Arterial hypotension:
ACE inhibitors can cause a sharp drop in blood pressure. Symptomatic arterial hypotension rarely develops in patients without concomitant diseases. The risk of a marked decrease in blood pressure is increased in patients with a reduced volume of circulating blood, for example, against a background of diuretic therapy, with strict salt-free diet, hemodialysis, diarrhea, or vomiting. Episodes of marked decrease in blood pressure are observed in patients with severe heart failure, both in the presence of concomitant renal failure and in its absence. Most often, this side effect was observed in patients receiving high doses of loop diuretics, as well as against hyponatremia or with renal dysfunction. In such patients, therapy should begin under careful medical supervision, preferably in a hospital setting. In this case, the drug is used in small doses, followed by a thorough titration of the dose. Similar rules should be followed when using the drug in patients with coronary heart disease, cerebrovascular insufficiency, in which a sharp decrease in blood pressure can lead to myocardial infarction or stroke.
Transient arterial hypotension is not a contraindication for taking the next dose of the drug.
Before applying Perindopril-Richter, as well as other ACE inhibitors, and at the time of its administration, the blood pressure level of kidney function and the content of potassium ions in blood serum should be closely monitored.
To reduce the likelihood of symptomatic arterial hypotension in patients receiving high-dose diuretics, the dose of diuretics should be reduced, if possible, a few days before the application of Perindopril-Richter.
In the case of development of arterial hypotension the patient should be transferred to a supine position on the back. If necessary, normalize the sodium content and / or replenish the volume of the liquid by administering an intravenously isotonic solution of sodium chloride. Arterial hypotension with the first intake of the drug is not a contraindication for the further use of the drug Perindopril-Richter.
In some patients with congestive heart failure who have normal or low blood pressure, the use of perindopril may cause an additional reduction in blood pressure. This effect usually does not require the cessation of treatment.If arterial hypotension is accompanied by clinical manifestations, a dose reduction or drug cancellation may be required.
Stable ischemic seudia:
In patients with stable coronary heart disease in the event of an episode of unstable angina (significant or not), during the first month of therapy with Perindopril-Richter, the ratio of expected benefit to the possible risk of continuing therapy should be assessed.
Patients with Renovascular Hypertension:
The use of ACE inhibitors in patients with renal arterial hypertension, as well as with stenosis of the renal artery, especially bilateral and with a single kidney, and also with hyponatremia is accompanied by an increased risk of severe arterial hypotension and kidney failure. Against the background of taking diuretic drugs, the risk of these complications increases. Impaired renal function may be manifested only by minor changes in serum creatinine. Treatment of such patients begins in a hospital under careful medical supervision with the use of small doses of the drug and further selection of a dose.During the first few weeks of therapy, it is necessary to temporarily stop treatment with diuretics and monitor kidney function.
Mitral stenosis / aortic stenosis / hypertrophic obstructive cardiomyopathy:
Perindopril-Richter, like other ACE inhibitors, should be used with caution in patients with obstruction of the left ventricular outflow tract (aortic stenosis, hypertrophic obstructive cardiomyopathy), as well as in patients with mitral stenosis.
Renal insufficiency:
Use ACE inhibitors in patients with renal insufficiency with caution, since the drug inhibits the activity of the renin-angiotensin-aldosterone system. In the case of renal insufficiency (creatinine clearance <60 ml / min), the initial dose of perindopril should be matched to the creatinine clearance (see section "Dosage and Administration"). In these cases, it is often necessary to reduce the dose or frequency of taking the drug. The kidney function should be monitored throughout the treatment. There are reports of the development of renal failure against the background of the use of ACE inhibitors,However, this is in most cases typical for patients with severe heart failure or kidney disease, including renal artery stenosis.
In some patients, concomitant use of diuretics may increase serum urea and creatinine levels. In these cases, a reduction in the dose of an ACE inhibitor and / or discontinuation of diuretics may be required. During the first few weeks of therapy with an ACE inhibitor, dynamic monitoring of renal function is recommended.
Patients on hemodialysis:
In patients on hemodialysis using high-flow membranes or receiving apheresis procedures for low-density lipoproteins with dextran sulfate, the use of an ACE inhibitor has been associated with the development of anaphylactic reactions that threaten life. In such cases it is necessary to consider
the possibility of using another type of membrane for dialysis or another antihypertensive agent.
Hypersensitivity / Angioedema:
Angioedema, swelling of the face, extremities, lips, tongue, epiglottis and / or larynx was rare in patients,treated patients with ACE inhibitors, especially during the first few weeks of therapy that may occur during any treatment period. In this case, treatment with Perindopril-Richter should be stopped as soon as possible, and the patient should be monitored until the symptoms regress completely. As a substitute, one should consider the possibility of using drugs of another pharmacological class. In cases where there was only edema of the face and lips, the condition usually passes without treatment, but antihistamines may be used.
Angioedema with edema of the larynx can lead to death. When swelling of the tongue, epiglottis or larynx, airway obstruction can occur, therefore, appropriate therapy should be performed immediately (0.3-0.5 ml of epinephrine (adrenaline) solution 1: 1000 subcutaneously, administration of glucocorticosteroids, antihistamines) and / or measures to ensure patency of the respiratory tract. The patient must be hospitalized.
Patients with a history of angioneurotic edema not associated with previous treatment with ACE inhibitors may be at increased risk of developing it during treatment with an ACE inhibitor.
In some cases, when desensitizing the venom of Hymenoptera (hymenoptera), treatment with ACE inhibitors was accompanied by an anaphylactic reaction. This can be avoided by interrupting the use of an ACE inhibitor.
Cough:
With the use of an ACE inhibitor, cough may occur. Cough is dry, prolonged, which disappears after discontinuing treatment with an ACE inhibitor. With a differential diagnosis of cough, one should also consider a cough caused by the use of an ACE inhibitor.
Chiturgy / General anesthesia:
When using drugs that reduce blood pressure in patients with extensive surgery or during general anesthesia perindopril can block the formation of angiotensin II. The pronounced decrease in blood pressure, caused by a sharp increase in antihypertensive action, which is considered a consequence of this mechanism, can be eliminated by increasing the volume of circulating blood.
Before surgery (including dentistry), it is necessary to alert the surgeon / anesthesiologist about the use of ACE inhibitors.
Use of recommended doses of the drug by patients old age may be accompanied by an increase in the concentration of perindopril in the blood, so the selection of a dose requires special attention and is carried out depending on the function of the kidneys and the patient's blood pressure. However, in elderly and young patients, the antihypertensive effect of perindopril is equally pronounced.
Hypeokaliemia:
An increase in potassium in the serum was observed in some patients receiving ACE inhibitors, including perindopril, especially if the patient has renal and / or chronic heart failure. It is usually not recommended to use potassium preparations and potassium-sparing diuretics or other medications that affect the increase in serum potassium (for example, heparin). If taking the above drugs in combination is necessary, they should be used against a background of regular monitoring of potassium in the blood serum.
Liver failure:
In rare cases, the use of ACE inhibitors has been associated with the onset of a syndrome that begins with cholestatic jaundice and rapidly progressing necrotic hepatitis, and sometimes fatal. The mechanism of this syndrome is unknown.In patients receiving ACE inhibitors, who have jaundice or a significant increase in liver transaminase activity, it is necessary to cancel the taking of these drugs and carry out medical supervision. Neutropenia / Agranuloietosis / Thrombotopenia / Anemia:
The risk of developing neutropenia against the background of the administration of ACE inhibitors is dose-dependent, depends on the drug taken and the presence of concomitant diseases. This reaction is very rare in patients without concomitant diseases, but the risk increases in patients with impaired renal function, especially against the background of systemic connective tissue diseases (systemic lupus erythematosus, scleroderma) and treatment with immunosuppressants. The disorders are reversible and pass after the withdrawal of the ACE inhibitor. Anemia can develop in patients after kidney transplantation or in people on hemodialysis.
A slight decrease in hemoglobin occurs during the first 6 months, then the hemoglobin content remains stable and completely restored after the drug is discontinued.In such patients, treatment can be continued, but haematological analyzes should be carried out regularly.
In patients with congenital deficiency of glucose-6-phosphate dehydrogenase, single cases of hemolytic anemia are described.
During the period of treatment, it is not recommended to drink alcoholic beverages, since alcohol increases the antihypertensive effect of the drug.
Care should be taken when doing physical exercises, hot weather (the risk of dehydration and excessive blood pressure lowering due to a decrease in the volume of circulating blood).
Because the potential risk of agranulocytosis can not be ruled out, periodic monitoring of the blood picture is required.
Paiyents of the Negroid race:
In patients of the Negroid race, the risk of developing angioedema is higher. Like other ACE inhibitors, perindopril less effective as an antihypertensive agent in patients of the Negroid race. This effect, perhaps, is associated with a marked predominance of low-grade status in patients of the Negroid race with arterial hypertension.
Lactose:
The drug Perindopril-Richter contains lactose monohydrate.Patients with rare hereditary lactose intolerance, lactase deficiency, or impaired glucose / galactose absorption should not take this drug.