perindopril

(per-in-do-pril) perindopril,

Aceon

(trade name),

Coversyl

(trade name)

Classification

Therapeutic: antihypertensives
Pharmacologic: ace inhibitors
Pregnancy Category: D

Indications

Alone or with other agents in the management of hypertension.Reduction of risk of death from cardiovascular causes or non-fatal myocardial infarction in patients with stable coronary artery disease.

Action

Angiotensin-converting enzyme (ACE) inhibitors block the conversion of angiotensin I to the vasoconstrictor angiotensin II. ACE inhibitors also prevent the degradation of bradykinin and other vasodilatory prostaglandins. ACE inhibitors also increase plasma renin levels and reduce aldosterone levels. Net result is systemic vasodilation.

Therapeutic effects

Lowering of BP in patients with hypertension.Decreased risk of death from cardiovascular causes or myocardial infarction in patients with stable coronary artery disease.

Pharmacokinetics

Absorption: 25% bioavailability as perindoprilat following oral administration.Distribution: Crosses the placenta; may enter breast milk.Metabolism and Excretion: Converted by the liver to perindoprilat, the active metabolite; primarily excreted in urine.Half-life: Perindoprilat: 3–10 hr (↑ in renal impairment).

Time/action profile (plasma concentrations)

ROUTE	ONSET	PEAK	DURATION
PO	within 1–2 hr	3–7 hr	up to 24 hr

Contraindications/Precautions

Contraindicated in: Hypersensitivity; History of angioedema with previous use of ACE inhibitors; History of hereditary or idiopathic angioedema; Concurrent use with aliskiren in patients with diabetes or moderate-to-severe renal impairment (CCr <60 mL/min) Obstetric: Can cause injury or death of fetus – if pregnancy occurs, discontinue immediately. Lactation: Discontinue drug or use formula.Use Cautiously in: Renal impairment, hypovolemia, hyponatremia, concurrent diuretic therapy (initial dosage ↓ recommended); genetic implication Black patients (monotherapy for hypertension less effective, may require additional therapy; higher risk of angioedema); Surgery/anesthesia (hypotension may be exaggerated); Women of childbearing potential; Pediatric: Safety not established Geriatric: Initial dosage ↓ recommended.Exercise Extreme Caution in: Family history of angioedema.

Adverse Reactions/Side Effects

Central nervous system

dizziness
headache
weakness

Respiratory

cough (most frequent)

Cardiovascular

hypotension (most frequent)

Gastrointestinal

diarrhea
dyspepsia

Genitourinary

impaired renal function

Dermatologic

rashes

Fluid and Electrolyte

hyperkalemia

Musculoskeletal

back pain

Miscellaneous

angioedema (life-threatening)

Interactions

Drug-Drug interaction

Excessive hypotension may occur with concurrent use of diuretics.Additive hypotension with other antihypertensives.↑ risk of hyperkalemia with concurrent use of potassium supplements,potassium-containing salt substitutes, and potassium-sparing diuretics.↑ risk of hyperkalemia, renal dysfunction, hypotension, and syncope with concurrent use of angiotensin II receptor antagonists or aliskiren ; avoid concurrent use with aliskiren in patients with diabetes or CCr <60 mL/minNSAIDs and selective COX-2 inhibitors may blunt the antihypertensive effect and ↑ the risk of renal dysfunction.May ↑ levels risk of toxicity of lithium.

Route/Dosage

Hypertension

Oral (Adults) 4 mg once daily, may be slowly ↑ up to 16 mg/day in 1–2 divided doses (should not exceed 8 mg/day in elderly patients) (initiate therapy at 2–4 mg/day (in 1–2 divided doses) in patients receiving diuretics).

Stable Coronary Artery Disease

Oral (Adults) 4 mg once daily for 2 wks, may be ↑, if tolerated, to 8 mg once daily. Elderly patients—2 mg once daily for 1 wk, may be ↑, if tolerated, to 4 mg once daily for 1 wk; then, ↑ as tolerated to 8 mg once daily.

Renal Impairment

Oral (Adults) CCr 30–60 ml/min—Initiate therapy at 2 mg once daily, may be slowly titrated up to 8 mg/day in 1–2 divided doses; CCr <30 ml/min—Not recommended.

Availability (generic available)

Tablets: 2 mg, 4 mg, 8 mg

Nursing implications

Nursing assessment

Monitor BP and pulse frequently during initial dose adjustment and periodically during therapy. Notify health care professional of significant changes.
Monitor frequency of prescription refills to determine compliance.
Assess patient for signs of angioedema (dyspnea, facial swelling).
Lab Test Considerations: Monitor renal function. May cause ↑ BUN and serum creatinine.
- Monitor serum potassium periodically during therapy. May cause hyperkalemia.
- Monitor CBC periodically during therapy in patients with collagen vascular disease and/or renal disease. May rarely cause ↓ hemoglobin and hematocrit as well as neutropenia and eosinophilia.
- May cause ↑ AST, ALT, alkaline phosphatase, uric acid, and glucose.

Potential Nursing Diagnoses

Decreased cardiac output (Indications, Side Effects)
Deficient knowledge, related to medication regimen (Patient/Family Teaching)
Noncompliance (Patient/Family Teaching)

Implementation

Correct volume depletion, if possible, before initiation of therapy.

Patient/Family Teaching

Emphasize the importance of continuing to take medication as directed at the same time each day, even if feeling well. Take missed doses as soon as remembered but not if almost time for next dose. Do not double doses. Warn patient not to discontinue ACE inhibitor therapy unless directed by health care professional.
- Caution patient to avoid salt substitutes containing potassium or foods containing high levels of potassium or sodium unless directed by health care professional (see ).
- Caution patient to change positions slowly to minimize orthostatic hypotension. Use of alcohol, standing for long periods, exercising, and hot weather may increase orthostatic hypotension.
- Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult health care professional before taking any Rx, OTC, or herbal products, especially cough, cold, or allergy remedies.
- May cause dizziness. Caution patient to avoid driving and other activities requiring alertness until response to medication is known.
- Advise patient to inform health care professional of medication regimen prior to treatment or surgery.
- Instruct patient to notify health care professional if rash; mouth sores; sore throat; fever; swelling of hands or feet; irregular heartbeat; chest pain; dry cough; hoarseness; swelling of face, eyes, lips, or tongue; or if difficulty swallowing or breathing occurs. Persistent dry cough may occur and may not subside until medication is discontinued. Consult health care professional if cough becomes bothersome. Also notify health care professional if nausea, vomiting, or diarrhea occurs and continues.
- Advise women of childbearing age to use contraception and notify health care professional of pregnancy is planned or suspected, or if breastfeeding.
- Emphasize the importance of follow-up examinations to evaluate effectiveness of medication.
Hypertension: Encourage patient to comply with additional interventions for hypertension (weight reduction, low-sodium diet, discontinuation of smoking, moderation of alcohol consumption, regular exercise, and stress management). Medication controls but does not cure hypertension.
- Instruct patient and family on correct technique for monitoring BP. Advise them to check BP at least weekly and to report significant changes to health care professional.

Evaluation/Desired Outcomes

Decrease in BP without appearance of excessive side effects.
Reduction in risk of death from cardiovascular causes and myocardial infarction in patients with stable coronary artery disease.

perindopril

An ANGIOTENSIN CONVERTING ENZYME INHIBITOR drug used to treat HEART FAILURE and high blood pressure (HYPERTENSION). A brand name is Coversyl.