ACE inhibitors · Cardiovascular
Perindopril
perindopril erbumine · perindopril arginine · Coversyl®(brand names vary by market)
A long-acting ACE inhibitor with a genuinely once-daily day.
Mechanism
Prodrug converted to perindoprilat, which blocks angiotensin-converting enzyme: less angiotensin II, less aldosterone, and more bradykinin.
Open the interactive pathwayIndications
- Hypertension
- Stable coronary artery disease
- Heart failure with reduced ejection fraction
Formulations
Dosing concepts
Starting
Started low in anyone volume-deplete, elderly, or already on a diuretic, because first-dose hypotension is a RAAS-blockade phenomenon rather than a dose-size one.
Renal response
A creatinine rise of up to about 30 percent after starting is expected haemodynamics, not injury, and is not a reason to stop. Beyond that, or with hyperkalemia, it is.
Concepts, not prescribing instructions. Practice numbers live in current references and local protocols.
Pharmacokinetics
- Bioavailability
- ~65 to 75% (prodrug)
- Half-life
- Effective half-life around 25 h for the active metabolite
- Elimination
- renal: Perindoprilat is renally cleared and accumulates as clearance falls
Adverse effects
- Dry coughcommonBradykinin-mediated, can appear months in, and does not respond to dose reduction.
- Hyperkalemiacommon & serious
- Acute kidney injury in the volume-deplete or bilateral renal artery stenosisserious
- AngioedemaseriousRare, potentially fatal, and an absolute bar to any ACE inhibitor thereafter.
- First-dose hypotensioncommon
Contraindications & precautions
Contraindications
- Pregnancy
- Prior ACE inhibitor angioedema
- Bilateral renal artery stenosis
Precautions
- Volume depletion
- Concurrent potassium-sparing agents or supplements
- Renal impairment
Interactions
- ACE inhibitors / ARBs + Potassium-sparing diuretics, K supplements, salt substitutescautionAdditive hyperkalemia, worst with renal impairment layered on top.
- ACE inhibitor / ARB + diuretic + NSAID (the 'triple whammy')avoidAcute kidney injury, classically in a dehydrated older adult who bought ibuprofen for a sore knee.
- ACE inhibitors / ARBs / thiazides + LithiumcautionLithium toxicity: tremor, confusion, ataxia, renal injury.
Monitoring
Creatinine and potassium
The two things RAAS blockade moves · Baseline, one to two weeks after starting or any increase, then periodically
Blood pressure
Effect and tolerability
Cough
The commonest reason the class is abandoned, and it is switchable to an ARB
Counselling points
- Take it at the same time daily; the first dose is often taken at bedtime.
- A persistent dry tickly cough is a known effect. Tell us, because there is an alternative that does not cause it.
- Stop it and contact us urgently if your lips, tongue or face swell.
- Avoid salt substitutes: most of them are potassium chloride.
- Tell any clinician you are pregnant or planning to be, because this class is stopped in pregnancy.
Clinical pearls
- Potassium-based salt substitutes are the invisible third agent in a great many ACE-inhibitor hyperkalemias, and nobody thinks to ask.
- The cough is not dose-related and not allergic; switching within the class achieves nothing, and an ARB is the answer.
References & review
- Perindopril product monograph (consult the current version for your market) (monograph)
- Goodman & Gilman's The Pharmacological Basis of Therapeutics, 14th ed. (reference-work)
Last reviewed 2026-08-16 · jurisdiction: global · drug information changes; verify against current references before practice use.