Common for perindopril and indapamide
Lithium:
It is not recommended to appoint perindopril and indapamide in combination with lithium preparations. Associated with perindopril
The risk of developing neutropenia / agranulocytosis in patients with immunodeficiency
The risk of developing neutropenia directly depends on the dose and on the drug taken, as well as the clinical state of the patient. In patients without concomitant diseases, neutropenia occurs rarely, the risk of its development increases in patients with renal insufficiency, systemic connective tissue diseases, for example, in systemic lupus erythematosus, scleroderma, and treatment with immunosuppressants. This condition is reversible after the withdrawal of ACE inhibitors (including perindopril). Strict adherence to prescriptions on the dosage regimen of the drug is the best way to avoid the development of the described complication.
Thus, appointing such patients an ACE inhibitor (including perindopril), the ratio of risk to expected benefits should be carefully assessed.
Angioedema (edema of Quincke)
Angioedema, extremities, lips, tongue, larynx and / or vocal cords in patients taking ACE inhibitors (including perindopril), is rare, In such cases, treatment with perindopril should be stopped immediately, the patient should be monitored until the symptoms of edema disappear completely. Angioedema, which is located in the face and lips, usually does not require special treatment. You can use antihistamines to relieve symptoms.
In combination with the laryngeal edema angioedema is a threat to life. When swelling of the tongue, vocal cords or larynx, airway obstruction may develop. If such symptoms appear, immediately inject epinephrine (adrenaline) solution in a 1: 1000 dilution (from 0.3 ml to 0.5 ml) in combination with other appropriate measures. In the future, the appointment of such patients with ACE inhibitors should be avoided.
In patients with a history of Quinck's edema not associated with the administration of ACE inhibitors, the development of angioedema in the administration of ACE inhibitors (including perindopril) is much more likely.
Anaphylactoid reactions with insect bites
In some cases, desensitization against Hymenoptera allergens treatment (ACE inhibitors was accompanied by hypersensitivity reactions, which can be avoided if the ACE inhibitors are temporarily interrupted.
Hemodialysis
Hemodialysis, which uses high-permeability membranes (polyacrylonitrile), can lead to the development of anaphylactic reactions in patients taking ACE inhibitors (swelling of the tongue and lips, accompanied by dyspnea and lowering blood pressure). A combination of hemodialysis using high-flux (polyacrylonitrile) membranes and treatment with ACE inhibitors should be avoided (including perindopril).
Potassium-sparing diuretics, potassium salts
It is not recommended simultaneous use of perindopril and potassium-sparing diuretics with potassium salts.
Indapamide-related
If the liver function is disturbed, the administration of thiazide diuretics can cause hepatic encephalopathy. If this complication occurs, diuretics should be discontinued immediately.
Sulphoprid
It is not recommended to combine the use of indapamide and sultopride.
Common for perindopril and indapamide
Renal insufficiency
In severe renal failure (creatinine clearance <30 ml / min), the use of Perindopril-Indapamid Richter is contraindicated.
With the development of clinical manifestations of renal dysfunction or the identification of the patient's evidence of renal insufficiency of laboratory data, treatment should be discontinued. Subsequently, therapy can be continued either at a lower dose or as one of the components of the drug with regular monitoring of creatinine concentration and potassium content - 2 weeks after the start of treatment and then every two months. About cases of renal insufficiency is reported mainly in patients with CHF or the Main disease leading to renal failure, including renal artery stenosis.
With bilateral renal artery stenosis or stenosis of the artery of a single functioning kidney, treatment with Perindopril-Indapamide Richter is not recommended.
Arterial hypotension and disturbance of water-electrolyte balance
With a reduced sodium content (especially in patients with renal artery stenosis), sudden development of arterial hypotension is possible. The risk of excessive reduction in blood pressure is increased in patients with a reduced volume of circulating blood, which is observed when observing a strict salt-free diet, with hemodialysis, as well as with vomiting and diarrhea. It is necessary to systematically control the appearance of symptoms of a decrease in bcc and disturbance of the water-electrolyte balance, and regularly determine the content of electrolytes in the blood serum.
Transient arterial hypotension with the first administration of Perindopril-Indapamid Richter is not a contraindication for the continuation of therapy.
After the recovery of bcc and blood pressure, one can resume therapy with low doses of a combination of perindopril and indapamide, or use drugs in monotherapy.
The content of potassium ions
With the simultaneous administration of the drug Perindopril-Indapamid Richter, hypokalemia may develop, especially in patients with diabetes mellitus and renal insufficiency.As with any combined antihypertensive drug containing a diuretic, you should regularly monitor the potassium content in the blood plasma.
Lactose Monohydrate
It should be noted that Perindopril-Indapamide Richter contains lactose monohydrate. As a result, Perindopril-Indapamide Richter should not be taken to patients with lactase deficiency, lactose intolerance, glucose / galactose malabsorption syndrome.
Perindopril
Cough
Against the background of therapy with an ACE inhibitor, dry cough may occur. Cough persists for a long time against the background of taking this group's drugs and disappears after their withdrawal. When a patient has a dry cough, remember the possible connection of this symptom with the use of an ACE inhibitor. If the doctor believes that therapy with an ACE inhibitor is necessary for the patient, taking the drug can be continued (this is important in the differential diagnosis of cough).
Perindopril (like other ACE inhibitors) has a less pronounced hypotensive effect in patients of the Negroid race compared with representatives of other races.
Children and teenagers under 18 years of age
Data on the efficacy and safety of perindopril and indapamide in this age group, both alone and in combination with other active substances, have not been studied.
The risk of developing arterial hypotension and / or renal failure (in cases of chronic heart failure, disturbance of water-electrolyte balance, etc.):
In patients with an initial decrease in blood pressure and the presence of renal artery stenosis, congestive heart failure, or cirrhosis accompanied by edema and ascites, activation of the renin-angiotensin-aldosterone system is observed. This activation is especially pronounced in hypovolemia and water-electrolyte disorders (with strict salt-free diet or prolonged treatment with diuretics).
As a result, there may be a marked decrease in blood pressure and / or a rise in plasma creatinine, which is evidence of renal failure. In rare cases, the disease can be acute and prolonged. Treatment should begin with lower doses and increase them gradually.
Elderly patients
Treatment should begin after a preliminary study of the potassium content and kidney function. The initial dose is selected taking into account the degree of BP reduction, taking into account the possible decrease in the volume of circulating blood and disturbance of the water-electrolyte balance.These measures will avoid a sharp decline in blood pressure.
Atherosclerosis
The risk of developing arterial hypotension exists in all patients, but patients with ischemic heart disease or cerebral circulatory insufficiency need special attention. In this case, treatment should begin with a lower dose.
Renovascular hypertension
The method of treating reninvascular hypertension is revascularization. Nevertheless, the use of ACE inhibitors has a beneficial effect in patients, both anticipating surgical intervention, and in the case when surgical intervention is impossible. Treatment should begin with low doses of the drug in a hospital with regular monitoring of kidney function and potassium content, because some patients may develop acute renal failure. This condition was reversible upon cancellation of treatment.
Other risk groups
Patients with severe heart failure (IV functional class by classification NYHA) or patients with type 1 diabetes mellitus (the risk of spontaneous increase in potassium content) treatment should start with a low dose of the drug and under constant medical supervision.Patients with hypertension and CHF should not stop taking beta-blockers: ACE inhibitors should be used in combination with beta-blockers.
Anemia
Anemia can develop in patients after kidney transplantation or in patients on dialysis.
The decrease in hemoglobin is greater, the higher its initial value was. This effect is not dose-dependent, but may be related to the mechanism of action of ACE inhibitors.
A slight decrease in hemoglobin occurs within 1-6 months, after which it remains stable and completely restored after drug withdrawal. Treatment can be continued under the condition of regular monitoring of hemoglobin of the blood.
Surgery / general anesthesia
ACE inhibitors can cause a marked decrease in blood pressure during general anesthesia, especially in cases where the injected anesthetic has a potentially hypotensive effect. It is recommended to stop the use of long-acting ACE inhibitors, including perindopril, 12 hours before surgery.
Aortic stenosis / hypertrophic obstructive cardiomyopathy
FROM caution should be prescribed ACE inhibitors in patients with obstruction of the left ventricular outflow tract.
Liver failure
In rare cases, the administration of ACE inhibitors is associated with a syndrome that begins with cholestatic jaundice, is transformed into fulminant necrotic hepatitis and (sometimes) leads to death. The mechanism of this state is not revealed. Patients taking ACE inhibitors who have jaundice or a significant increase in the activity of "liver" enzymes should stop taking ACE inhibitors and undergo the appropriate medical examination.
Hyperkalemia
In some patients who took ACE inhibitors, including perindopril, there was an increase in potassium in the blood serum. In patients with renal insufficiency, diabetes mellitus, and also those who receive concomitant treatment with potassium-sparing diuretics, potassium-containing additives or potassium-containing salt substitutes, there is a risk of developing hyperkalemia. Patients taking other medicines that increase the potassium content (for example, heparin) are also at risk.Simultaneous use of the above drugs is allowed in case of emergency with regular monitoring of potassium content in the blood serum. The drug is not recommended for use in cases of elevated potassium levels in the blood.
Indapamide
Hyponatremia
Before and during the treatment it is necessary to monitor the sodium content in the blood plasma, in the future such studies should be carried out regularly. Admission of any diuretic drugs can lead to a decrease in the sodium content in the blood plasma, in some cases asymptomatic, which, in turn, contributes to the development of a number of serious complications. The most common hyponatremia occurs in patients at risk, for example, elderly patients or patients with cirrhosis.
The content of potassium
In the treatment of thiazide and thiazide-like diuretics, the possibility of developing hypokalemia should be considered. Do not lower the potassium level below 3.4 mmol / l in elderly and / or weakened people, regardless of the use of several drugs, patients with cirrhosis accompanied by edema and ascites, patients with coronary heart disease or heart failure.This category of patients belongs to the group of high risk.
Reducing the potassium content increases the risk of heart rhythm disturbances. The high-risk group includes patients with an extended interval QT on the ECG. Hypokalemia, like bradycardia, contributes to the development of severe cardiac arrhythmias, up to a pirouette-type arrhythmia, which can lead to a fatal outcome.
In any case, regular monitoring of the potassium content in the blood plasma is necessary: the first study is conducted one week after the start of treatment. If there is a decrease in the potassium content in the blood plasma, a correction of the dose of the drug is required.
Calcium content
The use of thiazide and thiazide-like diuretics can reduce the excretion of calcium by the kidneys, which leads to a temporary and moderately elevated calcium content in the blood plasma. In the case of undiagnosed hyperparathyroidism, an increase in the calcium content in the blood plasma can be significant. In this case, treatment should be discontinued until the end of the parathyroid gland function.
Concentrationcentnersblood glucose
Control of this indicator is important for patients with diabetes mellitus, especially against hypokalemia.
Uric acid
In patients with a high concentration of uric acid in the blood plasma, the likelihood of an attack of gout or exacerbation of its latent form increases.
The effectiveness of thiazide and thiazide-like diuretics is fully manifested only under the condition of normal kidney function. They are also effective at a creatinine level below 25 mg / l, i.e. 220 mmol / l in adults.
When calculating the clearance of creatinine (CC) in blood plasma in the elderly for Cockcroft formula takes into account the age, weight and sex of the patient:
CK = (140 - age) x body weight / 0.814 x creatinine concentration in blood plasma, where: age is expressed in years, body weight is in kilograms, creatinine concentration in plasma is in mmol / l.
This formula is suitable for elderly male patients. When calculating the indicator for women, a correction factor of 0.85 is used.
At the beginning of treatment due to hypovolemia, due to loss of water and sodium, there is a decrease in the glomerular filtration rate. As a result, the concentration of urea and creatinine in the serum can increase.
Such temporary functional renal failure does not affect renal function in patients with normalfunction of the kidneys, but, nevertheless, can enhance the existing impairment of kidney function.
Indapamide can give a positive reaction during doping control.