Perindopril arginine with indapamide

How it works

Perindopril inhibits angiotensin-converting enzyme to reduce angiotensin-II formation and vasoconstriction, while indapamide promotes renal sodium and water loss and has a direct vasodilatory effect; together they lower blood pressure additively.

Prescribing in practice

• Avoid in pregnancy because the ACE-inhibitor component is foetotoxic; counsel and review contraception in women of childbearing potential.
• The combination can cause first-dose hypotension, hyperkalaemia and renal impairment, particularly with volume depletion, renal artery stenosis or concomitant NSAIDs; indapamide separately risks hyponatraemia and hypokalaemia.
• ACE inhibitors can cause a persistent dry cough and, rarely, angioedema that may be life-threatening and warrants permanent discontinuation.

Monitoring

Monitor blood pressure, renal function and serum electrolytes including sodium and potassium at baseline, after initiation and after dose changes.

Counselling the patient

• A persistent dry cough can occur; report it so an alternative can be considered.
• Seek urgent help for any swelling of the face, lips, tongue or throat.
• Tell your doctor immediately if you become pregnant.

Evidence & guidelines

Perindopril-indapamide reduced cardiovascular outcomes in trials such as ADVANCE in type-2 diabetes and HYVET in the very elderly, supporting its use beyond blood-pressure lowering alone.