CHD: decreased risk of cardiovascular complications in patients previously who underwent myocardial infarction and / or coronary revascularization. With the development of unstable angina during the first month of therapy with Perindopril TAJ should assess the benefits and risks before proceeding with treatment.
Arterial hypotension
ACE inhibitors can cause a sharp decrease in blood pressure.Symptomatic arterial hypotension rarely develops in patients without concomitant diseases. The risk of excessive blood pressure lowering was increased in patients with reduced BCC, which can be observed against diuretic therapy, with strict salt-free diet, hemodialysis, vomiting and diarrhea, as well as in patients with severe hypertension with high blood plasma repin activity (see " Interaction with other drugs "), In most cases, episodes of a marked decrease in blood pressure are observed in patients with severe chronic heart failure, as in the presence of concomitant renal failure, and in its absence. Most often, this side effect is observed in patients with hyponatremia or with renal dysfunction. At the beginning of therapy and with an increase in the dose of Perindopril-TAD, patients should be under careful medical control (see "Dosage and Administration" and "Side effect"), this approach should be used in patients with angina and cerebrovascular diseases, in which the expressed Arterial hypotension can lead to the development of myocardial infarction or cerebrovascular complications,rn a significant decrease in blood pressure, the patient should be transferred to the "lying" position on the eve with his raised legs and immediately make a replacement for the bcc (for example, intravenous infusion of 0.9% sodium chloride solution). Intravenous administration of catecholamines is also possible. The pronounced decrease in blood pressure at the first intake of the drug is not an obstacle for the further use of the drug. After the recovery of C'CK and AD, treatment can be continued by carefully selecting the doses of Perindopril-TAD.
In some patients with chronic heart failure and normal or decreased BP, Periyodilil-TAD can cause an additional reduction in blood pressure. This effect is predictable and usually does not require discontinuation of therapy. If symptoms of a marked decrease in blood pressure appear, reduce the dose or stop taking it.
Mitral stenosis / aortic stenosis / hypertrophic obstructive to cardiomyopathy
Perindopril-TAD, like other ACE inhibitors, should be used with caution in patients with obstruction of the left ventricular outflow tract (aortic stenosis, sertrophic obstructive cardiomyopathy), as well as in patients with mitral stenosis.
Impaired renal function
For patients with renal insufficiency (KC less than 60 ml / min), the initial dose of Perindopril-TAD is selected depending on the value of the CC (see "Method of administration and dose") and then depending on the therapeutic effect.
For such patients, regular monitoring of QC and potassium levels in blood plasma (see "Side effect") is necessary.
Arterial hypotension, which sometimes develops early in the administration of ACE inhibitors in patients with symptomatic chronic heart failure, can lead to impaired function of the nights. It is possible to develop acute renal failure, as a rule, reversible.
In patients with bilateral stenosis of the renal artery or stenosis of the artery of a single kidney (especially in the presence of kidney failure) against the background of therapy with ACE inhibitors, an increase in the concentration of urea and creatinine in the blood plasma, usually taking place when the therapy is withdrawn. The additional presence of reninvascular hypertension causes an increased risk of severe arterial hypotension and kidney failure.
Treatment of such patients begins under careful medical supervision with the use of low doses of the drug and further adequate selection of doses.
It is necessary to temporarily stop diuretic treatment and to conduct regular monitoring of potassium and creatinine content and blood serum during the first few weeks of therapy.
In some patients with arterial hypertension, in the presence of previously unrecognized renal failure, especially with the simultaneous use of diuretics, the concentration of urea and creatinine in serum can increase. These changes are usually not very pronounced and are reversible. In such cases, it may be necessary to cancel or reduce the dose of perindopril-TAD and / or diuretic.
Hemodialysis
In patients on hemodialysis using high-flux membranes, for example, AN69®), Several cases of development of persistent, life-threatening anaphylactic reactions were noted. The use of ACE inhibitors should be avoided when using this type of membrane. Night transplantation DData on the use of Perindopril-TAD after kidney transplantation are not available. Hypersensitivity / angioedema In patients taking AIF inhibitors, in rare cases, especially during the first few weeks of therapy,can develop angioedema, swelling of the face, extremities, lips, tongue, glottis and / or larynx. In rare cases, severe neoeurotic edema may occur with prolonged use of an ACE inhibitor. When these symptoms appear, Perindopril-TAD should be discontinued immediately, and preparations of another pharmacotherapeutic group should be used as a substitute. Angioedema, accompanied by swelling of the larynx, can lead to death. Swelling of the tongue, glottis or larynx can lead to airway obstruction. In its development, emergency therapy includes, in addition to other prescriptions, immediate subcutaneous injection of an epinephrine (adrenaline) 1: 1000 (1 mg / ml) solution of 0.3-0.5 ml or slow intravenous administration (according to the instructions for preparation infusion solution) under the control of ECG and blood pressure. The patient should be hospitalized for treatment and observation of at least: m at 12-24 h and until the symptoms regress completely. Patients with a history of edema with Quincke who were not associated with the use of ACE inhibitors. can be increased risk of its development with the intake of drugs of this group (see "Contraindications"). In rare cases, against the background of therapy with ACE inhibitors, 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 and with normal activity of the C1-esterase. The diagnosis is established using computed tomography of the abdominal region, ultrasound or at the time of surgery. Symptoms disappear after stopping the intake of ACE inhibitors. Patients with abdominal pain receiving ACE inhibitors. when conducting a differential diagnosis, it is necessary to take into account the possibility of developing a gigioietrotic edema of the intestine. Anaphylactic reactions in the apheresis of low-density lipoproteins (LDL) In rare cases, patients receiving ACE inhibitors. when performing the procedure of apheresis of low density lipoproteins with the help of dextran sulfate may develop life-threatening anaphylactic reactions. To prevent gnafilakticheskoy reaction should be temporarily discontinued therapy with an ACE inhibitor before each procedure for the apheresis of LDL withuse of dextran sulfate. Anaphylactic reactions during desensitization There are separate reports on the development of life-threatening anaphylactic reactions in patients receiving ACE inhibitors during desensitizing therapy with bee venom (bees, wasps). ACE inhibitors should be used with caution in patients with a predisposition to allergic reactions undergoing desensitization procedures. The use of ACE inhibitors in patients receiving immunotherapy with bee venom should be avoided. However, this reaction can be avoided by the temporary withdrawal of the ACE inhibitor before the desensitization procedure begins. Impaired liver function Acceptance of ACE inhibitors is sometimes associated with a syndrome that begins with the development of cholestatic jaundice, progressing to fulminant liver necrosis, and (sometimes) fatal. The mechanism of development of this syndrome is unclear. When there are symptoms of jaundice or increased activity of liver enzymes in patients, n(ACE inhibitors), discontinue drug therapy and conduct an appropriate examination (see Adverse Effect). Neutropenia / agranulocytosis / thrombocytopenia / anemia Against the background of therapy with ACE inhibitors, neutropenia / agranulocytosis, thrombocytopenia and anemia can develop. With normal kidney function and no other complications, foetrogenesis occurs rarely. ACE inhibitors are used only in emergency cases, in the presence of systemic vasculitis, immunosuppressive therapy, alliourinol or procainamide administration, and also when all these factors are combined, especially against the background of previous renal failure. There is a risk of developing severe infectious diseases resistant to intensive antibiotic resistance. When carrying out therapy with Perindopril-TAD, patients with the above factors, it is necessary to regularly monitor the content of leukocytes. Patients should inform the physician about the appearance of any signs of infectious diseases (eg, sore throat, lfever). Edifferences It should be borne in mind that in patients of the Negroid race the risk of angioedema development is higher. Like other ACE inhibitors, Perindopril-TAD is less effective at the reduction of blood pressure in patients of the Negroid race. This effect is probably associated with a marked predominance of low-grade status in patients of negroid race with arterial hypertension Cough Against the background of therapy with an ACE inhibitor, a dry, unproductive cough may occur, which stops after the drug is discontinued. |
Surgery / general anesthesia
The use of ACE inhibitors in patients who are undergoing surgery with general anesthesia can lead to a marked decrease in blood pressure, especially with the use of general anesthetic agents that exert a protective effect. The drug Perindopril-TAD should be discontinued one day before surgery. With the development of arterial hypotension, blood pressure should be maintained by replenishing the BCC.
It is necessary to warn an anesthesia doctor that the patient is taking ACE inhibitors.
Hyperkalemia
Hyperkalemia can develop during treatment with ACE inhibitors, especially if the patient has renal and / or cardiac failure, latent diabetes mellitus. It is usually not recommended to use potassium preparations,potassium-sparing diuretics and other drugs associated with a risk of increasing the potassium content (eg, heparin), because of the possibility of a pronounced hyperkaliemiaand. If co-administration of these drugs is necessary, then therapy should be accompanied by regular monitoring of potassium in serum torovi.
Diabetes
In patients taking hypoglycemic agents for ingestion or insulin, during the first month of therapy with ACE inhibitors, the concentration of glucose in the blood plasma should be monitored regularly (see "Interaction with Other Drugs").
Preparations lithium
Joint use of the drug Perindopril-TAD and lithium preparations is not recommended (see the section "Interaction with other drugs")
TOalysberegayuschie diuretiki, potassium preparations, potassium-containing substitutes for edible salt and food additives
It is not recommended joint use with ACE inhibitors (see "Interaction with other drugs").
Double blockade of RALS
Hypotension, syncope, stroke, gynecalismia and renal dysfunction (incl.acute juvenile insufficiency) have been reported in susceptible patients, especially in the combination of drugs that affect this system, and therefore, the double blockade of RAAS by a combination of ACE inhibitors and aliskiren is not recommended.
The use of a combination of ACE inhibitors and aliskiren is contraindicated in patients with diabetes mellitus or renal insufficiency (GFR <60 mL / min / 1.73 m2) (see the section "Contraindications").