Ko Perineva®
Lithium preparations:
It is not recommended simultaneous use of the preparation Ko-Perineva ® with lithium preparations.
Impaired renal function
| Therapy with Ko-Perineva® is contraindicated in patients with severe renal insufficiency (CC less than 30 ml / min). In some patients with hypertension without a previous impairment of kidney function, patients with acute Ko-Perineva® may develop signs of acute renal failure. In this case, treatment with Ko-Perineva should be discontinued. In the future, it is possible to resume combination therapy using low doses of Ko-Perineva®, or use drugs perindopril and indapamide in monotherapy.
Such patients need regular monitoring of potassium and creatinine in the blood serum every 2 weeks after the initiation of therapy and every subsequent 2 months of therapy with Ko-Perineva®.
Acute renal failure often develops in patients with severe CHF or initial renal impairment, including bilateral renal artery stenosis or arterial stenosis of a single functioning kidney.
The drug Ko-Perineva ® is not recommended for patients with bilateral stenosis of the renal arteries or stenosis of the artery of a single functioning kidney.
Reduction of blood pressure and violation of water-electrolyte balance
Hyponatremia is associated with a risk of a sudden drop in blood pressure (especially in patients with bilateral stenosis of the renal arteries or stenosis of the artery of a single functioning kidney). Therefore, when observing patients dynamically, attention should be paid to the possible symptoms of dehydration and decline the content of electrolytes in the blood plasma, for example, after prolonged diarrhea or vomiting. Such patients need regular monitoring of electrolytes in blood plasma. With a marked decrease in blood pressure, you may need to / in the introduction of 0.9% solution of sodium chloride.
Transient arterial hypotension is not a contraindication for further continuation of therapy. After the recovery of bcc and blood pressure, it is possible to resume therapy with Ko-Perineva®, using low doses of the drug, or using drugs perindopril and indapamide in monotherapy.
The content of potassium
The combined use of perindopril and indapamide does not prevent the development of hypokalemia, especially in patients with diabetes mellitus or renal insufficiency. As in the case of combined use of antihypertensive drugs and a diuretic, regular monitoring of the potassium content in the blood plasma is necessary.
Excipients
It should be taken into account that the composition of auxiliary substances of the preparation Ko-Perineva® includes lactose monohydrate, therefore the drug is contraindicated in patients with hereditary galactosemia, lactase deficiency, glucose-galactose malabsorption. (see the section "Contraindications")
Perindopril
Neutropenia / agranulocytosis
In patients taking ACE inhibitors, there may be cases of development of neutropenia / agranulocytosis, thrombocytopenia and anemia. In patients with normal renal function in the absence of other complications, neutropenia develops rarely and passes on its own after the withdrawal of ACE inhibitors.
Perindopril should be used with great care in patients with connective tissue diseases and simultaneously receiving immunosuppressive therapy, allopurinol or procainamide, especially with existing impairments of kidney function. These patients can develop severe infections that are not amenable to intensive antibiotic therapy. In the case of the appointment of perindopril it is recommended to periodically monitor the number of leukocytes in the blood. The patient should be warned that if any signs of an infectious disease (sore throat, fever) appear, you should immediately consult a doctor.
Hypersensitivity / angioedema (angioedema)
When taking ACE inhibitors, including perindopril, in rare cases, development of an angioedema of the face, lips, tongue, tongue of the upper palate, and / or larynx can be observed. When these symptoms occur, the drug should be stopped immediately, the patient should be observed until the signs of edema disappear completely.
If angioedema affects only the face and lips, then its manifestations usually go away alone or antihistamines may be used to treat its symptoms. Angioedema, accompanied by swelling of the tongue or larynx, can lead to airway obstruction and death.
When such symptoms occur, immediately enter subcutaneously epinephrine (adrenaline) (at 1: 1000 dilution (0.3 or 0.5 mL) and / or provide airway patency.
Patients with a history of Quincke edema not associated with the administration of ACE inhibitors may be at increased risk of developing it with the use of drugs of this group.
In rare cases, against the background of therapy with an ACE inhibitor, angioedema develops in the intestine.In this case, patients have abdominal pain as an isolated symptom or in combination with nausea and vomiting, in some cases without a previous angioedema of the Face and at a normal level of C1-esterase. The diagnosis is established by means of computed tomography of the abdominal cavity, ultrasound examination or at the time of surgical intervention. Symptoms disappear after stopping the intake of ACE inhibitors. In patients with abdominal pain receiving ACE inhibitors, the differential diagnosis should take into account the possibility of developing angioedema of the intestine.
Anaphylactoid reactions during desensitization procedures
There are separate reports on the development of long-term, life-threatening anaphylactoid reactions in patients receiving ACE inhibitors during desensitizing therapy with the poison of Hymenoptera insects (bees, wasps). ACE inhibitors should be used with caution in patients prone to allergic reactions undergoing desensitization procedures. The appointment of an ACE inhibitor should be avoided for patients receiving immunotherapy with venom of Hymenoptera.Nevertheless, the development of anaphylactoid reactions can be avoided by the temporary withdrawal of the ACE inhibitor at least 24 hours before the desensitization procedure begins.
Anaphylactoid reactions during apheresis of LDL
In rare cases, patients receiving ACE inhibitors may develop life-threatening anaphylactoid reactions in LDL-apheresis using dextran sulfate. To prevent the anaphylactoid reaction, ACE inhibitor therapy should be discontinued before each procedure for LDL apheresis using high-flow membranes.
Hemodialysis
In patients receiving ACE inhibitors, hemodialysis using high-flow membranes (for example, AN69®), anaphylactoid reactions were noted. Therefore, it is desirable to use a different type of membrane or use an antihypertensive drug of another pharmacotherapeutic group (see the section "With caution").
Potassium-sparing diuretics and potassium preparations
Joint use of perindopril and potassium-sparing diuretics, as well as preparations of potassium and potassium-containing substitutes for edible salt is not recommended.
Cough
Against the background of therapy with an ACE inhibitor, a dry cough may occur, which disappears after the withdrawal of this group. When dry cough occurs, remember the possible association of this symptom with the administration of an ACE inhibitor. If the doctor believes that therapy with an ACE inhibitor is necessary for the patient, the use of Ko-Perineva® can be continued.
Children and teenagers under the age of 18
The drug Ko-Perineva® is contraindicated in children and adolescents under the age of 18 due to lack of data on efficacy and safety of use.
The risk of arterial hypotension and / or renal insufficiency of patients with CHF, violation of water-electrolyte balance, etc.)
With cirrhosis of the liver, accompanied by edema and ascites, arterial hypotension, CHF, there may be a significant activation of the renin-angiotensin-aldosterone system (RAAS), especially with pronounced hypovolemia and a decrease in the electrolytes in the blood plasma (against a background of a salt-free diet or long-term diuretics).
The use of an ACE inhibitor causes blockade of the RAAS, in connection with this, a sharp decrease in blood pressure and / or an increase in the concentration of creatinine at blood plasma testifying to the development of acute renal failure, which is more often observed with the first dose of Ko-Perineva® or during the first two weeks of therapy.
Elderly patients
Before you start taking Co-Perineva®, you should evaluate the kidney function and the potassium content in the blood plasma. The initial dose of Ko-Perineva ® is selected depending on the degree of BP reduction, especially with a decrease in BCC and CHF (IV functional class by classification NYHA). Such measures allow to avoid a sharp decrease in blood pressure.
Atherosclerosis
The risk of arterial hypotension exists in all patients, but special care should be taken when using the drug Ko-Perineva ® in patients with coronary heart disease and cerebral circulatory insufficiency. In such patients, treatment should begin with a dose of 0.625 mg / 2 mg of the drug Ko-Perineva (initial dose).
Patients with Renovascular Hypertension
Treatment with Ko-Perineva for patients with diagnosed or suspected renal artery stenosis should be started in a hospital with a dose of Co-Perineva® 0.625 mg / 2 mg, monitoring the kidney function and the potassium content in the blood plasma.Some patients may develop acute renal failure, which is reversible after discontinuation of the drug.
Other risk groups
In patients with CHF (IV functional class by classification NYHA) and patients with type 1 diabetes (the risk of spontaneous increase in potassium content) treatment should start with an initial dose of 0.625 mg / 2 mg of the drug Ko-Perineva ® and under medical supervision.
Patients with diabetes mellitus
When prescribing Co-Perineva® for patients with diabetes mellitus receiving hypoglycemic agents for ingestion or insulin, during the first month of therapy it is necessary to regularly monitor the concentration of glucose in the blood.
Ethnic Features
Perindopril (like other ACE inhibitors) has a less pronounced hypotensive effect in patients of the Negroid race compared with representatives of other races.
Surgical procedures / General anesthesia
The use of ACE inhibitors in patients undergoing surgery with general anesthesia may result in a marked decrease in blood pressure, especially with the use of general anesthetic agents that have an antihypertensive effect.
It is recommended to stop the use of ACE inhibitors, including perindopril, 12 hours before surgery, warning the anesthesia doctor about the use of ACE inhibitors.
Aortic stenosis / mitral stenosis / Hypertrophic obstructive cardiomyopathy
ACE inhibitors should be used with caution in patients with obstruction of the left ventricular outflow tract and in aortic and / or mitral stenosis.
Liver failure
In rare cases, with the administration of ACE inhibitors, cholestatic jaundice occurs, with three progressions of fulminant hepatic necrosis, sometimes fatal. When jaundice or a significant increase in the activity of "hepatic" transaminases, when taking ACE inhibitors, the preparation of Ko-Perineva® should be discontinued.
Anemia
Anemia can develop in patients after kidney transplantation or in patients on hemodialysis.
Hyperkalemia
It can develop during treatment with ACE inhibitors, including perindopril. Risk factors for hyperkalemia are renal failure, advanced age, diabetes mellitus, some concomitant conditions (decreased BCC,acute heart failure in the stage of decompensation, metabolic acidosis), simultaneous reception of potassium-sparing diuretics (such as spironolactone, eplerenone, triamterene, amiloride), as well as preparations of potassium or potassium-containing substitutes for edible salt and the use of other drugs that increase the level of potassium in the blood plasma (for example, heparin). Hyperkalemia can lead to serious heart rhythm disturbances, sometimes with a fatal outcome. Combined use of the above drugs should be done with caution.
Indapamide
Photosensitivity
There are reports of cases of increased photosensitivity against thiazide and thiazide-like diuretics. When the photosensitivity reaction develops against the background of the Ko-Perineva® preparation, treatment should be stopped. If there is a need to renew the use of Ko-Perineva, protect open skin from direct exposure to sunlight and artificial ultraviolet rays.
Water-electrolyte balance
Sodium content in plasma blood
Before starting treatment with Ko-Perineva, you need to determine the sodium content in the blood plasma and on the background of taking the drug to conduct regular monitoring of electrolytes in blood plasma. All diuretics are capable of causing hyponatremia, leading to serious complications.
The content of potassium in blood plasma
Therapy with thiazide and thiazide-like diuretics is associated with a risk of hypokalemia (less than 3.4 mmol / L) in the following patients: the elderly, depleted patients, patients with cirrhosis, patients with peripheral edema, ascites, ischemic heart disease, CHF. Hypokalemia in these patients increases the toxic effect of cardiac glycosides and increases the risk of arrhythmia.
The high-risk group includes patients with an increased interval QT on the ECG.
Hypokalemia, like bradycardia, contributes to the development of severe cardiac rhythm disturbances, especially arrhythmias such as "pirouettes," which can be lethal. In all cases described, regular monitoring of the potassium content in the blood plasma is necessary. The first determination of the potassium content in the blood plasma should be carried out within the first week after the beginning of therapy with Ko-Perineva®.
Calcium in the blood plasma
Thiazide and thiazide-like diuretics reduce the excretion of calcium by the kidneys, leading to a slight and temporary increase in the calcium content in the blood plasma. Expressed hypercalcemia may be a consequence of latent hyperparathyroidism. Before examining the function of the parathyroid glands, you should cancel the use of Ko-Perineva®.
The concentration of glucose in the blood plasma
It is necessary to monitor the concentration of glucose in patients with diabetes mellitus.
Uric acid
In patients with a high concentration of uric acid in the blood plasma against the background of therapy with Ko-Perineva, the frequency of exacerbation of the gout current may increase.
Diuretics and renal function
Hypovolemia due to a decrease in bcc or hyponatremia caused by taking diuretics at the beginning of treatment with Ko-Perineva® can lead to a decrease in I glomerular filtration rate and is accompanied by an increase in concentration; creatinine and urea in blood plasma.
Athletes
Indapamide can give a false positive reaction during doping control.