y cannot be altered, provide close medical supervision with the first dose of perindopril erbumine, for at least two hours and until blood pressure has stabilized for another hour [see warnings and precautions (5.2) ] . the rate and extent of perindopril absorption and elimination are not affected by concomitant diuretics. the bioavailability of perindoprilat was reduced by diuretics, however, and this was associated with a decrease in plasma ace inhibition. 7.2 potassium supplements and potassium-sparing diuretics perindopril erbumine may increase serum potassium because of its potential to decrease aldosterone production. use of potassium-sparing diuretics (spironolactone, amiloride, triamterene and others), potassium supplements or other drugs capable of increasing serum potassium (indomethacin, heparin, cyclosporine and others) can increase the risk of hyperkalemia. therefore, if concomitant use of such agents is indicated, monitor the patient’s serum potassium frequently. 7.3 lithium increased serum lithium and symptoms of lithium toxicity have been reported in patients receiving concomitant lithium and ace inhibitor therapy. frequent monitoring of serum lithium concentration is recommended. use of a diuretic may further increase the risk of lithium toxicity. 7.4 gold nitritoid reactions (symptoms include facial flushing, nausea, vomiting and hypotension) have been reported rarely in patients on therapy with injectable gold (sodium aurothiomalate) and concomitant ace inhibitor therapy including perindopril erbumine. 7.5 digoxin a controlled pharmacokinetic study has shown no effect on plasma digoxin concentrations when coadministered with perindopril erbumine, but an effect of digoxin on the plasma concentration of perindopril/perindoprilat has not been excluded. 7.6 gentamicin animal data have suggested the possibility of interaction between perindopril and gentamicin. however, this has not been investigated in human studies. 7.7 non-steroidal anti-inflammatory agents including selective cyclooxygenase-2 inhibitors (cox-2 inhibitors) in patients who are elderly, volume-depleted (including those on diuretic therapy), or with compromised renal function, co-administration of nsaids, including selective cox-2 inhibitors, with ace inhibitors, including perindopril, may result in deterioration of renal function, including possible acute renal failure. these effects are usually reversible. monitor renal function periodically in patients receiving perindopril and nsaid therapy. the antihypertensive effect of ace inhibitors, including perindopril, may be attenuated by nsaids including selective cox-2 inhibitors. 7.8 dual blockade of the renin-angiotensin system (ras) dual blockade of the ras with angiotensin receptor blockers, ace inhibitors, or aliskiren is associated with increased risks of hypotension, hyperkalemia, and changes in renal function (including acute renal failure) compared to monotherapy. most patients receiving the combination of two ras inhibitors do not obtain any additional benefit compared to monotherapy. in general, avoid combined use of ras inhibitors. closely monitor blood pressure, renal function and electrolytes in patients on perindopril erbumine and other agents that affect the ras. do not co-administer aliskiren with perindopril erbumine in patients with diabetes. avoid use of aliskiren with perindopril erbumine in patients with renal impairment (gfr <60 ml/min). 7.9 mtor inhibitors patients taking concomitant mtor (mammalian target of rapamycin) inhibitor therapy may be at increased risk for angioedema [see warnings and precautions (5.1) ]. 7.10 neprilysin inhibitor patients taking concomitant neprilysin inhibitors may be at increased risk for angioedema. [see warnings and precautions (5.1) ]

erindopril erbumine treatment immediately and observe until the swelling disappears. when involvement of the tongue, glottis, or larynx appears likely to cause airway obstruction, administer appropriate therapy, such as subcutaneous epinephrine solution 1:1000 (0.3 to 0.5 ml), promptly. patients taking concomitant mtor inhibitor (e.g., temsirolimus) therapy or a neprilysin inhibitor may be at increased risk for angioedema [see drug interactions (7.9 ; 7.10) ]. intestinal angioedema: intestinal angioedema has been reported in patients treated with ace inhibitors. these patients presented with abdominal pain (with or without nausea or vomiting); in some cases there was no prior history of facial angioedema and c-1 esterase levels were normal. the angioedema was diagnosed by procedures including abdominal ct scan or ultrasound, or at surgery, and symptoms resolved after stopping the ace inhibitor. intestinal angioedema should be included in the differential diagnosis of patients on ace inhibitors presenting with abdominal pain. 5.2 hypotension perindopril erbumine can cause symptomatic hypotension. perindopril erbumine has been associated with hypotension in 0.3% of uncomplicated hypertensive patients in u.s. placebo-controlled trials. symptoms related to orthostatic hypotension were reported in another 0.8% of patients. symptomatic hypotension is most likely to occur in patients who have been volume or salt-depleted as a result of prolonged diuretic therapy, dietary salt restriction, dialysis, diarrhea or vomiting [see dosage and administration (2.1) ] . ace inhibitors may cause excessive hypotension, and may be associated with oliguria or azotemia, and rarely with acute renal failure and death. in patients with ischemic heart disease or cerebrovascular disease, an excessive fall in blood pressure could result in a myocardial infarction or a cerebrovascular accident. in patients at risk of excessive hypotension, perindopril erbumine therapy should be started under very close medical supervision. patients should be followed closely for the first two weeks of treatment and whenever the dose of perindopril erbumine and/or diuretic is increased. if excessive hypotension occurs, the patient should be placed immediately in a supine position and, if necessary, treated with an intravenous infusion of physiological saline. perindopril erbumine treatment can usually be continued following restoration of volume and blood pressure. 5.3 neutropenia/agranulocytosis ace inhibitors have been associated with agranulocytosis and bone marrow depression, most frequently in patients with renal impairment, especially patients with a collagen vascular disease such as systemic lupus erythematosus or scleroderma. 5.4 fetal toxicity pregnancy category d use of drugs that act on the renin-angiotensin system during the second and third trimesters of pregnancy reduces fetal renal function and increases fetal and neonatal morbidity and death. resulting oligohydramnios can be associated with fetal lung hypoplasia and skeletal deformations. potential neonatal adverse effects include skull hypoplasia, anuria, hypotension, renal failure, and death. when pregnancy is detected discontinue perindopril erbumine as soon as possible [see use in specific populations (8.1) ]. 5.5 impaired renal function as a consequence of inhibiting the renin-angiotensin-aldosterone system, changes in renal function may be anticipated in susceptible individuals. renal function should be monitored periodically in patients receiving perindopril erbumine [see dosage and administration (2.3) ], [see drug interactions (7)]. in patients with severe congestive heart failure, where renal function may depend on the activity of the renin-angiotensin-aldosterone system, treatment with ace inhibitors, including perindopril erbumine, may be associated with oliguria, progressive azotemia, and, rarely, acute renal failure and death. in hypertensive patients with unilateral or bilateral renal artery stenosis, increases in blood urea nitrogen and serum creatinine may occur; usually reversible upon discontinuation of the ace inhibitor. in such patients, renal function should be monitored during the first few weeks of therapy. some perindopril erbumine-treated patients have developed minor and transient increases in blood urea nitrogen and serum creatinine especially in those concomitantly treated with a diuretic. 5.6 hyperkalemia elevations of serum potassium have been observed in some patients treated with ace inhibitors, including perindopril erbumine. most cases were isolated single values that did not appear clinically relevant and were rarely a cause for withdrawal. risk factors for the development of hyperkalemia include renal insufficiency, diabetes mellitus and the concomitant use of agents such as potassium-sparing diuretics, potassium supplements and/or potassium-containing salt substitutes [see drug interactions (7.2) ] . serum potassium should be monitored periodically in patients receiving perindopril erbumine. 5.7 cough presumably because of the inhibition of the degradation of endogenous bradykinin, persistent nonproductive cough has been reported with all ace inhibitors, generally resolving after discontinuation of therapy. consider ace inhibitor-induced cough in the differential diagnosis of cough. 5.8 hepatic failure rarely, ace inhibitors have been associated with a syndrome that starts with cholestatic jaundice and progresses to fulminant hepatic necrosis and sometimes death. the mechanism of this syndrome is not understood. patients receiving ace inhibitors who develop jaundice or marked elevations of hepatic enzymes should discontinue the ace inhibitor and receive appropriate medical follow-up. 5.9 surgery/anesthesia in patients undergoing surgery or during anesthesia with agents that produce hypotension, perindopril erbumine may block angiotensin ii formation that would otherwise occur secondary to compensatory renin release. hypotension attributable to this mechanism can be corrected by volume expansion.

elderly at doses exceeding 8 mg. dosages above 8 mg should be administered with careful blood pressure monitoring and dose titration [see use in specific populations (8.5) ] . use with diuretics: in patients who are currently being treated with a diuretic, symptomatic hypotension can occur following the initial dose of perindopril erbumine tablets. consider reducing the dose of diuretic prior to starting perindopril erbumine tablets [see drug interactions (7.1) ] . 2.2 stable coronary artery disease in patients with stable coronary artery disease, perindopril erbumine tablets should be given at an initial dose of 4 mg once daily for 2 weeks, and then increased as tolerated, to a maintenance dose of 8 mg once daily. in elderly patients (greater than 70 years), perindopril erbumine tablets should be given as a 2 mg dose once daily in the first week, followed by 4 mg once daily in the second week and 8 mg once daily for maintenance dose if tolerated. 2.3 dose adjustment in renal impairment and dialysis perindoprilat elimination is decreased in renally impaired patients. perindopril erbumine tablets are not recommended in patients with creatinine clearance <30 ml/min. for patients with lesser degrees of impairment, the initial dosage should be 2 mg/day and dosage should not exceed 8 mg/day. during dialysis, perindopril is removed with the same clearance as in patients with normal renal function.

nal function [see warnings and precautions (5.5) ] hyperkalemia [see warnings and precautions (5.6) ] cough [see warnings and precautions (5.7) ] hypertension perindopril erbumine has been evaluated for safety in approximately 3,400 patients with hypertension in u.s. and foreign clinical trials. the data presented here are based on results from the 1,417 perindopril erbumine-treated patients who participated in the u.s. clinical trials. over 220 of these patients were treated with perindopril erbumine for at least one year. in placebo-controlled u.s. clinical trials, the incidence of premature discontinuation of therapy due to adverse events was 6.5% in patients treated with perindopril erbumine and 6.7% in patients treated with placebo. the most common causes were cough, headache, asthenia and dizziness. among 1,012 patients in placebo-controlled u.s. trials, the overall frequency of reported adverse events was similar in patients treated with perindopril erbumine and in those treated with placebo (approximately 75% in each group). the only adverse events whose incidence on perindopril erbumine was at least 2% greater than on placebo were cough (12% vs. 4.5%) and back pain (5.8% vs. 3.1%). dizziness was not reported more frequently in the perindopril group (8.2%) than in the placebo group (8.5%), but its likelihood increased with dose, suggesting a causal relationship with perindopril. stable coronary artery disease perindopril has been evaluated for safety in europa, a double-blind, placebo-controlled study in 12,218 patients with stable coronary artery disease. the overall rate of discontinuation was about 22% on drug and placebo. the most common medical reasons for discontinuation that were more frequent on perindopril than placebo were cough, drug intolerance and hypotension. 6.2 postmarketing experience voluntary reports of adverse events in patients taking perindopril erbumine that have been received since market introduction and are of unknown causal relationship to perindopril erbumine include: cardiac arrest, eosinophilic pneumonitis, neutropenia/agranulocytosis, pancytopenia, anemia (including hemolytic and aplastic), thrombocytopenia, acute renal failure, nephritis, hepatic failure, jaundice (hepatocellular or cholestatic), symptomatic hyponatremia, bullous pemphigoid, pemphigus, acute pancreatitis, falls, psoriasis, exfoliative dermatitis and a syndrome which may include: arthralgia/arthritis, vasculitis, serositis, myalgia, fever, rash or other dermatologic manifestations, a positive antinuclear antibody (ana), leukocytosis, eosinophilia or an elevated erythrocyte sedimentation rate (esr). 6.3 clinical laboratory test findings hematology: small decreases in hemoglobin and hematocrit occur frequently in hypertensive patients treated with perindopril erbumine, but are rarely of clinical importance. in controlled clinical trials, no patient was discontinued from therapy due to the development of anemia. leukopenia (including neutropenia) was observed in 0.1% of patients in u.s. clinical trials [see warnings and precautions (5.3) ] . liver function tests: elevations in alt (1.6% perindopril erbumine versus 0.9% placebo) and ast (0.5% perindopril erbumine versus 0.4% placebo) have been observed in placebo-controlled clinical trials. the elevations were generally mild and transient and resolved after discontinuation of therapy.

y cannot be altered, provide close medical supervision with the first dose of perindopril erbumine, for at least two hours and until blood pressure has stabilized for another hour [see warnings and precautions (5.2) ] . the rate and extent of perindopril absorption and elimination are not affected by concomitant diuretics. the bioavailability of perindoprilat was reduced by diuretics, however, and this was associated with a decrease in plasma ace inhibition. 7.2 potassium supplements and potassium-sparing diuretics perindopril erbumine may increase serum potassium because of its potential to decrease aldosterone production. use of potassium-sparing diuretics (spironolactone, amiloride, triamterene and others), potassium supplements or other drugs capable of increasing serum potassium (indomethacin, heparin, cyclosporine and others) can increase the risk of hyperkalemia. therefore, if concomitant use of such agents is indicated, monitor the patient’s serum potassium frequently. 7.3 lithium increased serum lithium and symptoms of lithium toxicity have been reported in patients receiving concomitant lithium and ace inhibitor therapy. frequent monitoring of serum lithium concentration is recommended. use of a diuretic may further increase the risk of lithium toxicity. 7.4 gold nitritoid reactions (symptoms include facial flushing, nausea, vomiting and hypotension) have been reported rarely in patients on therapy with injectable gold (sodium aurothiomalate) and concomitant ace inhibitor therapy including perindopril erbumine. 7.5 digoxin a controlled pharmacokinetic study has shown no effect on plasma digoxin concentrations when coadministered with perindopril erbumine, but an effect of digoxin on the plasma concentration of perindopril/perindoprilat has not been excluded. 7.6 gentamicin animal data have suggested the possibility of interaction between perindopril and gentamicin. however, this has not been investigated in human studies. 7.7 non-steroidal anti-inflammatory agents including selective cyclooxygenase-2 inhibitors (cox-2 inhibitors) in patients who are elderly, volume-depleted (including those on diuretic therapy), or with compromised renal function, co-administration of nsaids, including selective cox-2 inhibitors, with ace inhibitors, including perindopril, may result in deterioration of renal function, including possible acute renal failure. these effects are usually reversible. monitor renal function periodically in patients receiving perindopril and nsaid therapy. the antihypertensive effect of ace inhibitors, including perindopril, may be attenuated by nsaids including selective cox-2 inhibitors. 7.8 dual blockade of the renin-angiotensin system (ras) dual blockade of the ras with angiotensin receptor blockers, ace inhibitors, or aliskiren is associated with increased risks of hypotension, hyperkalemia, and changes in renal function (including acute renal failure) compared to monotherapy. most patients receiving the combination of two ras inhibitors do not obtain any additional benefit compared to monotherapy. in general, avoid combined use of ras inhibitors. closely monitor blood pressure, renal function and electrolytes in patients on perindopril erbumine and other agents that affect the ras. do not co-administer aliskiren with perindopril erbumine in patients with diabetes. avoid use of aliskiren with perindopril erbumine in patients with renal impairment (gfr <60 ml/min). 7.9 mtor inhibitors patients taking concomitant mtor (mammalian target of rapamycin) inhibitor therapy may be at increased risk for angioedema [see warnings and precautions (5.1) ]. 7.10 neprilysin inhibitor patients taking concomitant neprilysin inhibitors may be at increased risk for angioedema. [see warnings and precautions (5.1) ]

s after exposure to antihypertensive use in the first trimester have not distinguished drugs affecting the renin-angiotensin system from other antihypertensive agents. appropriate management of maternal hypertension during pregnancy is important to optimize outcomes for both mother and fetus. in the unusual case that there is no appropriate alternative to therapy with drugs affecting the renin-angiotensin system for a particular patient, apprise the mother of the potential risk to the fetus. perform serial ultrasound examinations to assess the intra-amniotic environment. if oligohydramnios is observed, discontinue perindopril erbumine, unless it is considered lifesaving for the mother. fetal testing may be appropriate, based on the week of pregnancy. patients and physicians should be aware, however, that oligohydramnios may not appear until after the fetus has sustained irreversible injury. closely observe infants with histories of in utero exposure to perindopril erbumine for hypotension, oliguria, and hyperkalemia [see use in specific populations (8.4) ] . radioactivity was detectable in fetuses after administration of 14 c-perindopril to pregnant rats. 8.3 nursing mothers milk of lactating rats contained radioactivity following administration of 14 c-perindopril. it is not known whether perindopril is secreted in human milk. because many drugs are secreted in human milk, caution should be exercised when perindopril erbumine is given to nursing mothers. 8.4 pediatric use neonates with a history of in utero exposure to perindopril erbumine: if oliguria or hypotension occurs, direct attention toward support of blood pressure and renal perfusion. exchange transfusions or dialysis may be required as a means of reversing hypotension and/or substituting for disordered renal function. perindopril, which crosses the placenta, can theoretically be removed from the neonatal circulation by these means, but limited experience has not shown that such removal is central to the treatment of these infants. safety and effectiveness of perindopril erbumine in pediatric patients have not been established. 8.5 geriatric use the mean blood pressure effect of perindopril was somewhat smaller in patients over 60 than in younger patients, although the difference was not significant. plasma concentrations of both perindopril and perindoprilat were increased in elderly patients compared to concentrations in younger patients. no adverse effects were clearly increased in older patients with the exception of dizziness and possibly rash. start at a low dose and titrate slowly as needed. monitor for dizziness because of potential for falls. experience with perindopril erbumine in elderly patients at daily doses exceeding 8 mg is limited. 8.6 renal impairment dosage adjustment may be necessary in renally impaired patients [see dosage and administration (2.3) and clinical pharmacology (12.3) ] . 8.7 hepatic impairment the bioavailability of perindoprilat is increased in patients with impaired hepatic function [see clinical pharmacology (12.3) ] .

mportant to optimize outcomes for both mother and fetus. in the unusual case that there is no appropriate alternative to therapy with drugs affecting the renin-angiotensin system for a particular patient, apprise the mother of the potential risk to the fetus. perform serial ultrasound examinations to assess the intra-amniotic environment. if oligohydramnios is observed, discontinue perindopril erbumine, unless it is considered lifesaving for the mother. fetal testing may be appropriate, based on the week of pregnancy. patients and physicians should be aware, however, that oligohydramnios may not appear until after the fetus has sustained irreversible injury. closely observe infants with histories of in utero exposure to perindopril erbumine for hypotension, oliguria, and hyperkalemia [see use in specific populations (8.4) ] . radioactivity was detectable in fetuses after administration of 14 c-perindopril to pregnant rats.

de, play a role in the therapeutic effects of perindopril erbumine remains to be elucidated. while the principal mechanism of perindopril in blood pressure reduction is believed to be through the renin-angiotensin-aldosterone system, ace inhibitors have some effect even in apparent low-renin hypertension. perindopril has been studied in relatively few black patients, usually a low-renin population, and the average response of diastolic blood pressure to perindopril was about half the response seen in nonblack patients, a finding consistent with previous experience of other ace inhibitors. 12.2 pharmacodynamics after administration of perindopril, ace is inhibited in a dose and blood concentration-related fashion, with the maximal inhibition of 80 to 90% attained by 8 mg persisting for 10 to 12 hours. twenty-four hour ace inhibition is about 60% after these doses. the degree of ace inhibition achieved by a given dose appears to diminish over time (the id 50 increases). the pressor response to an angiotensin i infusion is reduced by perindopril, but this effect is not as persistent as the effect on ace; there is about 35% inhibition at 24 hours after a 12 mg dose. 12.3 pharmacokinetics absorption: oral administration of perindopril erbumine results in peak plasma concentrations that occur at approximately 1 hour. the absolute oral bioavailability of perindopril is about 75%. following absorption, approximately 30 to 50% of systemically available perindopril is hydrolyzed to its active metabolite, perindoprilat, which has a mean bioavailability of about 25%. peak plasma concentrations of perindoprilat are attained 3 to 7 hours after perindopril administration. oral administration of perindopril erbumine with food does not significantly lower the rate or extent of perindopril absorption relative to the fasted state. however, the extent of biotransformation of perindopril to the active metabolite, perindoprilat, is reduced approximately 43%, resulting in a reduction in the plasma ace inhibition curve of approximately 20%, probably clinically insignificant. in clinical trials, perindopril was generally administered in a non-fasting state. with 4 mg, 8 mg and 16 mg doses of perindopril erbumine, c max and auc of perindopril and perindoprilat increase in a dose-proportional manner following both single oral dosing and at steady state during a once-a-day multiple dosing regimen. distribution: approximately 60% of circulating perindopril is bound to plasma proteins, and only 10 to 20% of perindoprilat is bound. therefore, drug interactions mediated through effects on protein binding are not anticipated. metabolism and elimination: following oral administration perindopril exhibits multicompartment pharmacokinetics including a deep tissue compartment (ace binding sites). the mean half-life of perindopril associated with most of its elimination is approximately 0.8 to 1 hours. perindopril is extensively metabolized following oral administration, with only 4 to 12% of the dose recovered unchanged in the urine. six metabolites resulting from hydrolysis, glucuronidation and cyclization via dehydration have been identified. these include the active ace inhibitor, perindoprilat (hydrolyzed perindopril), perindopril and perindoprilat glucuronides, dehydrated perindopril and the diastereoisomers of dehydrated perindoprilat. in humans, hepatic esterase appears to be responsible for the hydrolysis of perindopril. the active metabolite, perindoprilat, also exhibits multicompartment pharmacokinetics following the oral administration of perindopril erbumine. formation of perindoprilat is gradual with peak plasma concentrations occurring between 3 and 7 hours. the subsequent decline in plasma concentration shows an apparent mean half-life of 3 to 10 hours for the majority of the elimination, with a prolonged terminal elimination half-life of 30 to 120 hours resulting from slow dissociation of perindoprilat from plasma/tissue ace binding sites. during repeated oral once daily dosing with perindopril, perindoprilat accumulates about 1.5 to 2 fold and attains steady state plasma levels in 3 to 6 days. the clearance of perindoprilat and its metabolites is almost exclusively renal. elderly: plasma concentrations of both perindopril and perindoprilat in elderly patients (greater than 70 years) are approximately twice those observed in younger patients, reflecting both increased conversion of perindopril to perindoprilat and decreased renal excretion of perindoprilat [see dosage and administration (2.1) and use in specific populations (8.5) ] . heart failure: perindoprilat clearance is reduced in congestive heart failure patients, resulting in a 40% higher dose interval auc. renal impairment: with perindopril doses of 2 mg to 4 mg, perindoprilat auc increases with decreasing renal function. at creatinine clearances of 30 to 80 ml/min, auc is about double that at 100 ml/min. when creatinine clearance drops below 30 ml/min, auc increases more markedly. in a limited number of patients studied, perindopril clearance by dialysis ranged from about 40 to 80 ml/min. perindoprilat clearance by dialysis ranged from about 40 to 90 ml/min [see dosage and administration (2.3) ] . hepatic impairment: the bioavailability of perindoprilat is increased in patients with impaired hepatic function. plasma concentrations of perindoprilat in patients with impaired liver function were about 50% higher than those observed in healthy subjects or hypertensive patients with normal liver function.

8 mg and 16 mg doses of perindopril erbumine, c max and auc of perindopril and perindoprilat increase in a dose-proportional manner following both single oral dosing and at steady state during a once-a-day multiple dosing regimen. distribution: approximately 60% of circulating perindopril is bound to plasma proteins, and only 10 to 20% of perindoprilat is bound. therefore, drug interactions mediated through effects on protein binding are not anticipated. metabolism and elimination: following oral administration perindopril exhibits multicompartment pharmacokinetics including a deep tissue compartment (ace binding sites). the mean half-life of perindopril associated with most of its elimination is approximately 0.8 to 1 hours. perindopril is extensively metabolized following oral administration, with only 4 to 12% of the dose recovered unchanged in the urine. six metabolites resulting from hydrolysis, glucuronidation and cyclization via dehydration have been identified. these include the active ace inhibitor, perindoprilat (hydrolyzed perindopril), perindopril and perindoprilat glucuronides, dehydrated perindopril and the diastereoisomers of dehydrated perindoprilat. in humans, hepatic esterase appears to be responsible for the hydrolysis of perindopril. the active metabolite, perindoprilat, also exhibits multicompartment pharmacokinetics following the oral administration of perindopril erbumine. formation of perindoprilat is gradual with peak plasma concentrations occurring between 3 and 7 hours. the subsequent decline in plasma concentration shows an apparent mean half-life of 3 to 10 hours for the majority of the elimination, with a prolonged terminal elimination half-life of 30 to 120 hours resulting from slow dissociation of perindoprilat from plasma/tissue ace binding sites. during repeated oral once daily dosing with perindopril, perindoprilat accumulates about 1.5 to 2 fold and attains steady state plasma levels in 3 to 6 days. the clearance of perindoprilat and its metabolites is almost exclusively renal. elderly: plasma concentrations of both perindopril and perindoprilat in elderly patients (greater than 70 years) are approximately twice those observed in younger patients, reflecting both increased conversion of perindopril to perindoprilat and decreased renal excretion of perindoprilat [see dosage and administration (2.1) and use in specific populations (8.5) ] . heart failure: perindoprilat clearance is reduced in congestive heart failure patients, resulting in a 40% higher dose interval auc. renal impairment: with perindopril doses of 2 mg to 4 mg, perindoprilat auc increases with decreasing renal function. at creatinine clearances of 30 to 80 ml/min, auc is about double that at 100 ml/min. when creatinine clearance drops below 30 ml/min, auc increases more markedly. in a limited number of patients studied, perindopril clearance by dialysis ranged from about 40 to 80 ml/min. perindoprilat clearance by dialysis ranged from about 40 to 90 ml/min [see dosage and administration (2.3) ] . hepatic impairment: the bioavailability of perindoprilat is increased in patients with impaired hepatic function. plasma concentrations of perindoprilat in patients with impaired liver function were about 50% higher than those observed in healthy subjects or hypertensive patients with normal liver function.

over several weeks. formal interaction studies of perindopril erbumine have not been carried out with antihypertensive agents other than thiazides. limited experience in controlled and uncontrolled trials coadministering perindopril erbumine with a calcium channel blocker, a loop diuretic or triple therapy (beta-blocker, vasodilator and a diuretic), does not suggest any unexpected interactions. in general, ace inhibitors have less than additive effects when given with beta-adrenergic blockers, presumably because both work in part through the renin angiotensin system. in uncontrolled studies in patients with insulin-dependent diabetes, perindopril did not appear to affect glycemic control. in long-term use, no effect on urinary protein excretion was seen in these patients. the effectiveness of perindopril erbumine was not influenced by sex and it was less effective in black patients than in nonblack patients. in elderly patients (greater than or equal to 60 years), the mean blood pressure effect was somewhat smaller than in younger patients, although the difference was not significant. 14.2 stable coronary artery disease the european trial on reduction of cardiac events with perindopril in stable coronary artery disease (europa) was a multicenter, randomized, double-blind and placebo-controlled study conducted in 12,218 patients who had evidence of stable coronary artery disease without clinical heart failure. patients had evidence of coronary artery disease documented by previous myocardial infarction more than 3 months before screening, coronary revascularization more than 6 months before screening, angiographic evidence of stenosis (at least 70% narrowing of one or more major coronary arteries), or positive stress test in men with a history of chest pain. after a run-in period of 4 weeks during which all patients received perindopril 2 mg to 8 mg, the patients were randomly assigned to perindopril 8 mg once daily (n=6,110) or matching placebo (n=6,108). the mean follow-up was 4.2 years. the study examined the long-term effects of perindopril on time to first event of cardiovascular mortality, nonfatal myocardial infarction, or cardiac arrest in patients with stable coronary artery disease. the mean age of patients was 60 years; 85% were male, 92% were taking platelet inhibitors, 63% were taking ? blockers, and 56% were taking lipid-lowering therapy. the europa study showed that perindopril significantly reduced the relative risk for the primary endpoint events (table 1). this beneficial effect is largely attributable to a reduction in the risk of nonfatal myocardial infarction. this beneficial effect of perindopril on the primary outcome was evident after about one year of treatment (figure 1). the outcome was similar across all predefined subgroups by age, underlying disease or concomitant medication (figure 2). table 1. primary endpoint and relative risk reduction perindopril (n = 6,110) placebo (n = 6,108) rrr (95% ci) p ci=confidence interval; rrr: relative risk reduction; mi: myocardial infarction combined endpoint cardiovascular mortality, nonfatal mi or cardiac arrest 488 (8%) 603 (9.9%) 20% (9 to 29) 0.0003 component endpoint cardiovascular mortality 215 (3.5%) 249 (4.1%) 14% (-3 to 28) 0.107 nonfatal mi 295 (4.8%) 378 (6.2%) 22% (10 to 33) 0.001 cardiac arrest 6 (0.1%) 11 (0.2%) 46% (-47 to 80) 0.22 size of squares proportional to the number of patients in that group. dashed line indicates overall relative risk. figure 1 figure 2. beneficial effect of perindopril treatment on primary endpoint in predefined subgroups

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