ACE inhibitor Pregnancy: Not recommended during the first trimester of pregnancy and contraindicated during the second and third trimesters. Stop treatment immediately when pregnancy is diagnosed and start alternative therapy if appropriate. Second and third trimester exposure is known to induce human foetotoxicity (decreased renal function, oligohydramnios, skull ossification retardation) and neonatal toxicity (renal failure, hypotension, hyperkalaemia). Not recommended during breast-feeding (eMC 4.6). US labelling classifies perindopril as Pregnancy Category D with a boxed warning on fetal toxicity.

Perindopril erbumine

Brand names: Coversyl

Perindopril erbumine is an oral angiotensin-converting enzyme (ACE) inhibitor used in hypertension, heart failure, stable coronary artery disease and to reduce cardiovascular risk.

Auto-extracted from the source labelling — not yet independently clinician-verified. These values were distilled from the UK SPC (or the US label where noted) but have not had a clinician sign-off. Confirm against the current SmPC before prescribing.

Adult dose

Dose: Hypertension: 4 mg (recommended starting dose)

Route: Oral

Frequency: Once daily in the morning, before a meal

Max: 8 mg once daily (UK SPC)

eMC SPC 4.2 (Perindopril Erbumine 8 mg tablets). The dose should be individualised according to the patient profile and blood pressure response; the dose may be increased to 8 mg once daily after one month of treatment. A starting dose of 2 mg is recommended, with initiation under medical supervision, in patients with a strongly activated renin-angiotensin-aldosterone system (in particular renovascular hypertension, salt and/or volume depletion, cardiac decompensation or severe hypertension). Symptomatic hypotension may occur after initiation, more likely in patients concurrently treated with diuretics - if possible discontinue the diuretic 2 to 3 days before starting; where the diuretic cannot be discontinued, initiate at 2 mg and monitor renal function and serum potassium, adjusting subsequent dosage according to blood pressure response. ELDERLY (hypertension): initiate at 2 mg, increase progressively to 4 mg after one month, then to 8 mg if necessary depending on renal function. STABLE CORONARY ARTERY DISEASE: 4 mg once daily for two weeks, then increased to 8 mg once daily depending on renal function and provided the 4 mg dose is well tolerated; elderly patients should receive 2 mg once daily for one week, then 4 mg once daily the next week, before increasing up to 8 mg once daily depending on renal function. Increase the dose only if the previous lower dose is well tolerated. HEPATIC IMPAIRMENT: no dosage adjustment is necessary. PAEDIATRIC: efficacy and safety in children and adolescents aged below 18 years have not been established; no recommendation on a posology can be made and use is not recommended - no per-kg dose is stated; refer to a children's formulary. US LABELLING DIFFERS (openFDA, Aurobindo, 2024-03-13): hypertension initial 4 mg once a day, titrated as needed to a MAXIMUM of 16 mg per day, usual maintenance range 4 mg to 8 mg as a single daily dose or in two divided doses; elderly initial 4 mg daily in one or two divided doses with limited experience above 8 mg; stable coronary artery disease 4 mg once daily for 2 weeks then 8 mg once daily maintenance (patients over 70 years: 2 mg in week 1, 4 mg in week 2, then 8 mg). The UK SPC figures are used for the dose field above. NOTE: eMC 4.5 was not captured in this bundle - the interaction list below is drawn from eMC 4.2/4.3/4.4 and from the US label section 7 where marked.

Dose adjustments

Renal

UK SPC Table 1, dose based on creatinine clearance: ClCR >= 60 ml/min - 4 mg per day; 30 < ClCR < 60 ml/min - 2 mg per day; 15 < ClCR < 30 ml/min - 2 mg every other day; haemodialysed patients with ClCR < 15 ml/min - 2 mg on the day of dialysis, taken after dialysis (dialysis clearance of perindoprilat is 70 ml/min). US labelling: not recommended in patients with creatinine clearance < 30 mL/min; for lesser degrees of impairment the initial dosage should be 2 mg/day and the dosage should not exceed 8 mg/day.

Dose auto-extracted from UK Summary of Product Characteristics (SPC) via the eMC; US FDA prescribing information (openFDA / DailyMed) — cross-check; US labelling may differ from UK — not yet clinician-verified. Always confirm against the product SmPC and your local formulary before prescribing.

Contraindications

Hypersensitivity to the active substance, to any of the excipients or to any other ACE inhibitor
History of angioedema associated with previous ACE inhibitor therapy; hereditary or idiopathic angioedema
Concomitant use with sacubitril/valsartan therapy - must not be initiated earlier than 36 hours after the last dose of sacubitril/valsartan
Second and third trimesters of pregnancy
Concomitant use with aliskiren-containing products in patients with diabetes mellitus or renal impairment (GFR < 60 ml/min/1.73 m2)
Extracorporeal treatments leading to contact of blood with negatively charged surfaces
Significant bilateral renal artery stenosis or stenosis of the artery to a single functioning kidney

Side effects

Headache, dizziness, vertigo, paraesthesia (common)
Cough, dyspnoea (common)
Hypotension and effects related to hypotension (common)
Gastrointestinal: nausea, vomiting, abdominal pain, dysgeusia, dyspepsia, diarrhoea, constipation (common)
Rash and pruritus (common); angioedema of face, extremities, lips, mucous membranes, tongue, glottis and/or larynx, and urticaria (uncommon)
Hyperkalaemia (reversible on discontinuation), hyponatraemia, hypoglycaemia (uncommon); vision disturbance and tinnitus (common)

Interactions

Dual blockade of the RAAS (ACE inhibitor with an angiotensin II receptor blocker or aliskiren) - increased risk of hypotension, hyperkalaemia and decreased renal function including acute renal failure; not recommended, and ACE inhibitors and ARBs should not be used concomitantly in diabetic nephropathy (eMC 4.4)
Sacubitril/valsartan and other neprilysin inhibitors - contraindicated; risk of angioedema; do not administer within 36 hours of switching to or from sacubitril/valsartan (eMC 4.3/4.4; US label 4)
Diuretics - excessive drop in blood pressure, especially if recently started; reduce or discontinue the diuretic, or increase salt intake, before initiation, or provide close supervision with the first dose (eMC 4.2/4.4; US label 7.1)
Potassium-sparing diuretics and potassium supplements - hyperkalaemia (US label 7.2)
Lithium - increased serum lithium levels and symptoms of lithium toxicity (US label 7.3)
Injectable gold - nitritoid reactions (facial flushing, nausea, vomiting, hypotension) (US label 7.4). NSAIDs - increased risk of renal impairment and loss of antihypertensive effect (US label 7.7)

Clinical monograph

How it works

Its active metabolite perindoprilat inhibits angiotensin-converting enzyme, reducing formation of angiotensin II and decreasing aldosterone, which lowers vasoconstriction and sodium retention and reduces blood pressure and cardiac afterload.

Prescribing in practice

It is contraindicated in pregnancy and in a history of ACE-inhibitor-associated angioedema, and can cause hyperkalaemia and renal impairment, especially with concomitant potassium-sparing agents, NSAIDs or in bilateral renal artery stenosis.
A dry persistent cough is a common reason for discontinuation, and first-dose hypotension may occur, particularly in volume-depleted or diuretic-treated patients.
Check renal function and electrolytes before starting and after initiation or dose increase; consult the SPC for cautions and interactions.

Monitoring

Monitor blood pressure, serum creatinine and potassium before starting and after initiation and dose changes.

Counselling the patient

Advise reporting any swelling of the face, lips or throat urgently, as this can indicate angioedema.
Explain that a dry cough may occur and to seek advice, and to avoid pregnancy and salt substitutes containing potassium.
Suggest taking the first dose at a time when any dizziness can be managed safely.

Evidence & guidelines

Perindopril-based regimens reduced cardiovascular events in trials such as EUROPA and PROGRESS, and ACE inhibitors are recommended in NICE guidance for hypertension and heart failure.

Reference: NICE NG136/NG106; ESC; Drug verified in RxNorm (NLM); confirm dosing against the manufacturer SPC (eMC). Verify against your local formulary and current prescribing references before prescribing. The structured dose values shown have been reviewed by a clinician. Monograph status: clinician-reviewed (2026-07-04).

Curated clinical cross-links plus same-class fallbacks.

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