2) of the free fraction is about 17 hours, so the equilibrium state is achieved within 4 days.

The elimination of perindopril slows down in old age and in patients with heart and renal failure.

The dialysis clearance of perindopril is 70 ml/min.

In patients with liver cirrhosis, the hepatic clearance of perindopril is reduced by 2 times, while the total amount of perindoprilate formed does not decrease, and no dosage adjustment is required.

Special instructions

Common to perindopril and indapamide

The use of the drug Indapamide/Perindopril-Teva is not accompanied by a significant reduction in the frequency of side effects, with the exception of hypokalemia, compared to taking individual components of the drug in the lowest doses approved for use (see section “Side Effects”). At the beginning of therapy with two antihypertensive drugs that the patient has not previously received, an increase in the incidence of idiosyncrasy cannot be excluded. Careful monitoring of the patient can minimize this risk.

Lithium preparations

The combined use of a combination of perindopril and indapamide with lithium preparations is not recommended (see section “Interaction with other drugs”).

Renal dysfunction

Therapy is contraindicated in patients with severe renal impairment (creatinine clearance less than 30 ml/min). In some patients with arterial hypertension without previous obvious renal impairment, laboratory signs of functional renal failure may appear during therapy. In this case, treatment should be stopped. In the future, you can resume combination therapy using low doses of drugs, or use only one of the drugs. Such patients require regular monitoring of the concentration of potassium and creatinine in the blood – 2 weeks after the start of therapy and subsequently every 2 months during the period when the dose of the drug is selected. Renal failure occurs more often in patients with severe heart failure or underlying renal failure, including renal artery stenosis.

The drug Indapamide/Perindopril-Teva is not recommended for use in cases of bilateral renal artery stenosis or in the case of a single functioning kidney.

Hypotension and water-electrolyte imbalance

In the case of initial hyponatremia, there is a risk of sudden development of arterial hypotension, in particular in patients with renal artery stenosis. Therefore, systematic assessment of symptoms of dehydration and decreased plasma electrolyte levels, such as after diarrhea or vomiting, is necessary. Such patients require regular monitoring of blood plasma electrolyte levels.

In case of severe arterial hypotension, intravenous administration of isotonic saline solution may be required.

Transient hypotension is not a contraindication for continued therapy. After restoration of circulating blood volume and blood pressure, therapy can be resumed using low doses, or only one of the drugs can be used.

Potassium content

The combined use of perindopril and indapamide does not prevent the development of hypokalemia, especially in patients with diabetes mellitus or renal failure. As with the use of any antihypertensive drug in combination with a diuretic, regular monitoring of the concentration of potassium in the blood plasma is necessary.

Excipients

The drug Indapamide/Perindopril-Teva contains an excipient – lactose monohydrate and is contraindicated in patients with hereditary galactose intolerance, lactase deficiency and glucose-galactose malabsorption.

Sodium content

The drug Indapamide/Perindopril-Teva contains less than 1 mmol of sodium (less than 23 mg) per tablet, that is, practically “sodium-free”.

Childhood

The drug Indapamide/Perindopril-Teva is contraindicated in children and adolescents under the age of 18 years due to the lack of data on the effectiveness and safety of the use of perindopril and indapamide, both separately and together in patients of this age group.

Indapamide

Hepatic encephalopathy

In the presence of liver dysfunction, taking thiazide and thiazide-like diuretics can lead to the development of hepatic encephalopathy. In such a situation, you should immediately stop taking the diuretic.

Photosensitivity

While taking thiazide and thiazide-like diuretics, cases of photosensitivity reactions have been reported (see section “Side effects”). If photosensitivity reactions develop while taking the drug, treatment should be discontinued. If it is necessary to continue diuretic therapy, it is recommended to protect the skin from exposure to sunlight or artificial ultraviolet rays.

Water and electrolyte balance

Concentration of sodium ions in blood plasma

The concentration of sodium ions in the blood plasma must be determined before starting treatment, and then regularly monitored while taking the drug. A decrease in the concentration of sodium ions at the initial stage may not be accompanied by clinical symptoms, so regular laboratory monitoring is necessary. More frequent monitoring of sodium ion levels is indicated for patients with liver cirrhosis and elderly patients (see sections “Side effects” and “Overdose”). Treatment with any diuretics can cause hyponatremia, sometimes with very serious consequences. Hyponatremia accompanied by hypovolemia can lead to dehydration and orthostatic hypotension. A concomitant decrease in the content of chlorine ions can lead to the development of secondary compensatory metabolic alkalosis: the frequency of its occurrence and severity are insignificant.

Concentration of potassium ions in blood plasma

Decreased potassium concentrations with hypokalemia are the main risk associated with therapy with thiazide and thiazide-like diuretics.

It is necessary to prevent the risk of a decrease in the concentration of potassium ions (less than 3.4 mmol/l) in the following categories of high-risk patients: elderly patients and/or debilitated patients, both receiving and not receiving concomitant drug therapy, patients with cirrhosis of the liver with edema and ascites, coronary heart disease, heart failure. Hypokalemia in these patients increases the toxic effect of cardiac glycosides and increases the risk of rhythm disturbances.

Patients with a prolonged QT interval, either congenital or drug-induced, are also at increased risk.

Hypokalemia, like bradycardia, contributes to the development of severe heart rhythm disturbances, especially polymorphic ventricular tachycardia of the “pirouette” type, which can be fatal. In all the cases described above, more frequent monitoring of the content of potassium ions in the blood plasma is necessary. The first measurement of potassium ion content should be carried out within the first week from the start of therapy.

If hypokalemia is detected, appropriate correction should be made.

Concentration of calcium ions in blood plasma

Thiazide and thiazide-like diuretics may reduce the excretion of calcium ions by the kidneys, leading to a slight and temporary increase in plasma calcium concentrations. A marked increase in the concentration of calcium ions may be associated with undiagnosed hyperparathyroidism. Before studying the function of the parathyroid glands, you should stop taking diuretics.

Blood glucose concentration

It is necessary to monitor the concentration of glucose in the blood in patients with diabetes, especially when the concentration of potassium ions is low.

Uric acid

Patients with elevated plasma uric acid concentrations tend to have an increased incidence of gout attacks.

Diuretics and kidney function

Thiazide and thiazide-like diuretics are fully effective only in patients with normal or slightly impaired renal function (creatinine concentration in adult patients below 25 mg/l or 220 µmol/l).

In elderly patients, plasma creatinine levels should be assessed taking into account age, weight and sex, according to the Cockroft formula:

Creatinine clearance (CC) = (140 – age) x weight/0.814 x plasma creatinine concentration,

where: age in years, weight in kg, plasma creatinine concentration in µmol/l.

The formula is suitable for older men; for older women, the result should be multiplied by a factor of 0.85.

At the beginning of diuretic treatment in patients, due to hypovolemia (due to the excretion of water and sodium ions), a temporary decrease in glomerular filtration rate and an increase in the concentration of urea and creatinine in the blood plasma may be observed. This transient functional renal failure does not have adverse consequences for patients with initially normal renal function, but may aggravate pre-existing renal impairment before treatment.

Athletes

Athletes should pay attention to the fact that the drug contains an active substance that can give a positive result during a doping test.

Acute myopia and secondary angle-closure glaucoma

Sulfonamides and their derivatives can cause the development of an idiosyncratic reaction, leading to temporary myopia and acute angle-closure glaucoma. Without proper treatment, acute angle-closure glaucoma can lead to vision loss. First of all, you need to stop taking the drug as soon as possible. If intraocular pressure continues to be high, immediate medical or surgical treatment may be required. Risk factors that can lead to the development of acute angle-closure glaucoma include an allergy to sulfonamide or penicillin.

Perindopril

Dual blockade of the renin-angiotensin-aldosterone system (RAAS)

There is evidence of an increased risk of arterial hypotension, hyperkalemia and decreased renal function (including acute renal failure) when ACE inhibitors are used together with ARB II or aliskiren. Therefore, double blockade of the RAAS by combining an ACE inhibitor with ARA II or aliskiren is not recommended (see sections “Pharmacodynamics”, “Interaction with other drugs”). If a double blockade is absolutely necessary, it should be performed under the strict supervision of a specialist with regular monitoring of renal function, plasma electrolytes and blood pressure.

The use of ACE inhibitors in combination with ARA II receptor antagonists is contraindicated in patients with diabetic nephropathy and is not recommended in other patients (see sections “Contraindications” and “Interaction with other drugs”).

Potassium-sparing diuretics, potassium supplements, potassium-containing table salt substitutes and food supplements

The combined use of perindopril and potassium-sparing diuretics, as well as potassium preparations, potassium-containing table salt substitutes and food additives is not recommended (see section “Interaction with other drugs”).

Neutropenia/agranulocytosis/thrombocytopenia/anemia

There are reports of the development of neutropenia/agranulocytosis, thrombocytopenia and anemia while taking ACE inhibitors. In patients with normal renal function and without concomitant risk factors, neutropenia rarely occurs. Perindopril should be used with extreme caution against the background of systemic connective tissue diseases, as well as while taking immunosuppressants, allopurinol or procainamide, or a combination of these factors, especially in patients with initially impaired renal function.

Some patients developed severe infectious diseases, in some cases resistant to intensive antibiotic therapy. When prescribing perindopril to such patients, it is recommended to periodically monitor the number of leukocytes in the blood. Patients should tell their doctor about any signs of infectious diseases (for example, sore throat, fever) (see sections “Side effects” and “Interaction with other drugs”).

Anemia can develop in patients after kidney transplantation or in patients on hemodialysis. In this case, the decrease in hemoglobin is greater, the higher its initial value. This effect does not appear to be dose-dependent, but may be related to the mechanism of action of ACE inhibitors.

A slight decrease in hemoglobin occurs during the first 6 months of treatment, then it remains stable and is completely restored after discontinuation of the drug. In such patients, treatment can be continued, but hematological tests should be carried out regularly.

Renovascular hypertension

In patients with bilateral renal artery stenosis or arterial stenosis of a single functioning kidney, the risk of hypotension and renal failure increases while using an ACE inhibitor (see section “Contraindications”). Taking diuretics may be an additional risk factor (see section “Contraindications”). Deterioration of renal function can be observed with even a slight change in serum creatinine concentration, even in patients with unilateral renal artery stenosis.

The treatment method for renovascular hypertension is revascularization. However, the use of ACE inhibitors may have a positive effect in this category of patients, both awaiting surgery and in cases where surgery is not possible.

If therapy with the indapamide/perindopril combination is prescribed to patients with established or suspected renal artery stenosis, it should be initiated with low doses in a hospital setting under monitoring of renal function and potassium levels, since some patients developed functional renal failure, which regressed after discontinuation of therapy.

Hypersensitivity/angioedema

When taking ACE inhibitors, including perindopril, in rare cases, the development of angioedema of the face, extremities, lips, tongue, vocal folds and/or larynx may occur (see section “Side effects”). This can happen at any time during therapy. If symptoms occur, perindopril should be discontinued immediately and the patient should be observed until signs of edema have completely resolved. If the swelling affects only the face and lips, it usually goes away on its own, and antihistamines can be used as symptomatic therapy.

Angioedema, accompanied by swelling of the larynx, can be fatal. Swelling of the tongue, vocal folds, or larynx can lead to airway obstruction. If such symptoms appear, you should immediately begin appropriate therapy, for example, subcutaneously administer epinephrine (adrenaline) at a dilution of 1:1000 (0.3 – 0.5 ml) and/or ensure airway patency.

A higher risk of developing angioedema has been reported in black patients.

Patients with a history of angioedema not associated with taking ACE inhibitors may have an increased risk of developing it when taking drugs of this group (see section “Contraindications”).

In rare cases, angioedema of the intestine develops during therapy with ACE inhibitors.

In this case, patients experienced abdominal pain as an isolated symptom or in combination with nausea and vomiting, in some cases without previous angioedema of the face and with normal levels of C1-esterase. Diagnosis was made using abdominal computed tomography, ultrasound, or at the time of surgery. Symptoms resolved after discontinuation of ACE inhibitors. Therefore, in patients with abdominal pain receiving ACE inhibitors, when carrying out differential diagnosis, it is necessary to take into account the possibility of developing angioedema of the intestine.

Combined use with combination drugs containing valsartan + sacubitril

The combined use of perindopril with combination drugs containing valsartan + sacubitril is contraindicated, as the risk of developing angioedema is increased (see section “Contraindications”). The use of a combination drug containing valsartan + sacubitril is possible no earlier than 36 hours after the last dose of perindopril. The use of perindopril is possible no earlier than 36 hours after stopping the combination drug containing valsartan + sacubitril (see sections “Contraindications” and “Interaction with other drugs”). When ACE inhibitors are used together with other neprilysin inhibitors (for example, racecadotril), the risk of developing angioedema may be increased (see section “Interaction with other drugs”). In patients receiving perindopril therapy, a careful risk/benefit assessment should be performed before initiating treatment with neprilysin inhibitors (eg, racecadotril).

mTOR (mammalian target of rapamycin) inhibitors (eg, sirolimus, everolimus, temsirolimus)

When used together with mTOR inhibitors (for example, sirolimus, everolimus, temsirolimus), the risk of developing angioedema (for example, swelling of the airways or tongue, with or without impairment of respiratory function) increases (see section “Interaction with other drugs”).

Anaphylactoid reactions during desensitization

There are isolated reports of the development of long-term, life-threatening anaphylactic reactions in patients receiving ACE inhibitors during desensitizing therapy with the venom of hymenoptera insects (bees, wasps). ACE inhibitors should be used with caution in patients prone to allergic reactions undergoing desensitization procedures. The use of an ACE inhibitor should be avoided in patients receiving immunotherapy with hymenoptera venom. However, in patients who require both the use of an ACE inhibitor and a desensitization procedure, an anaphylactoid reaction can be avoided by temporarily discontinuing the ACE inhibitor at least 24 hours before the procedure.

Anaphylactoid reactions during LDL apheresis

In rare cases, life-threatening anaphylactoid reactions have developed in patients receiving ACE inhibitors during LDL apheresis using dextran sulfate. To prevent an anaphylactoid reaction, ACE inhibitor therapy should be temporarily discontinued before each apheresis procedure.

Patients on hemodialysis

Anaphylactoid reactions have been reported in patients receiving ACE inhibitors during hemodialysis using high-flux membranes (eg, AN69®). Therefore, it is advisable to use a different type of membrane or use an antihypertensive agent of a different pharmacotherapeutic group.

Primary hyperaldosteronism

Patients with primary hyprealdosteronism are usually not susceptible to antihypertensive drugs whose action is based on inhibition of the RAAS. Therefore, the use of the drug in such patients is not recommended.

Cough

During therapy with an ACE inhibitor, a dry persistent cough may occur, which disappears after discontinuation of the drug. If a patient develops a dry cough, one should be aware of the possible iatrogenic nature of this symptom. If the attending physician believes that ACE inhibitor therapy is necessary for the patient, it is possible to continue taking the drug.

Children

The effectiveness and tolerability of perindopril in children and adolescents as monotherapy or in combination with other drugs have not been established.

Risk of arterial hypotension and/or renal failure (in patients with heart failure, fluid and electrolyte imbalance, etc.)

In some pathological conditions, significant activation of the renin-angiotensin-aldosterone system may be observed, especially with severe hypovolemia and a decrease in plasma electrolytes (due to a salt-free diet or long-term use of diuretics), in patients with initially low blood pressure, renal artery stenosis, congestive heart failure or cirrhosis of the liver with edema and ascites.

The use of an ACE inhibitor causes blockade of the RAAS and therefore may be accompanied by a sharp decrease in blood pressure and/or an increase in the concentration of creatinine in the blood plasma, indicating the development of functional renal failure. These phenomena are more often observed when taking the first dose of the drug or during the first two weeks of therapy. In rare cases, these conditions develop acutely and during other periods of therapy. In such cases, when resuming therapy, it is recommended to use the drug at a lower dose and then gradually increase the dose.

Old age

Before starting perindopril, it is necessary to assess the functional activity of the kidneys and the potassium content in the blood plasma. At the beginning of therapy, the dose of the drug is selected taking into account the degree of reduction in blood pressure, especially in the case of dehydration and loss of electrolytes. Such measures help to avoid a sharp decrease in blood pressure.

Atherosclerosis

The risk of arterial hypotension exists in all patients, however, special care should be taken when using the drug in patients with coronary heart disease and cerebrovascular insufficiency. In such patients, treatment should begin with low doses of the drug.

Heart failure/severe heart failure

In patients with severe heart failure (NYHA functional class IV), treatment should begin with a low dose of the drug and under close medical supervision.

Hypertensive patients with coronary artery disease should not stop taking beta-blockers: ACE inhibitors should be used together with beta-blockers.

Patients with diabetes mellitus

In patients with insulin-dependent diabetes mellitus (risk of spontaneous increase in potassium levels), treatment should begin with minimal doses and be under constant medical supervision.

Glycemic levels should be carefully monitored in patients with diabetes mellitus who have previously received oral hypoglycemic agents or insulin, particularly during the first month of ACE inhibitor therapy (see section “Interactions with other drugs”).

Ethnic differences

Perindopril, like other ACE inhibitors, has a less pronounced antihypertensive effect in patients of the Negroid race compared to representatives of other races. This difference may be due to the fact that black patients with arterial hypertension are more likely to have low renin activity.

Surgery/anesthesia

The use of ACE inhibitors may lead to hypotension, especially when used concomitantly with anesthetic agents that have antihypertensive effects. Therefore, it is recommended to stop taking long-acting ACE inhibitors such as perindopril the day before surgery if possible.

Aortic or mitral valve stenosis/hypertrophic obstructive cardiomyopathy

ACE inhibitors should be prescribed with caution to patients with left ventricular outflow tract obstruction.

Liver failure

In rare cases, cholestatic jaundice occurs while taking ACE inhibitors. As this syndrome progresses, fulminant liver necrosis may develop, sometimes with death. The mechanism of development of this syndrome is unclear. If jaundice appears or if there is a significant increase in the activity of liver enzymes while taking ACE inhibitors, the patient should stop taking the ACE inhibitor and be under appropriate medical supervision (see section “Side Effects”).

Hyperkalemia

Hyperkalemia may develop during treatment with ACE inhibitors, including perindopril. Risk factors for hyperkalemia include renal failure, deterioration of renal function, age over 70 years, diabetes mellitus, certain concomitant conditions, in particular dehydration, acute cardiac decompensation, metabolic acidosis, concomitant use of potassium-sparing diuretics (such as spironolactone, eplerenone, triamterene, amiloride), as well as potassium or potassium-containing drugs table salt substitutes, as well as the use of other drugs that help increase potassium levels in the blood plasma (for example, heparin, co-trimoxazole, also known as the combination of sulfomethoxazole + trimethoprim, other ACE inhibitors, angiotensin II receptor antagonists, acetylsalicylic acid (3 g / day or more), cyclooxygenase-2 (COX-2) inhibitors and non-selective NSAIDs, immunosuppressants such as cyclosporine or tacrolimus, trimethoprim).

The use of potassium supplements, potassium-sparing diuretics, and potassium-containing table salt substitutes can lead to a significant increase in potassium levels in the blood, especially in patients with reduced renal function. Hyperkalemia can cause serious, sometimes fatal, abnormal heart rhythms. If the combined use of the above drugs is necessary, treatment should be carried out with caution against the background of regular monitoring of potassium concentration in the blood serum (see section “Interaction with other drugs”).

Impact on the ability to drive vehicles and machinery

Neither indapamide nor perindopril, either in monotherapy or in combination with each other, have a negative effect on concentration and the speed of psychomotor reactions. However, some patients, especially at the beginning of treatment or in combination with other antihypertensive drugs, may experience episodes of severe or sudden decrease in blood pressure and dizziness, which may reduce the ability to drive vehicles and operate machinery.

Active ingredient

Indapamide, Perindopril

Composition

1 tablet contains:

active ingredients: indapamide 0.625 mg/1.25 mg; perindopril tosylate 2.50 mg/5.00 mg, which corresponds to perindopril 1.7 mg/3.4 mg;

excipients: lactose monohydrate 74.056 mg/148.112 mg; corn starch 2.70 mg/5.40 mg; sodium bicarbonate 0.793 mg/1.586 mg; pregelatinized corn starch 7.20 mg/14.40 mg; povidone-K30 1.80 mg/3.60 mg; magnesium stearate 0.90 mg/1.80 mg;

coating for tablets 0.625 mg + 2.5 mg; 1.25 mg + 5 mg: Opadry II white 85F18422 (partially hydrolyzed polyvinyl alcohol 1.800 mg/3.600 mg; titanium dioxide (E171) 1.125 mg/2.250 mg; macrogol-3350 (polyethylene glycol-3350) 0.909 mg/1.818 mg; talc 0.666 mg/1.332 mg).

Pregnancy

Pregnancy

The use of the drug Indapamide/Perindopril-Teva is contraindicated during pregnancy.

It is necessary to assess the significance of therapy for the mother and make a decision to stop breastfeeding or stop taking the drug.

Indapamide

There are no or limited data on the use of indapamide in pregnant women (less than 300 cases). Long-term use of thiazide diuretics in the third trimester of pregnancy can cause hypovolemia in the mother and a decrease in uteroplacental blood flow, which leads to fetoplacental ischemia and fetal growth retardation.

Animal studies have not revealed direct or indirect reproductive toxicity.

In rare cases, while taking diuretics shortly before birth, newborns develop hypoglycemia and thrombocytopenia.

If the patient received the drug Indapamide/Perindopril-Teva during the second or third trimesters of pregnancy, it is recommended to conduct an ultrasound examination of the newborn to assess the condition of the skull and renal function.

As a precaution, it is recommended to avoid the use of indapamide during pregnancy.

Perindopril

There have been no adequate controlled studies on the use of ACE inhibitors in pregnant women. At the moment, there is no convincing epidemiological data on the teratogenic risk when taking ACE inhibitors in the first trimester of pregnancy, but some increase in the risk of fetal development disorders cannot be excluded. When planning pregnancy, the drug should be discontinued and other antihypertensive drugs approved for use during pregnancy should be prescribed. If pregnancy is detected, therapy with ACE inhibitors should be immediately discontinued and, if necessary, other therapy should be prescribed.

It is known that the effect of ACE inhibitors on the fetus in the second and third trimesters of pregnancy can lead to disruption of its development (decreased renal function, oligohydramnios, delayed ossification of the skull bones) and the development of complications in the newborn (renal failure, arterial hypotension, hyperkalemia).

If the patient received ACE inhibitors during the second or third trimester of pregnancy, it is recommended to perform an ultrasound examination of the fetus to assess the condition of the skull and renal function.

In newborns whose mothers received therapy with ACE inhibitors, arterial hypotension may be observed, and therefore newborns should be under close medical supervision.

Breastfeeding period

The drug Indapamide/Perindopril-Teva is contraindicated during breastfeeding.

Indapamide

At the moment, there is no reliable information about the excretion of indapamide or its metabolites in breast milk. The newborn may develop hypersensitivity to sulfonamide derivatives and hypokalemia.

A risk to neonates/infants cannot be excluded.

Indapamide is close in structure to thiazide diuretics, the use of which causes a decrease in the amount of breast milk or suppression of lactation.

Indapamide is contraindicated during breastfeeding.

Perindopril

It is currently not known whether perindopril is excreted in breast milk. Due to the lack of information regarding the use of perindopril during breastfeeding, its use is not recommended; it is preferable to use other drugs with a more studied safety profile, especially when feeding newborns and premature infants.

Fertility

General information for perindopril and indapamide

Reproductive toxicity studies showed no effect on fertility in rats of both sexes. Presumably there is no effect on human fertility.

Contraindications

– Hypersensitivity to active substances, other ACE inhibitors, sulfonamide derivatives, excipients included in the drug (see section “Composition”).

– Angioedema (Quincke’s edema) in anamnesis while taking other ACE inhibitors (see section “Special indications”).

– Hereditary/idiopathic angioedema.

– Pregnancy and breastfeeding (see section “Use during pregnancy and breastfeeding”).

– Concomitant use with aliskiren and medicinal products containing aliskiren in patients with diabetes mellitus and/or moderate or severe renal impairment (glomerular filtration rate (GFR) less than 60 ml/min/1.73 m2 body surface area) (see sections “Pharmacodynamics” and “Interaction with other drugs”).

– Simultaneous use with ARA II in patients with diabetic nephropathy (see section “Special instructions”).

– Children under 18 years of age (efficacy and safety have not been established).

– Severe renal failure (creatinine clearance (CC) less than 30 ml/min).

– Hepatic encephalopathy.

– Hypokalemia.

– Severe liver failure.

– Simultaneous use with non-antiarrhythmic drugs that can cause polymorphic ventricular tachycardia of the “pirouette” type (see section “Interaction with other drugs”).

– Severe bilateral renal artery stenosis or stenosis of the artery of a single functioning kidney.

– Due to the lack of sufficient clinical experience, the drug Indapamide/Perindopril-Teva should not be used in patients on hemodialysis, as well as in patients with untreated decompensated heart failure.

– Presence of lactase deficiency, galactosemia or glucose-galactose malabsorption syndrome (the drug contains lactose).

– Concomitant use with neutral endopeptidase inhibitors (for example, with drugs containing sacubitril) due to the high risk of developing angioedema.

With caution

Systemic connective tissue diseases (including systemic lupus erythematosus, scleroderma); therapy with immunosuppressants (risk of developing neutropenia, agranulocytosis); concomitant therapy with lithium drugs; gold preparations, non-steroidal anti-inflammatory drugs (NSAIDs), baclofen, corticosteroids; drugs that can cause prolongation of the QT interval, drugs that can cause polymorphic ventricular tachycardia of the “pirouette” type, except for non-antiarrhythmic drugs (see section “Contraindications”); inhibition of bone marrow hematopoiesis; reduced circulating blood volume (taking diuretics, salt-free diet, vomiting, diarrhea, hemodialysis); angina pectoris; cerebrovascular diseases; renovascular hypertension; diabetes mellitus; chronic heart failure (functional class IV according to the NYHA classification); liver failure; hyperuricemia (especially accompanied by gout and urate nephrolithiasis); blood pressure lability; old age; hemodialysis using high-flow membranes or desensitization before the LDL apheresis procedure; condition after kidney transplantation; anesthesia; Aortic valve stenosis/hypertrophic obstructive cardiomyopathy; atherosclerosis; representatives of the Negroid race (less pronounced effect of use); athletes (possible positive reaction during doping control), bilateral renal artery stenosis or the presence of only one functioning kidney, concomitant therapy with potassium-sparing diuretics, potassium supplements or in patients with elevated plasma potassium levels; hyperkalemia; hyponatremia; burdened allergy history.

Side Effects

The frequency of adverse reactions that may occur during therapy is given in the following gradation: very often (≥1/10); often (≥1/100, but <1/10); uncommon (≥1/1000, but <1/100); rare (≥1/10000, but <1/1000); very rare (< 1/10000); unknown frequency (the frequency of development cannot be calculated from the available data).

MedDRA

classes and organ systems

Side effect

Frequency

Indapamide

Perindopril

Infectious and parasitic disorders

Rhinitis

–

Very rarely

Blood and lymphatic system disorders

Eosinophilia

–

Uncommon*

Agranulocytosis

(see section “Special instructions”)

Very rarely

Very rarely

Aplastic anemia

Very rarely

–

Pancytopenia

–

Very rarely

Leukopenia

Very rarely

Very rarely

Neutropenia

(see section “Special instructions”)

–

Very rarely

Hemolytic anemia

Very rarely

Very rarely

Thrombocytopenia

(see section “Special instructions”)

Very rarely

Very rarely

Immune system disorders

Hypersensitivity reactions (mainly dermatological reactions, in patients with a predisposition to allergic and broncho-obstructive reactions)

Often

–

Metabolic and nutritional disorders

Hypoglycemia

(see sections “Special instructions” and “Interaction with other drugs”)

–

Uncommon*

Hyperkalemia, reversible when the drug is discontinued (see section “Special instructions”)

–

Uncommon*

Hyponatremia

(see section “Special instructions”)

Frequency unknown

Uncommon*

Hypercalcemia

Very rarely

–

Decreased potassium levels and hypokalemia, especially significant for patients at risk (see section “Special Instructions”)

Frequency unknown

–

Mental disorders

Mood lability

–

Uncommon

Sleep disturbance

–

Uncommon

Confusion

–

Very rarely

Nervous system disorders

Dizziness

–

Often

Headache

Rarely

Often

Parasthesia

Rarely

Often

Dysgeusia

–

Often

Drowsiness

–

Uncommon*

Fainting

Frequency unknown

Uncommon*

Stroke, possibly due to an excessive decrease in blood pressure in high-risk patients (see section “Special instructions”)

–

Very rarely

Possible development of hepatic encephalopathy in patients with liver failure (see sections “Contraindications” and “Special instructions”)

Frequency unknown

–

Visual disorders

Visual impairment

Frequency unknown

Often

Myopia

Frequency unknown

–

Blurred vision

Frequency unknown

–

Hearing and labyrinth disorders

Vertigo

Rarely

Often

Tinnitus

–

Often

Heart disorders

Feeling of heartbeat

–

Uncommon*

Tachycardia

–

Uncommon*

Angina (see section “Special instructions”)

–

Very rarely

Heart rhythm disturbances (including bradycardia, ventricular tachycardia and atrial fibrillation)

Very rarely

Very rarely

Myocardial infarction, possibly due to an excessive decrease in blood pressure in high-risk patients (see section “Special instructions”)

–

Very rarely

Polymorphic ventricular tachycardia of the “pirouette” type (possibly fatal) (see sections “Interaction with other drugs” and “Special instructions”)

Frequency unknown

–

Vascular disorders

Arterial hypotension (excessive decrease in blood pressure) and associated symptoms (see section “Special instructions”)

Very rarely

Often

Vasculitis

–

Uncommon*

Raynaud’s syndrome

–

Frequency unknown

Respiratory, thoracic and mediastinal disorders

Cough (see section “Special instructions”)

–

Often

Dyspnea

–

Often

Bronchospasm

–

Uncommon

Eosinophilic pneumonia

–

Very rarely

Gastrointestinal disorders

Abdominal pain

–

Often

Constipation

Rarely

Often

Diarrhea

–

Often

Dyspepsia

–

Often

Nausea

Rarely

Often

Vomit

Uncommon

Often

Dryness of the oral mucosa

Rarely

Uncommon

Pancreatitis

Very rarely

Very rarely

Disorders of the liver and biliary tract

Hepatitis (see section “Special instructions”)

Frequency unknown

Very rarely

Liver dysfunction

Very rarely

–

Skin and subcutaneous tissue disorders

Itchy skin

–

Often

Exacerbation of psoriasis

–

Rarely*

Skin rash

–

Often

Maculopapular rash

Often

–

Urticaria (see section “Special instructions”)

Very rarely

Uncommon

Angioedema (see section “Special instructions”)

Very rarely

Uncommon

Purpura

Uncommon

–

Increased sweating

–

Uncommon

Photosensitivity reaction

Frequency unknown

Uncommon*

Pemphigoid

–

Uncommon*

Erythema multiforme

–

Very rarely

Toxic epidermal necrolysis

Very rarely

–

Stevens-Johnson syndrome

Very rarely

–

Musculoskeletal and connective tissue disorders

Muscle spasms

–

Often

Possible exacerbation of existing systemic lupus erythematosus

Frequency unknown

–

Arthralgia

–

Uncommon*

Myalgia

–

Uncommon*

Renal and urinary tract disorders

Kidney failure

–

Uncommon

Acute renal failure

Very rarely

Very rarely

Disorders of the genital organs and breast

Erectile dysfunction

–

Uncommon

Common disorders and symptoms

Asthenia

–

Often

Chest pain

–

Uncommon*

Malaise

–

Uncommon*

Peripheral edema

–

Uncommon*

Fever

–

Uncommon*

Increased fatigue

Rarely

–

Laboratory and instrumental data

Increased urea concentration in the blood

–

Uncommon*

Increased creatinine concentration in the blood

–

Uncommon*

Increased concentration of bilirubin in the blood

–

Rarely

Increased activity of liver enzymes

Frequency unknown

Rarely

Decrease in hemoglobin and hematocrit

(see section “Special instructions”)

–

Very rarely

Increased blood glucose levels

Frequency unknown

–

Increased uric acid levels in the blood

Frequency unknown

–

Prolongation of the QT interval on the ECG (see sections “Special instructions” and “Interaction with other drugs”)

Frequency unknown

–

Injuries, poisoning, complications after interventions

Fall

–

Uncommon*

* The frequency of adverse reactions identified by spontaneous reports was assessed based on the results of clinical trials

The development of syndrome of inappropriate antidiuretic hormone secretion (SIADH) has been reported when used together with other ACE inhibitors. In terms of frequency of occurrence, the syndrome of inappropriate secretion of antidiuretic hormone is a very rare but possible complication caused by therapy with ACE inhibitors, including perindopril.

Interaction

Common to perindopril and indapamide

Combinations not recommended for use

Lithium preparations

With the combined use of lithium preparations and ACE inhibitors, a reversible increase in plasma lithium levels and associated toxic effects have been reported. The combined use of a combination of perindopril and indapamide with lithium preparations is not recommended. If such therapy is necessary, the lithium content in the blood plasma should be regularly monitored (see section “Special Instructions”).

Medicines, combination with which requires special attention and caution

Baclofen

Strengthening the antihypertensive effect. Blood pressure and renal function should be monitored and, if necessary, the dose of antihypertensive drugs should be adjusted.

Nonsteroidal anti-inflammatory drugs (NSAIDs), including high doses of acetylsalicylic acid (≥ 3 g/day)

With the simultaneous use of ACE inhibitors and NSAIDs (acetylsalicylic acid in a dose that has an anti-inflammatory effect, cyclooxygenase-2 (COX-2) inhibitors and non-selective NSAIDs), a weakening of the antihypertensive effect may be observed. The combined use of ACE inhibitors and NSAIDs may lead to an increased risk of deterioration of renal function, including the development of acute renal failure, and an increase in serum potassium, especially in patients with initially reduced renal function. Caution should be exercised when using a combination of the drug and NSAIDs, especially in elderly patients. Patients should receive an adequate amount of fluid, and it is recommended to monitor renal function both at the beginning of joint therapy and periodically during treatment.

Combination of drugs requiring attention

Tricyclic antidepressants, antipsychotic drugs (neuroleptics) Drugs of these classes enhance the antihypertensive effect and increase the risk of orthostatic hypotension (additive effect).

Indapamide

Combination of drugs requiring special attention

Drugs that can cause polymorphic ventricular tachycardia of the “pirouette” type

antiarrhythmic drugs of class IA (quinidine, hydroquinidine, disopyramide, procainamide) and class IC (flecainide);
class III antiarrhythmic drugs (amiodarone, sotalol, dofetilide, ibutilide, bretylium tosylate, dronedarone);
neuroleptics: phenothiazines (chlorpromazine, cyamemazine, levomepromazine, thioridazine, trifluoperazine, fluphenazine), benzamides (amisulpride, sulpiride, sultopride, tiapride), butyrophenones (droperidol, haloperidol), pimozide, sertindole;
antidepressants: tricyclic antidepressants, selective serotonin reuptake inhibitors (citalopram, escitalopram);
antibacterial agents: fluoroquinolones (levofloxacin, moxifloxacin, sparfloxacin, ciprofloxacin); macrolides (erythromycin for intravenous administration, azithromycin, clarithromycin, roxithromycin, spiramycin); co-trimoxazole;
antifungals of the azole group (voriconazole, itraconazole, ketoconazole, fluconazole);
antimalarials (quinine, chloroquine, mefloquine, halofantrine, lumefantrine);
antianginal agents (ranolazine, bepridil);
antitumor drugs and immunomodulators (vandetanib, arsenic trioxide, oxaliplatin, tacrolimus, anagrelide);
antiemetics (ondansetron);
drugs that affect gastrointestinal motility (cisapride, domperidone);
antihistamines (astemizole, terfenadine, mizolastine);
others: pentamidine, diphemanil, vincamine for intravenous administration, vasopressin, terlipressin, ketanserin, probucol, propofol, sevoflurane, terodiline, cilostazol.

Hypokalemia should be prevented and, if necessary, corrected; monitor the QT interval.

Drugs that can cause hypokalemia

Amphotericin B (iv), gluco- and mineralocorticosteroids (with systemic use), tetracosactide, laxatives that stimulate intestinal motility: increased risk of hypokalemia (additive effect). It is necessary to monitor the potassium content in the blood plasma and, if necessary, correct it. Particular attention should be paid to patients concomitantly receiving cardiac glycosides. Laxatives that do not stimulate intestinal motility should be used.

Cardiac glycosides

Hypokalemia enhances the toxic effect of cardiac glycosides. When using indapamide and cardiac glycosides together, the potassium content in the blood plasma and ECG values ​​should be monitored and, if necessary, therapy should be adjusted.

Allopurinol

When used together with indapamide, an increase in the frequency of hypersensitivity reactions is possible.

Combination of drugs requiring attention

Potassium-sparing diuretics (amiloride, spironolactone, triamterene)

This combination is justified in some patients. In this case, hypokalemia or hyperkalemia may occur (especially in patients with renal failure or diabetes mellitus). If simultaneous use of indapamide and the above potassium-sparing diuretics is necessary, the potassium content in the blood plasma and ECG parameters should be monitored. If necessary, the treatment regimen can be revised.

Metformin

Functional renal failure, which can occur during the use of diuretics, especially loop diuretics, when combined with metformin, increases the risk of developing lactic acidosis. Metformin should not be used if the plasma creatinine concentration exceeds 15 mg/l (135 µmol/l) in men and 12 mg/l (110 µmol/l) in women.

Iodinated contrast agents

Dehydration while taking diuretics increases the risk of developing acute renal failure, especially when using high doses of iodinated contrast agents. Before using iodinated contrast agents, patients need to compensate for fluid loss.

Calcium (salts)

With simultaneous use, hypercalcemia may develop due to decreased excretion of calcium ions by the kidneys.

Cyclosporine, tacrolimus

It is possible to increase the concentration of creatinine in the blood plasma without changing the concentration of cyclosporine in the blood plasma, even with normal levels of water and sodium ions.

Corticosteroids, tetracosactide (for systemic use)

Reduced antihypertensive effect (salt and water retention due to the use of corticosteroids).

Perindopril

Data from clinical studies show that dual blockade of the RAAS as a result of the combined use of ACE inhibitors, ARB II or aliskiren leads to an increased incidence of adverse events such as arterial hypotension, hyperkalemia and decreased renal function (including acute renal failure), compared with situations where only one drug acting on the RAAS is used (see sections “Pharmacodynamics”, “Contraindications” and “Special Instructions”).

Drugs that cause hyperkalemia

Certain drugs or classes of drugs may increase the incidence of hyperkalemia: aliskiren, potassium salts, potassium-sparing diuretics, ACE inhibitors, ARB II, NSAIDs, heparins, immunosuppressants (such as cyclosporine or tacrolimus), trimethoprim and drugs containing co-trimoxazole (sulfomethoxazole + trimethoprim). The combination of these drugs increases the risk of developing hyperkalemia.

Concomitant use is contraindicated

Aliskiren and medicinal products containing aliskiren

The combined use of ACE inhibitors with medicinal products containing aliskiren is contraindicated in patients with diabetes mellitus and/or moderate or severe renal impairment (GFR < 60 ml/min/1.73 m2 body surface area) (see section "Contraindications"). The risk of hyperkalemia, deterioration of renal function, cardiovascular morbidity and mortality increases.

Combined therapy with ACE inhibitors and angiotensin receptor antagonists

The use of ACE inhibitors in combination with angiotensin II receptor antagonists (ARBs) is contraindicated in patients with diabetic nephropathy (see section “Contraindications”).

Extracorporeal therapy

Extracorporeal treatments that expose blood to negatively charged surfaces, such as dialysis or hemofiltration using certain high-flux membranes (eg, polyacrylonitrile), or low-density lipoprotein (LDL) apheresis using dextran sulfate, are contraindicated due to the increased risk of severe anaphylactoid reactions (see Contraindications). If the patient requires extracorporeal therapy, the use of a different type of dialysis membrane or a different class of antihypertensive drugs should be considered.

Combined use with combination drugs containing valsartan + sacubitril

The combined use of perindopril with the combination of valsartan + sacubitril is contraindicated, since suppression of neprilysin activity during combined use of an ACE inhibitor may increase the risk of developing angioedema. The use of the combination of valsartan + sacubitril is possible no earlier than 36 hours after the last dose of perindopril. The use of perindopril is possible no earlier than 36 hours after the last dose of the combination of valsartan + sacubitril (see sections “Contraindications” and “Special instructions”).

Combinations not recommended for use

Aliskiren, and drugs containing aliskiren

In patients who do not have diabetes mellitus or impaired renal function (GFR < 60 ml/min/1.73 m2 body surface area), there is an increased risk of developing hyperkalemia, deterioration of renal function, and increased incidence of cardiovascular morbidity and mortality (see section "Special Instructions").

Combination of therapy with ACE inhibitors and AR II

According to the available literature, in patients with established atherosclerotic disease, heart failure or diabetes mellitus with target organ damage, the simultaneous use of ACE inhibitors and ARB II leads to an increased incidence of arterial hypotension, syncope, hyperkalemia and deterioration of renal function (including acute renal failure), compared with situations where only one drug acting on the RAAS is used. The use of double blockade of the RAAS (for example, in the case of simultaneous use of ACE inhibitors and ARA II) should be limited to isolated cases with strict monitoring of renal function, potassium levels in the blood plasma and blood pressure (see section “Special instructions”).

Estramustine

Concomitant use may result in an increased risk of side effects such as angioedema (Quincke’s edema).

Potassium-sparing diuretics (eg, triamterene, amiloride) and potassium (salts)

Hyperkalemia (possibly fatal), especially if renal function is impaired (additive effects associated with hyperkalemia).

The combination of perindopril with the above-mentioned drugs is not recommended (see section “Special instructions”). If, however, combined use is indicated, they should be used with precautions and regular monitoring of serum potassium levels.

Features of the use of spironolactone in chronic heart failure are described further in the text (see the subsection “Combination of drugs that require special attention”).

Co-trimoxazole (sulfamethoxazole + trimethoprim)

When used together with co-trimoxazole (sulfamethoxazole + trimethoprim), the risk of developing hyperkalemia may increase (see section “Special instructions”).

Combination of drugs requiring special attention

Hypoglycemic agents (insulin, oral hypoglycemic drugs)

Epidemiological studies have shown that the combined use of ACE inhibitors and hypoglycemic agents (insulins, oral hypoglycemic drugs) can enhance the hypoglycemic effect of insulin and oral hypoglycemic agents up to the development of hypoglycemia.

This effect is most likely to be observed during the first weeks of joint therapy, as well as in patients with impaired renal function.

Potassium-sparing diuretics

In patients receiving diuretics, especially in patients with hypovolemia and/or reduced salt concentrations, an excessive decrease in blood pressure may be observed at the beginning of perindopril therapy, the risk of which can be reduced by discontinuing the diuretic, replacing fluid or salt losses before starting perindopril therapy, as well as prescribing perindopril at a low dose and then gradually increasing it.

For arterial hypertension in patients with hypovolemia or reduced salt concentrations during diuretic therapy, diuretics should either be discontinued before starting the ACE inhibitor (while a potassium-sparing diuretic can be reintroduced later), or the ACE inhibitor should be prescribed at a low dose and then gradually increase it.

When using diuretics in the case of congestive heart failure, the ACE inhibitor should be prescribed at a very low dose, possibly after reducing the dose of the concomitant potassium-sparing diuretic.

In all cases, renal function (creatinine concentration) should be monitored in the first weeks of using ACE inhibitors.

Potassium-sparing diuretics (eplerenone, spironolactone)

The use of eplerenone or spironolactone in doses from 12.5 mg to 50 mg per day and low doses of ACE inhibitors:

When treating chronic heart failure of functional class II-IV according to the NYHA classification with a left ventricular ejection fraction <40% and previously used ACE inhibitors and loop diuretics, there is a risk of hyperkalemia (with possible death), especially if the recommendations for this combination of drugs are not followed.

Before using this combination of drugs, you must ensure that there is no hyperkalemia or impaired renal function.

It is recommended to regularly monitor the concentration of creatinine and potassium in the blood: weekly in the first month of treatment and monthly thereafter.

Racecadotril

While taking ACE inhibitors (including perindopril), the development of angioedema may occur. This risk may be increased when used concomitantly with racecadotril (a medicine used to treat acute diarrhea).

mTOR (mammalian target of rapamycin) inhibitors (eg, sirolimus, everolimus, temsirolimus)

When used together with mTOR inhibitors, the risk of developing angioedema increases (see section “Special Instructions”).

Recombinant tissue plasminogen activators (rtPA, alteplase)

Patients receiving ACE inhibitors and receiving alteplase for thrombolytic therapy for acute ischemic stroke may be at increased risk of developing angioedema.

Combination of drugs requiring attention

Antihypertensives and vasodilators

The combined use of these drugs may enhance the antihypertensive effect of perindopril. When used together with nitroglycerin and other nitrates or other vasodilators, an additional reduction in blood pressure is possible.

Allopurinol, cytotoxic and immunosuppressive agents, systemic corticosteroids and procainamide

Concomitant use with ACE inhibitors may be accompanied by an increased risk of leukopenia (see section “Special Instructions”).

Anesthetic agents

ACE inhibitors may enhance the hypotensive effect of some general anesthesia agents (see section “Special Instructions”).

Gliptins (linagliptin, saxagliptin, sitagliptin, vildagliptin)

When used together with ACE inhibitors, the risk of angioedema increases due to a decrease in the activity of dipeptidyl peptidase-4 (DPP-IV) under the influence of gliptin.

Sympathomimetics

Sympathomimetics may reduce the antihypertensive effect of ACE inhibitors.

Gold preparations

Rare cases of nitrite reactions (with symptoms such as facial flushing, nausea, vomiting, hypotension) have been reported in patients during the combined use of ACE inhibitors, including perindopril, and injectable gold (sodium aurothiomalate).

Overdose

Symptoms: marked decrease in blood pressure, nausea, vomiting, muscle cramps, dizziness, drowsiness, confusion, oliguria, turning into anuria (decrease in blood volume), water-electrolyte imbalance (hypokalemia, hyponatremia).

Treatment: gastric lavage and/or use of activated carbon, restoration of water and electrolyte balance. If there is a pronounced decrease in blood pressure, the patient should be transferred to the “lying” position with his legs raised up, and if necessary, take measures aimed at replenishing the blood volume (for example, intravenous (iv) administration of 0.9% sodium chloride solution). Perindoprilat can be removed from the body using dialysis.

Storage conditions

Store at a temperature not exceeding 25 °C.
Keep out of the reach of children!

Shelf life

2 years.
Do not use after expiration date.

Manufacturer

Teva Pharmaceutical Works Private Limited Company, Hungary