Limited data are available for overdosage in humans. Symptoms associated with overdosage of ACE inhibitors may include hypotension, circulatory shock, electrolyte disturbances, renal failure, hyperventilation, tachycardia, palpitations, bradycardia, dizziness, anxiety, and cough.
The recommended treatment of overdosage is intravenous infusion of sodium chloride 9 mg/ml (0.9%) solution. If hypotension occurs, the patient should be placed in the shock position. If available, treatment with angiotensin II infusion and/or intravenous catecholamines may also be considered. Coverene may be removed from the general circulation by haemodialysis. Pacemaker therapy is indicated for therapy-resistant bradycardia. Vital signs, serum electrolytes and creatinine concentrations should be monitored continuously.
Limited data are available for overdosage in humans. Symptoms associated with overdosage of ACE inhibitors may include hypotension, circulatory shock, electrolyte disturbances, renal failure, hyperventilation, tachycardia, palpitations, bradycardia, dizziness, anxiety, and cough.
The recommended treatment of overdosage is intravenous infusion of sodium chloride 9 mg/ml (0.9%) solution. If hypotension occurs, the patient should be placed in the shock position. If available, treatment with angiotensin II infusion and/or intravenous catecholamines may also be considered. Perindopril may be removed from the general circulation by haemodialysis. Pacemaker therapy is indicated for therapy-resistant bradycardia. Vital signs, serum electrolytes and creatinine concentrations should be monitored continuously.
- ) or to any other ACE inhibitor;
- History of angioedema associated with previous ACE inhibitor therapy;
- Hereditary or idiopathic angioedema;
- Second and third trimesters of pregnancy.
- Concomitant use of Coverene Erbumine with aliskiren-containing products in patients with diabetes mellitus or renal impairment (GFR < 60 ml/min/1.73 m2).
- ) or to any other ACE inhibitor;
- History of angioedema associated with previous ACE inhibitor therapy;
- Hereditary or idiopathic angioedema;
- Second and third trimesters of pregnancy.
- Concomitant use of Coverene with aliskiren-containing products in patients with diabetes mellitus or renal impairment (GFR < 60 ml/min/1.73 m2).
Not applicable.
Summary of safety profile
The safety profile of Coverene is consistent with the safety profile of ACE inhibitors:
The most frequent adverse events reported in clinical trials and observed with Coverene are: dizziness, headache, paraesthesia, vertigo, visual disturbances, tinnitus, hypotension, cough, dyspnoea, abdominal pain, constipation, diarrhoea, dysgeusia, dyspepsia, nausea, vomiting, pruritis, rash, muscle cramps, and asthenia.
Tabulated list of adverse reactions
The following undesirable effects have been observed during clinical trials and/or post-marketing use with Coverene and ranked under the following frequency:
Very common (>1/10); common (>1/100 to <1/10); uncommon (>1/1000 to <1/100); rare (>1/10000 to <1/1000); very rare (<1/10000); not known (cannot be estimated from the available data).
| Blood and lymphatic system disorders | |
| Uncommon: | eosinophilia* |
| Very rare: | Decreases in haemoglobin and haematocrit, thrombocytopenia, leucopenia/neutropenia, agranulocytosis, pancytopenia |
| In patients with a congenital deficiency of G-6PDH, very rare cases of haemolytic anaemia have been reported. Metabolism and nutrition disorders | |
| Uncommon: | hypoglycaemia* , hyperkalaemia,* reversible on discontinuation , hyponatraemia* |
| Psychiatric disorders | |
| Uncommon: | mood or sleep disturbances. |
| Nervous system disorders | |
| Common: | headache, dizziness, vertigo, paresthaesia. |
| Uncommon: | somnolence*, syncope* |
| Very rare: | confusion. |
| Eye and labyrinth disorders | |
| Common: | vision disturbance. |
| Ear and labyrinth disorders | |
| Common: | tinnitus. |
| Cardiac disorders | |
| Uncommon: | palpitations*, tachycardia* |
| Very rare: | arrhythmia, angina pectoris and myocardial infarction, possibly secondary to excessive hypotension in high-risk patients. |
| Vascular disorders | |
| Common: | hypotension (and effects related to hypotension). |
| Uncommon: | vasculitis* |
| Very rare: | stroke, possibly secondary to excessive hypotension in high-risk patients. |
| Respiratory, thoracic and mediastinal disorders | |
| Common: | cough, dyspnoea. |
| Uncommon: | bronchospasm. |
| Very rare: | eosinophilic pneumonia, rhinitis. |
| Gastro-intestinal disorders | |
| Common: | nausea, vomiting, abdominal pain, dysgeusia, dyspepsia, diarrhoea, constipation. |
| Uncommon: | dry mouth |
| Very rare: | pancreatitis |
| Hepato-biliary disorders | |
| Very rare: | hepatitis, either cytolytic or cholestatic. |
| Skin and subcutaneous tissue disorders | |
| Common: | rash, pruritus. |
| Uncommon: | angioedema of face, extremities, lips, mucous membranes, tongue, glottis and/or larynx, urticaria , photosensitivity reactions*, pemphigoid*, hyperhidrosis |
| Rare: | psoriasis aggravation |
| Very rare: | erythema multiforme. |
| Musculoskeletal and connective tissue disorders | |
| Common: | muscle cramps. |
| Uncommon: | arthralgia*, myalgia* |
| Renal and urinary disorders | |
| Uncommon: | renal insufficiency. |
| Very rare: | acute renal failure. |
| Reproductive system and breast disorders | |
| Uncommon: | erectile dysfunction |
| General disorders and administration site conditions | |
| Common: | asthenia |
| Uncommon: | chest pain*, malaise*, oedema peripheral*, pyrexia* |
| Investigations | |
| Uncommon: | blood urea increased*, blood creatinine increased* |
| Rare: | blood bilirubin increased, hepatic enzyme increased |
| Injury, poisoning and procedural complications | |
| Uncommon: | fall* |
* Frequency calculated from clinical trials for adverse events detected from spontaneous report.
Clinical trials
During the randomised period of the EUROPA study, only serious adverse events were collected. Few patients experienced serious adverse events: 16 (0.3%) of the 6122 Coverene patients and 12 (0.2%) of the 6107 placebo patients. In Coverene-treated patients, hypotension was observed in 6 patients, angioedema in 3 patients and sudden cardiac arrest in 1 patient. More patients withdrew for cough, hypotension or other intolerance on Coverene than on placebo, 6.0% (n=366) versus 2.1% (n=129) respectively.
Reporting of suspected adverse reactions
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the internet at www.mhra.gov.uk/yellowcard.
Summary of safety profile
The safety profile of perindopril is consistent with the safety profile of ACE inhibitors:
The most frequent adverse events reported in clinical trials and observed with perindopril are: dizziness, headache, paraesthesia, vertigo, visual disturbances, tinnitus, hypotension, cough, dyspnoea, abdominal pain, constipation, diarrhoea, dysgeusia, dyspepsia, nausea, vomiting, pruritis, rash, muscle cramps, and asthenia.
Tabulated list of adverse reactions
The following undesirable effects have been observed during clinical trials and/or post-marketing use with perindopril and ranked under the following frequency:
Very common (>1/10); common (>1/100 to <1/10); uncommon (>1/1000 to <1/100); rare (>1/10000 to <1/1000); very rare (<1/10000); not known (cannot be estimated from the available data).
| Blood and lymphatic system disorders | |
| Uncommon: | eosinophilia* |
| Very rare: | Decreases in haemoglobin and haematocrit, thrombocytopenia, leucopenia/neutropenia, agranulocytosis, pancytopenia |
| In patients with a congenital deficiency of G-6PDH, very rare cases of haemolytic anaemia have been reported. Metabolism and nutrition disorders | |
| Uncommon: | hypoglycaemia* , hyperkalaemia,* reversible on discontinuation , hyponatraemia* |
| Psychiatric disorders | |
| Uncommon: | mood or sleep disturbances. |
| Nervous system disorders | |
| Common: | headache, dizziness, vertigo, paresthaesia. |
| Uncommon: | somnolence*, syncope* |
| Very rare: | confusion. |
| Eye and labyrinth disorders | |
| Common: | vision disturbance. |
| Ear and labyrinth disorders | |
| Common: | tinnitus. |
| Cardiac disorders | |
| Uncommon: | palpitations*, tachycardia* |
| Very rare: | arrhythmia, angina pectoris and myocardial infarction, possibly secondary to excessive hypotension in high-risk patients. |
| Vascular disorders | |
| Common: | hypotension (and effects related to hypotension). |
| Uncommon: | vasculitis* |
| Very rare: | stroke, possibly secondary to excessive hypotension in high-risk patients. |
| Respiratory, thoracic and mediastinal disorders | |
| Common: | cough, dyspnoea. |
| Uncommon: | bronchospasm. |
| Very rare: | eosinophilic pneumonia, rhinitis. |
| Gastro-intestinal disorders | |
| Common: | nausea, vomiting, abdominal pain, dysgeusia, dyspepsia, diarrhoea, constipation. |
| Uncommon: | dry mouth |
| Very rare: | pancreatitis |
| Hepato-biliary disorders | |
| Very rare: | hepatitis, either cytolytic or cholestatic. |
| Skin and subcutaneous tissue disorders | |
| Common: | rash, pruritus. |
| Uncommon: | angioedema of face, extremities, lips, mucous membranes, tongue, glottis and/or larynx, urticaria , photosensitivity reactions*, pemphigoid*, hyperhidrosis |
| Rare: | psoriasis aggravation |
| Very rare: | erythema multiforme. |
| Musculoskeletal and connective tissue disorders | |
| Common: | muscle cramps. |
| Uncommon: | arthralgia*, myalgia* |
| Renal and urinary disorders | |
| Uncommon: | renal insufficiency. |
| Very rare: | acute renal failure. |
| Reproductive system and breast disorders | |
| Uncommon: | erectile dysfunction |
| General disorders and administration site conditions | |
| Common: | asthenia |
| Uncommon: | chest pain*, malaise*, oedema peripheral*, pyrexia* |
| Investigations | |
| Uncommon: | blood urea increased*, blood creatinine increased* |
| Rare: | blood bilirubin increased, hepatic enzyme increased |
| Injury, poisoning and procedural complications | |
| Uncommon: | fall* |
* Frequency calculated from clinical trials for adverse events detected from spontaneous report.
Clinical trials
During the randomised period of the EUROPA study, only serious adverse events were collected. Few patients experienced serious adverse events: 16 (0.3%) of the 6122 perindopril patients and 12 (0.2%) of the 6107 placebo patients. In perindopril-treated patients, hypotension was observed in 6 patients, angioedema in 3 patients and sudden cardiac arrest in 1 patient. More patients withdrew for cough, hypotension or other intolerance on perindopril than on placebo, 6.0% (n=366) versus 2.1% (n=129) respectively.
Reporting of suspected adverse reactions
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the internet at www.mhra.gov.uk/yellowcard.
In the chronic oral toxicity studies (rats and monkeys), the target organ is the kidney, with reversible damage.
No mutagenicity has been observed in in vitro or in vivo studies.
Reproduction toxicology studies (rats, mice, rabbits and monkeys) showed no sign of embryotoxicity or teratogenicity. However, angiotensin converting-enzyme inhibitors, as a class, have been shown to induce adverse effects on late fetal development, resulting in fetal death and congenital effects in rodents and rabbits: renal lesions and an increase in peri- and postnatal mortality have been observed. Fertility was not impaired wither in male or in female rats.
No carcinogenicity has been observed in long-term studies in rats and mice.
Hypertension:
Treatment of hypertension.
Heart failure:
Treatment of symptomatic heart failure.
Stable coronary artery disease:
Reduction of risk of cardiac events in patients with a history of myocardial infarction and/or revascularisation.
Pharmacotherapeutic group: ACE inhibitor, plain, ATC code: C09A A04
Mechanism of action
Coverene is an inhibitor of the enzyme that converts angiotensin I into angiotensin II (Angiotensin Converting Enzyme, ACE). The converting enzyme, or kinase, is an exopeptidase that allows conversion of angiotensin I into the vasoconstrictor angiotensin II as well as causing the degradation of the vasodilator bradykinin into an inactive heptapeptide. Inhibition of ACE results in a reduction of angiotensin II in the plasma, which leads to increased plasma renin activity (by inhibition of the negative feedback of renin release), and reduced secretion of aldosterone. Since ACE inactivates bradykinin, inhibition of ACE also results in an increased activity of circulating and local kallikrein-kinin systems (and thus also activation of the prostaglandin system). It is possible that this mechanism contributes to the blood pressure-lowering action of ACE inhibitors and is partially responsible for certain of their side effects (e.g. cough).
Coverene acts through its active metabolite, Covereneat. The other metabolites show no inhibition of ACE activity in vitro.
Clinical efficacy and safety
Dual blockade of the reninangiotensinaldosterone system (RAAS) clinical trial data
Two large randomised, controlled trials (ONTARGET (ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial) and VA NEPHRON-D (The Veterans Affairs Nephropathy in Diabetes)) have examined the use of the combination of an ACE-inhibitor with an angiotensin II receptor blocker.
ONTARGET was a study conducted in patients with a history of cardiovascular or cerebrovascular disease, or type 2 diabetes mellitus accompanied by evidence of end-organ damage. VA NEPHRON-D was a study in patients with type 2 diabetes mellitus and diabetic nephropathy.
These studies have shown no significant beneficial effect on renal and/or cardiovascular outcomes and mortality, while an increased risk of hyperkalaemia, acute kidney injury and/or hypotension as compared to monotherapy was observed.
Given their similar pharmacodynamic properties, these results are also relevant for other ACE-inhibitors and angiotensin II receptor blockers.
ACE-inhibitors and angiotensin II receptor blockers should therefore not be used concomitantly in patients with diabetic nephropathy.
ALTITUDE (Aliskiren Trial in Type 2 Diabetes Using Cardiovascular and Renal Disease Endpoints) was a study designed to test the benefit of adding aliskiren to a standard therapy of an ACE-inhibitor or an angiotensin II receptor blocker in patients with type 2 diabetes mellitus and chronic kidney disease, cardiovascular disease, or both. The study was terminated early because of an increased risk of adverse outcomes. Cardiovascular death and stroke were both numerically more frequent in the aliskiren group than in the placebo group and adverse events and serious adverse events of interest (hyperkalaemia, hypotension and renal dysfunction) were more frequently reported in the aliskiren group than in the placebo group.
Hypertension
Coverene is active in all grades of hypertension: mild, moderate, severe; a reduction in systolic and diastolic blood pressures in both supine and standing positions is observed.
Coverene reduces peripheral vascular resistance, leading to blood pressure reduction. As a consequence, peripheral blood flow increases, with no effect on heart rate.
Renal blood flow increases as a rule, while the glomerular filtration rate (GFR) is usually unchanged.
The anti-hypertensive activity is maximal between 4 and 6 hours after a single dose and is sustained for at least 24 hours: trough effects are about 87-100 % of peak effects.
The decrease in blood pressure occurs rapidly. In responding patients, normalisation is achieved within a month and persists without the occurrence of tachyphylaxis.
Discontinuation of treatment does not lead to a rebound effect.
Coverene reduces left ventricular hypertrophy.
In man, Coverene has been confirmed to demonstrate vasodilatory properties. It improves large artery elasticity and decreases the media: lumen ratio of small arteries.
An adjunctive therapy with a thiazide diuretic produces an additive type of synergy. The combination of an ACE inhibitor and a thiazide also decreases the risk of hypokalaemia induced by the diuretic treatment.
Heart failure
Coverene Erbumine reduces cardiac work by a decrease in pre-load and after-load.
Studies in patients with heart failure have demonstrated:
- Decreased left and right ventricular filling pressures,
- Reduced total peripheral vascular resistance,
- Increased cardiac output and improved cardiac index.
In comparative studies, the first administration of 2 mg of Coverene to patients with mild to moderate heart failure was not associated with any significant reduction of blood pressure as compared to placebo.
Patients with stable coronary artery disease
The EUROPA study was a multicentre, international, randomised, double-blind, placebo-controlled clinical trial lasting 4 years.
Twelve thousand two hundred and eighteen (12218) patients aged over 18 were randomised to 8 mg Coverene (n=6110) or placebo (n=6108).
The trial population had evidence of coronary artery disease with no evidence of clinical signs of heart failure. Overall, 90% of the patients had a previous myocardial infarction and/or a previous coronary revascularisation. Most of the patients received the study medication on top of conventional therapy including platelet inhibitors, lipid lowering agents and beta-blockers.
The main efficacy criterion was the composite of cardiovascular mortality, non-fatal myocardial infarction and/or cardiac arrest with successful resuscitation. The treatment with 8 mg Coverene once daily resulted in a significant absolute reduction in the primary endpoint of 1.9% (relative risk reduction of 20%, 95%CI [9.4; 28.6] - p<0.001).
In patients with a history of myocardial infarction and/or revascularisation, an absolute reduction of 2.2% corresponding to a RRR of 22.4% (95%CI [12.0; 31.6] - p<0.001) in the primary endpoint was observed by comparison to placebo.
Paediatric population
The safety and efficacy of Coverene in children and adolescents aged below 18 years have not been established.
In an open, non-comparative clinical study in 62 hypertensive children aged from 2 to 15 years with a glomerular filtration rate > 30 ml/min/1.73 m2, patients received Coverene with an average dose of 0.07 mg/kg. The dose was individualised according to the patient profile and blood pressure response up to a maximum dose of 0.135 mg/kg/day.
Fifty-nine patients completed the period of three months, and 36 patients completed the extension period of the study, i.e. were followed at least 24 months (mean study duration: 44 months).
Systolic and diastolic blood pressure remained stable from the inclusion to the last assessment in patients previously treated by other antihypertensive treatments, and decreased in naïve patients.
More than 75% of children had systolic and diastolic blood pressure below the 95th percentile at their last assessment.
The safety was consistent with the known safety profile of Coverene.
Pharmacotherapeutic group: ACE inhibitor, plain, ATC code: C09A A04
Mechanism of action
Perindopril is an inhibitor of the enzyme that converts angiotensin I into angiotensin II (Angiotensin Converting Enzyme, ACE). The converting enzyme, or kinase, is an exopeptidase that allows conversion of angiotensin I into the vasoconstrictor angiotensin II as well as causing the degradation of the vasodilator bradykinin into an inactive heptapeptide. Inhibition of ACE results in a reduction of angiotensin II in the plasma, which leads to increased plasma renin activity (by inhibition of the negative feedback of renin release), and reduced secretion of aldosterone. Since ACE inactivates bradykinin, inhibition of ACE also results in an increased activity of circulating and local kallikrein-kinin systems (and thus also activation of the prostaglandin system). It is possible that this mechanism contributes to the blood pressure-lowering action of ACE inhibitors and is partially responsible for certain of their side effects (e.g. cough).
Perindopril acts through its active metabolite, perindoprilat. The other metabolites show no inhibition of ACE activity in vitro.
Clinical efficacy and safety
Dual blockade of the reninangiotensinaldosterone system (RAAS) clinical trial data
Two large randomised, controlled trials (ONTARGET (ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial) and VA NEPHRON-D (The Veterans Affairs Nephropathy in Diabetes)) have examined the use of the combination of an ACE-inhibitor with an angiotensin II receptor blocker.
ONTARGET was a study conducted in patients with a history of cardiovascular or cerebrovascular disease, or type 2 diabetes mellitus accompanied by evidence of end-organ damage. VA NEPHRON-D was a study in patients with type 2 diabetes mellitus and diabetic nephropathy.
These studies have shown no significant beneficial effect on renal and/or cardiovascular outcomes and mortality, while an increased risk of hyperkalaemia, acute kidney injury and/or hypotension as compared to monotherapy was observed.
Given their similar pharmacodynamic properties, these results are also relevant for other ACE-inhibitors and angiotensin II receptor blockers.
ACE-inhibitors and angiotensin II receptor blockers should therefore not be used concomitantly in patients with diabetic nephropathy.
ALTITUDE (Aliskiren Trial in Type 2 Diabetes Using Cardiovascular and Renal Disease Endpoints) was a study designed to test the benefit of adding aliskiren to a standard therapy of an ACE-inhibitor or an angiotensin II receptor blocker in patients with type 2 diabetes mellitus and chronic kidney disease, cardiovascular disease, or both. The study was terminated early because of an increased risk of adverse outcomes. Cardiovascular death and stroke were both numerically more frequent in the aliskiren group than in the placebo group and adverse events and serious adverse events of interest (hyperkalaemia, hypotension and renal dysfunction) were more frequently reported in the aliskiren group than in the placebo group.
Hypertension
Perindopril is active in all grades of hypertension: mild, moderate, severe; a reduction in systolic and diastolic blood pressures in both supine and standing positions is observed.
Perindopril reduces peripheral vascular resistance, leading to blood pressure reduction. As a consequence, peripheral blood flow increases, with no effect on heart rate.
Renal blood flow increases as a rule, while the glomerular filtration rate (GFR) is usually unchanged.
The anti-hypertensive activity is maximal between 4 and 6 hours after a single dose and is sustained for at least 24 hours: trough effects are about 87-100 % of peak effects.
The decrease in blood pressure occurs rapidly. In responding patients, normalisation is achieved within a month and persists without the occurrence of tachyphylaxis.
Discontinuation of treatment does not lead to a rebound effect.
Perindopril reduces left ventricular hypertrophy.
In man, perindopril has been confirmed to demonstrate vasodilatory properties. It improves large artery elasticity and decreases the media: lumen ratio of small arteries.
An adjunctive therapy with a thiazide diuretic produces an additive type of synergy. The combination of an ACE inhibitor and a thiazide also decreases the risk of hypokalaemia induced by the diuretic treatment.
Heart failure
Coverene reduces cardiac work by a decrease in pre-load and after-load.
Studies in patients with heart failure have demonstrated:
- Decreased left and right ventricular filling pressures,
- Reduced total peripheral vascular resistance,
- Increased cardiac output and improved cardiac index.
In comparative studies, the first administration of 2 mg of perindopril to patients with mild to moderate heart failure was not associated with any significant reduction of blood pressure as compared to placebo.
Patients with stable coronary artery disease
The EUROPA study was a multicentre, international, randomised, double-blind, placebo-controlled clinical trial lasting 4 years.
Twelve thousand two hundred and eighteen (12218) patients aged over 18 were randomised to 8 mg perindopril (n=6110) or placebo (n=6108).
The trial population had evidence of coronary artery disease with no evidence of clinical signs of heart failure. Overall, 90% of the patients had a previous myocardial infarction and/or a previous coronary revascularisation. Most of the patients received the study medication on top of conventional therapy including platelet inhibitors, lipid lowering agents and beta-blockers.
The main efficacy criterion was the composite of cardiovascular mortality, non-fatal myocardial infarction and/or cardiac arrest with successful resuscitation. The treatment with 8 mg perindopril once daily resulted in a significant absolute reduction in the primary endpoint of 1.9% (relative risk reduction of 20%, 95%CI [9.4; 28.6] - p<0.001).
In patients with a history of myocardial infarction and/or revascularisation, an absolute reduction of 2.2% corresponding to a RRR of 22.4% (95%CI [12.0; 31.6] - p<0.001) in the primary endpoint was observed by comparison to placebo.
Paediatric population
The safety and efficacy of perindopril in children and adolescents aged below 18 years have not been established.
In an open, non-comparative clinical study in 62 hypertensive children aged from 2 to 15 years with a glomerular filtration rate > 30 ml/min/1.73 m2, patients received perindopril with an average dose of 0.07 mg/kg. The dose was individualised according to the patient profile and blood pressure response up to a maximum dose of 0.135 mg/kg/day.
Fifty-nine patients completed the period of three months, and 36 patients completed the extension period of the study, i.e. were followed at least 24 months (mean study duration: 44 months).
Systolic and diastolic blood pressure remained stable from the inclusion to the last assessment in patients previously treated by other antihypertensive treatments, and decreased in naïve patients.
More than 75% of children had systolic and diastolic blood pressure below the 95th percentile at their last assessment.
The safety was consistent with the known safety profile of perindopril.
Absorption
After oral administration, the absorption of Coverene is rapid and the peak concentration is achieved within 1 hour. The plasma half-life of Coverene is equal to 1 hour.
Coverene is a pro-drug. Twenty seven percent of the administered Coverene dose reaches the bloodstream as the active metabolite Covereneat. In addition to active Covereneat, Coverene yields five metabolites, all inactive. The peak plasma concentration of Covereneat is achieved within 3 to 4 hours.
As ingestion of food decreases conversion to Covereneat, hence bioavailability, Coverene erbumine should be administered orally in a single daily dose in the morning before a meal.
It has been demonstrated a linear relationship between the dose of Coverene and its plasma exposure.
Distribution
The volume of distribution is approximately 0.2 l/kg for unbound Covereneat. Binding of Covereneat to plasma proteins is 20%, principally to angiotensin-converting enzyme, but is concentration-dependent.
Elimination
Covereneat is eliminated in the urine and the terminal half-life of the unbound fraction is approximately 17 hours, resulting in steady-state within 4 days.
Special populations
Elimination of Covereneat is decreased in the elderly, and also in patients with heart or renal failure. Dosage adjustment in renal insufficiency is desirable depending on the degree of impairment (creatinine clearance).
Dialysis clearance of Covereneat is equal to 70 ml/min.
Coverene kinetics are modified in patients with cirrhosis: hepatic clearance of the parent molecule is reduced by half. However, the quantity of Covereneat formed is not reduced and therefore no dosage adjustment is required.
Absorption
After oral administration, the absorption of perindopril is rapid and the peak concentration is achieved within 1 hour. The plasma half-life of perindopril is equal to 1 hour.
Perindopril is a pro-drug. Twenty seven percent of the administered perindopril dose reaches the bloodstream as the active metabolite perindoprilat. In addition to active perindoprilat, perindopril yields five metabolites, all inactive. The peak plasma concentration of perindoprilat is achieved within 3 to 4 hours.
As ingestion of food decreases conversion to perindoprilat, hence bioavailability, Coverene should be administered orally in a single daily dose in the morning before a meal.
It has been demonstrated a linear relationship between the dose of perindopril and its plasma exposure.
Distribution
The volume of distribution is approximately 0.2 l/kg for unbound perindoprilat. Binding of perindoprilat to plasma proteins is 20%, principally to angiotensin-converting enzyme, but is concentration-dependent.
Elimination
Perindoprilat is eliminated in the urine and the terminal half-life of the unbound fraction is approximately 17 hours, resulting in steady-state within 4 days.
Special populations
Elimination of perindoprilat is decreased in the elderly, and also in patients with heart or renal failure. Dosage adjustment in renal insufficiency is desirable depending on the degree of impairment (creatinine clearance).
Dialysis clearance of perindoprilat is equal to 70 ml/min.
Perindopril kinetics are modified in patients with cirrhosis: hepatic clearance of the parent molecule is reduced by half. However, the quantity of perindoprilat formed is not reduced and therefore no dosage adjustment is required.
Stable coronary artery disease
If an episode of unstable angina pectoris (major or not) occurs during the first month of Coverene treatment, a careful appraisal of the benefit/risk should be performed before treatment continuation.
Hypotension
ACE inhibitors may cause a fall in blood pressure. Symptomatic hypotension is seen rarely in uncomplicated hypertensive patients and is more likely to occur in patients who have been volume-depleted, e.g. by diuretic therapy, dietary salt restriction, dialysis, diarrhoea or vomiting, or who have severe renin-dependent hypertension. In patients with symptomatic heart failure, with or without associated renal insufficiency, symptomatic hypotension has been observed. This is most likely to occur in those patients with more severe degrees of heart failure, as reflected by the use of high doses of loop diuretics, hyponatraemia or functional renal impairment. In patients at increased risk of symptomatic hypotension, initiation of therapy and dose adjustment should be closely monitored. Similar considerations apply to patients with ischaemic heart or cerebrovascular disease in whom an excessive fall in blood pressure could result in a myocardial infarction or cerebrovascular accident.
If hypotension occurs, the patient should be placed in the supine position and, if necessary, should receive an intravenous infusion of sodium chloride 9 mg/ml (0.9%) solution. A transient hypotensive response is not a contraindication to further doses, which can be given usually without difficulty once the blood pressure has increased after volume expansion. In some patients with congestive heart failure who have normal or low blood pressure, additional lowering of systemic blood pressure may occur with Coverene erbumine. This effect is anticipated and is usually not a reason to discontinue treatment. If hypotension becomes symptomatic, a reduction of dose or discontinuation of Coverene Erbumine may be necessary.
Aortic and mitral valve stenosis / hypertrophic cardiomyopathy
As with other ACE inhibitors, Coverene erbumine should be given with caution to patients with mitral valve stenosis and obstruction in the outflow of the left ventricle such as aortic stenosis or hypertrophic cardiomyopathy.
Dual blockade of the renin-angiotensin-aldosterone system (RAAS)
There is evidence that the concomitant use of ACE-inhibitors, angiotensin II receptor blockers or aliskiren increases the risk of hypotension, hyperkalaemia and decreased renal function (including acute renal failure). Dual blockade of RAAS through the combined use of ACE-inhibitors, angiotensin II receptor blockers or aliskiren is therefore not recommended. If dual blockade therapy is considered absolutely necessary, this should only occur under specialist supervision and subject to frequent close monitoring of renal function, electrolytes and blood pressure.
ACE-inhibitors and angiotensin II receptor blockers should not be used concomitantly in patients with diabetic nephropathy.
Renal impairment
In cases of renal impairment (creatinine clearance < 60 ml/min) the initial Coverene dosage should be adjusted according to the patient's creatinine clearance and then as a function of the patient's response to treatment. Routine monitoring of potassium and creatinine are part of normal medical practice for these patients.
In patients with symptomatic heart failure, hypotension following the initiation of therapy with ACE inhibitors may lead to some further impairment in renal function. Acute renal failure, usually reversible, has been reported in this situation.
In some patients with bilateral renal artery stenosis or stenosis of the artery to a solitary kidney, who have been treated with ACE inhibitors, increases in blood urea and serum creatinine, usually reversible upon discontinuation of therapy, have been seen. This is especially likely in patients with renal insufficiency. If renovascular hypertension is also present there is an increased risk of severe hypotension and renal insufficiency. In these patients, treatment should be started under close medical supervision with low doses and careful dose titration. Since treatment with diuretics may be a contributory factor to the above, they should be discontinued and renal function should be monitored during the first weeks of Coverene Erbumine therapy.
Some hypertensive patients with no apparent pre-existing renal vascular disease have developed increases in blood urea and serum creatinine, usually minor and transient, especially when Coverene erbumine has been given concomitantly with a diuretic. This is more likely to occur in patients with pre-existing renal impairment. Dosage reduction and/or discontinuation of the diuretic and/or Coverene Erbumine may be required.
Haemodialysis patients
Anaphylactoid reactions have been reported in patients dialysed with high flux membranes, and treated concomitantly with an ACE inhibitor. In these patients consideration should be given to using a different type of dialysis membrane or different class of anti-hypertensive agent.
Kidney transplantation
There is no experience regarding the administration of Coverene erbumine in patients with a recent kidney transplantation.
Hypersensitivity/Angioedema
Angioedema of the face, extremities, lips, mucous membranes, tongue, glottis and/or larynx has been reported rarely in patients treated with ACE inhibitors, including Coverene erbumine. This may occur at any time during therapy. In such cases, Coverene Erbumine should promptly be discontinued and appropriate monitoring should be initiated and continued until complete resolution of symptoms has occurred. In those instances where swelling was confined to the face and lips the condition generally resolved without treatment, although antihistamines have been useful in relieving symptoms.
Angioedema associated with laryngeal oedema may be fatal. Where there is involvement of the tongue, glottis or larynx, likely to cause airway obstruction, emergency therapy should be administered promptly. This may include the administration of adrenaline and/or the maintenance of a patent airway. The patient should be under close medical supervision until complete and sustained resolution of symptoms has occurred.
Patients with a history of angioedema unrelated to ACE inhibitor therapy may be at increased risk of angioedema while receiving an ACE inhibitor.
Intestinal angioedema has been reported rarely 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 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.
Concomitant use of mTOR inhibitors (e.g. sirolimus, everolimus, temsirolimus)
Patients taking concomitant mTOR inhibitors (e.g. sirolimus, everolimus, temsirolimus) therapy may be at increased risk for angioedema (e.g. swelling of the airways or tongue, with or without respiratory impairment).
Anaphylactoid reactions during low-density lipoproteins (LDL) apheresis
Rarely, patients receiving ACE inhibitors during low-density lipoprotein (LDL) apheresis with dextran sulfate have experienced life-threatening anaphylactoid reactions. These reactions were avoided by temporarily withholding ACE inhibitor therapy prior to each apheresis.
Anaphylactic reactions during desensitisation
Patients receiving ACE inhibitors during desensitisation treatment (e.g. hymenoptera venom) have experienced anaphylactoid reactions. In the same patients, these reactions have been avoided when ACE inhibitors were temporarily withheld, but they reappeared upon inadvertent rechallenge.
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.
Neutropenia/Agranulocytosis/Thrombocytopenia/Anaemia
Neutropenia/agranulocytosis, thrombocytopenia and anaemia have been reported in patients receiving ACE inhibitors. In patients with normal renal function and no other complicating factors, neutropenia occurs rarely. Coverene should be used with extreme caution in patients with collagen vascular disease, immunosuppressant therapy, treatment with allopurinol or procainamide, or a combination of these complicating factors, especially if there is pre-existing impaired renal function. Some of these patients developed serious infections, which in a few instances did not respond to intensive antibiotic therapy. If Coverene is used in such patients, periodic monitoring of white blood cell counts is advised and patients should be instructed to report any sign of infection (e.g. sore throat, fever).
Race
ACE inhibitors cause a higher rate of angioedema in black patients than in non-black patients.
As with other ACE inhibitors, Coverene may be less effective in lowering blood pressure in black people than in non-blacks, possibly because of a higher prevalence of low-renin states in the black hypertensive population.
Cough
Cough has been reported with the use of ACE inhibitors. Characteristically, the cough is non-productive, persistent and resolves after discontinuation of therapy. ACE inhibitor-induced cough should be considered as part of the differential diagnosis of cough.
Surgery/Anaesthesia
In patients undergoing major surgery or during anaesthesia with agents that produce hypotension, Coverene erbumine may block angiotensin II formation secondary to compensatory renin release. The treatment should be discontinued one day prior to the surgery. If hypotension occurs and is considered to be due to this mechanism, it can be corrected by volume expansion.
Hyperkalaemia
Elevations in serum potassium have been observed in some patients treated with ACE inhibitors, including Coverene. Risk factors for the development of hyperkalaemia include those with renal insufficiency, worsening of renal function, age (> 70 years), diabetes mellitus, inter-current events, in particular dehydration, acute cardiac decompensation, metabolic acidosis and concomitant use of potassium-sparing diuretics (e.g. spironolactone, eplerenone, triamterene, or amiloride), potassium supplements or potassium-containing salt substitutes; or those patients taking other medicinal products associated with increases in serum potassium (e.g. heparin, co-trimoxazole also known as trimethoprim/sulfamethoxazole). The use of potassium supplements, potassium sparing diuretics, or potassium containing salt substitutes particularly in patients with impaired renal function may lead to a significant increase in serum potassium. Hyperkalaemia can cause serious, sometimes fatal arrhythmias. If concomitant use of the above-mentioned medicinal products is deemed appropriate, they should be used with caution and with frequent monitoring of serum potassium.
Diabetic patients
In diabetic patients treated with oral antidiabetic agents or insulin, glycaemic control should be closely monitored during the first month of treatment with an ACE inhibitor.
Lithium
The combination of lithium and Coverene is generally not recommended.
Potassium-sparing diuretics, potassium supplements or potassium-containing salt substitutes
The combination of Coverene and potassium-sparing diuretics, potassium supplements or potassium-containing salt substitutes is generally not recommended.
Pregnancy
ACE inhibitors should not be initiated during pregnancy. Unless continued ACE inhibitor therapy is considered essential, patients planning pregnancy should be changed to alternative anti-hypertensive treatments, which have an established safety profile for use in pregnancy. When pregnancy is diagnosed, treatment with ACE inhibitors should be stopped immediately, and, if appropriate, alternative therapy should be started.
Excipients
Due to the presence of lactose, patients with rare hereditary problems of galactose intolerance, glucose-galactose malabsorption, or the Lapp lactase deficiency should not take this medicinal product.
Stable coronary artery disease
If an episode of unstable angina pectoris (major or not) occurs during the first month of perindopril treatment, a careful appraisal of the benefit/risk should be performed before treatment continuation.
Hypotension
ACE inhibitors may cause a fall in blood pressure. Symptomatic hypotension is seen rarely in uncomplicated hypertensive patients and is more likely to occur in patients who have been volume-depleted, e.g. by diuretic therapy, dietary salt restriction, dialysis, diarrhoea or vomiting, or who have severe renin-dependent hypertension. In patients with symptomatic heart failure, with or without associated renal insufficiency, symptomatic hypotension has been observed. This is most likely to occur in those patients with more severe degrees of heart failure, as reflected by the use of high doses of loop diuretics, hyponatraemia or functional renal impairment. In patients at increased risk of symptomatic hypotension, initiation of therapy and dose adjustment should be closely monitored. Similar considerations apply to patients with ischaemic heart or cerebrovascular disease in whom an excessive fall in blood pressure could result in a myocardial infarction or cerebrovascular accident.
If hypotension occurs, the patient should be placed in the supine position and, if necessary, should receive an intravenous infusion of sodium chloride 9 mg/ml (0.9%) solution. A transient hypotensive response is not a contraindication to further doses, which can be given usually without difficulty once the blood pressure has increased after volume expansion. In some patients with congestive heart failure who have normal or low blood pressure, additional lowering of systemic blood pressure may occur with Coverene. This effect is anticipated and is usually not a reason to discontinue treatment. If hypotension becomes symptomatic, a reduction of dose or discontinuation of Coverene may be necessary.
Aortic and mitral valve stenosis / hypertrophic cardiomyopathy
As with other ACE inhibitors, Coverene should be given with caution to patients with mitral valve stenosis and obstruction in the outflow of the left ventricle such as aortic stenosis or hypertrophic cardiomyopathy.
Dual blockade of the renin-angiotensin-aldosterone system (RAAS)
There is evidence that the concomitant use of ACE-inhibitors, angiotensin II receptor blockers or aliskiren increases the risk of hypotension, hyperkalaemia and decreased renal function (including acute renal failure). Dual blockade of RAAS through the combined use of ACE-inhibitors, angiotensin II receptor blockers or aliskiren is therefore not recommended. If dual blockade therapy is considered absolutely necessary, this should only occur under specialist supervision and subject to frequent close monitoring of renal function, electrolytes and blood pressure.
ACE-inhibitors and angiotensin II receptor blockers should not be used concomitantly in patients with diabetic nephropathy.
Renal impairment
In cases of renal impairment (creatinine clearance < 60 ml/min) the initial perindopril dosage should be adjusted according to the patient's creatinine clearance and then as a function of the patient's response to treatment. Routine monitoring of potassium and creatinine are part of normal medical practice for these patients.
In patients with symptomatic heart failure, hypotension following the initiation of therapy with ACE inhibitors may lead to some further impairment in renal function. Acute renal failure, usually reversible, has been reported in this situation.
In some patients with bilateral renal artery stenosis or stenosis of the artery to a solitary kidney, who have been treated with ACE inhibitors, increases in blood urea and serum creatinine, usually reversible upon discontinuation of therapy, have been seen. This is especially likely in patients with renal insufficiency. If renovascular hypertension is also present there is an increased risk of severe hypotension and renal insufficiency. In these patients, treatment should be started under close medical supervision with low doses and careful dose titration. Since treatment with diuretics may be a contributory factor to the above, they should be discontinued and renal function should be monitored during the first weeks of Coverene therapy.
Some hypertensive patients with no apparent pre-existing renal vascular disease have developed increases in blood urea and serum creatinine, usually minor and transient, especially when Coverene has been given concomitantly with a diuretic. This is more likely to occur in patients with pre-existing renal impairment. Dosage reduction and/or discontinuation of the diuretic and/or Coverene may be required.
Haemodialysis patients
Anaphylactoid reactions have been reported in patients dialysed with high flux membranes, and treated concomitantly with an ACE inhibitor. In these patients consideration should be given to using a different type of dialysis membrane or different class of anti-hypertensive agent.
Kidney transplantation
There is no experience regarding the administration of Coverene in patients with a recent kidney transplantation.
Hypersensitivity/Angioedema
Angioedema of the face, extremities, lips, mucous membranes, tongue, glottis and/or larynx has been reported rarely in patients treated with ACE inhibitors, including Coverene. This may occur at any time during therapy. In such cases, Coverene should promptly be discontinued and appropriate monitoring should be initiated and continued until complete resolution of symptoms has occurred. In those instances where swelling was confined to the face and lips the condition generally resolved without treatment, although antihistamines have been useful in relieving symptoms.
Angioedema associated with laryngeal oedema may be fatal. Where there is involvement of the tongue, glottis or larynx, likely to cause airway obstruction, emergency therapy should be administered promptly. This may include the administration of adrenaline and/or the maintenance of a patent airway. The patient should be under close medical supervision until complete and sustained resolution of symptoms has occurred.
Patients with a history of angioedema unrelated to ACE inhibitor therapy may be at increased risk of angioedema while receiving an ACE inhibitor.
Intestinal angioedema has been reported rarely 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 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.
Concomitant use of mTOR inhibitors (e.g. sirolimus, everolimus, temsirolimus)
Patients taking concomitant mTOR inhibitors (e.g. sirolimus, everolimus, temsirolimus) therapy may be at increased risk for angioedema (e.g. swelling of the airways or tongue, with or without respiratory impairment).
Anaphylactoid reactions during low-density lipoproteins (LDL) apheresis
Rarely, patients receiving ACE inhibitors during low-density lipoprotein (LDL) apheresis with dextran sulfate have experienced life-threatening anaphylactoid reactions. These reactions were avoided by temporarily withholding ACE inhibitor therapy prior to each apheresis.
Anaphylactic reactions during desensitisation
Patients receiving ACE inhibitors during desensitisation treatment (e.g. hymenoptera venom) have experienced anaphylactoid reactions. In the same patients, these reactions have been avoided when ACE inhibitors were temporarily withheld, but they reappeared upon inadvertent rechallenge.
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.
Neutropenia/Agranulocytosis/Thrombocytopenia/Anaemia
Neutropenia/agranulocytosis, thrombocytopenia and anaemia have been reported in patients receiving ACE inhibitors. In patients with normal renal function and no other complicating factors, neutropenia occurs rarely. Perindopril should be used with extreme caution in patients with collagen vascular disease, immunosuppressant therapy, treatment with allopurinol or procainamide, or a combination of these complicating factors, especially if there is pre-existing impaired renal function. Some of these patients developed serious infections, which in a few instances did not respond to intensive antibiotic therapy. If perindopril is used in such patients, periodic monitoring of white blood cell counts is advised and patients should be instructed to report any sign of infection (e.g. sore throat, fever).
Race
ACE inhibitors cause a higher rate of angioedema in black patients than in non-black patients.
As with other ACE inhibitors, perindopril may be less effective in lowering blood pressure in black people than in non-blacks, possibly because of a higher prevalence of low-renin states in the black hypertensive population.
Cough
Cough has been reported with the use of ACE inhibitors. Characteristically, the cough is non-productive, persistent and resolves after discontinuation of therapy. ACE inhibitor-induced cough should be considered as part of the differential diagnosis of cough.
Surgery/Anaesthesia
In patients undergoing major surgery or during anaesthesia with agents that produce hypotension, Coverene may block angiotensin II formation secondary to compensatory renin release. The treatment should be discontinued one day prior to the surgery. If hypotension occurs and is considered to be due to this mechanism, it can be corrected by volume expansion.
Hyperkalaemia
Elevations in serum potassium have been observed in some patients treated with ACE inhibitors, including perindopril. Risk factors for the development of hyperkalaemia include those with renal insufficiency, worsening of renal function, age (> 70 years), diabetes mellitus, inter-current events, in particular dehydration, acute cardiac decompensation, metabolic acidosis and concomitant use of potassium-sparing diuretics (e.g. spironolactone, eplerenone, triamterene, or amiloride), potassium supplements or potassium-containing salt substitutes; or those patients taking other medicinal products associated with increases in serum potassium (e.g. heparin, co-trimoxazole also known as trimethoprim/sulfamethoxazole). The use of potassium supplements, potassium sparing diuretics, or potassium containing salt substitutes particularly in patients with impaired renal function may lead to a significant increase in serum potassium. Hyperkalaemia can cause serious, sometimes fatal arrhythmias. If concomitant use of the above-mentioned medicinal products is deemed appropriate, they should be used with caution and with frequent monitoring of serum potassium.
Diabetic patients
In diabetic patients treated with oral antidiabetic agents or insulin, glycaemic control should be closely monitored during the first month of treatment with an ACE inhibitor.
Lithium
The combination of lithium and perindopril is generally not recommended.
Potassium-sparing diuretics, potassium supplements or potassium-containing salt substitutes
The combination of perindopril and potassium-sparing diuretics, potassium supplements or potassium-containing salt substitutes is generally not recommended.
Pregnancy
ACE inhibitors should not be initiated during pregnancy. Unless continued ACE inhibitor therapy is considered essential, patients planning pregnancy should be changed to alternative anti-hypertensive treatments, which have an established safety profile for use in pregnancy. When pregnancy is diagnosed, treatment with ACE inhibitors should be stopped immediately, and, if appropriate, alternative therapy should be started.
Excipients
Due to the presence of lactose, patients with rare hereditary problems of galactose intolerance, glucose-galactose malabsorption, or the Lapp lactase deficiency should not take this medicinal product.
Coverene erbumine has no direct influence on the ability to drive and use machines but individual reactions related to low blood pressure may occur in some patients, particularly at the start of treatment or in combination with another antihypertensive medication. As a result the ability to drive or operate machinery may be impaired.
Coverene has no direct influence on the ability to drive and use machines but individual reactions related to low blood pressure may occur in some patients, particularly at the start of treatment or in combination with another antihypertensive medication. As a result the ability to drive or operate machinery may be impaired.
Posology
The dose should be individualised according to the patient profile and blood pressure response.
Hypertension
Coverene erbumine may be used in monotherapy or in combination with other classes of anti-hypertensive therapy.
The recommended starting dose is 4 mg given once daily in the morning.
Patients with a strongly activated renin-angiotensin-aldosterone system (in particular, renovascular hypertension, salt and/or volume depletion, cardiac decompensation or severe hypertension) may experience an excessive drop in blood pressure following the initial dose. A starting dose of 2 mg is recommended in such patients and the initiation of treatment should take place under medical supervision. The dose may be increased to 8 mg once daily after one month of treatment.
Symptomatic hypotension may occur following initiation of therapy with Coverene erbumine; this is more likely in patients who are being treated concurrently with diuretics. Caution is therefore recommended since these patients may be volume and/or salt depleted.
If possible, the diuretic should be discontinued 2 to 3 days before beginning therapy with Coverene erbumine.
In hypertensive patients in whom the diuretic cannot be discontinued, therapy with Coverene erbumine should be initiated with a 2 mg dose. Renal function and serum potassium should be monitored. The subsequent dosage of Coverene erbumine should be adjusted according to blood pressure response. If required, diuretic therapy may be resumed.
In elderly patients treatment should be initiated at a dose of 2 mg, which may be progressively increased to 4 mg after one month, then to 8 mg if necessary, depending on renal function (see Table 1 “Dosage adjustment in renal impairmentâ€, below).
Symptomatic heart failure
It is recommended that Coverene erbumine, generally associated with a non-potassium-sparing diuretic and/or digoxin and/or a beta-blocker, be introduced under close medical supervision with a recommended starting dose of 2 mg taken in the morning. This dose may be increased after 2 weeks to 4 mg once daily, if tolerated.
The dose adjustment should be based on the clinical response of the individual patient.
In severe heart failure and in other patients considered to be at high risk (patients with impaired renal function and a tendency to have electrolyte disturbances, patients receiving simultaneous treatment with diuretics and/or treatment with vasodilating agents), treatment should be initiated under careful supervision.
Patients at high risk of symptomatic hypotension, e.g. patients with salt depletion, with or without hyponatraemia, patients with hypovolaemia or patients who have been receiving vigorous diuretic therapy, should have these conditions corrected, if possible, prior to therapy with Coverene erbumine. Blood pressure, renal function and serum potassium should be monitored closely, both before and during treatment with Coverene Erbumine.
Stable coronary artery disease
Coverene erbumine should be introduced at a dose of 4 mg once daily for two weeks, then increased to 8 mg once daily, depending on renal function and provided that the 4 mg dose is well tolerated.
Elderly patients should receive 2 mg once daily for one week, then 4 mg once daily the next week, before increasing the dose up to 8 mg once daily, depending on renal function (see Table 1 “Dosage adjustment in renal impairmentâ€, below). The dose should be increased only if the previous lower dose is well tolerated.
Special populations
Renal impairment
Dosage in patients with renal impairment should be based on creatinine clearance as outlined in table 1 below:
Table 1: dosage adjustment in renal impairment
| Creatinine clearance (ml/min) | Recommended dose |
| ClCR > 60 | 4 mg per day |
| 30 < ClCR < 60 | 2 mg per day |
| 15 < ClCR < 30 | 2 mg every other day |
| Haemodialysed patients * | |
| ClCR < 15 | 2 mg on the day of dialysis |
* Dialysis clearance of Covereneat is 70 ml/min.
For patients on haemodialysis, the dose should be taken after dialysis.
Hepatic impairment
No dosage adjustment is necessary in patients with hepatic impairment.
Paediatric population
Efficacy and safety of use in children and adolescents aged below 18 years have not been established. Therefore, use in children and adolescents is not recommended.
Method of administration
For oral use.
It is recommended that Coverene Erbumine is taken once daily in the morning, before a meal.
Posology
The dose should be individualised according to the patient profile and blood pressure response.
Hypertension
Coverene may be used in monotherapy or in combination with other classes of anti-hypertensive therapy.
The recommended starting dose is 4 mg given once daily in the morning.
Patients with a strongly activated renin-angiotensin-aldosterone system (in particular, renovascular hypertension, salt and/or volume depletion, cardiac decompensation or severe hypertension) may experience an excessive drop in blood pressure following the initial dose. A starting dose of 2 mg is recommended in such patients and the initiation of treatment should take place under medical supervision. The dose may be increased to 8 mg once daily after one month of treatment.
Symptomatic hypotension may occur following initiation of therapy with Coverene; this is more likely in patients who are being treated concurrently with diuretics. Caution is therefore recommended since these patients may be volume and/or salt depleted.
If possible, the diuretic should be discontinued 2 to 3 days before beginning therapy with Coverene.
In hypertensive patients in whom the diuretic cannot be discontinued, therapy with Coverene should be initiated with a 2 mg dose. Renal function and serum potassium should be monitored. The subsequent dosage of Coverene should be adjusted according to blood pressure response. If required, diuretic therapy may be resumed.
In elderly patients treatment should be initiated at a dose of 2 mg, which may be progressively increased to 4 mg after one month, then to 8 mg if necessary, depending on renal function (see Table 1 “Dosage adjustment in renal impairmentâ€, below).
Symptomatic heart failure
It is recommended that Coverene, generally associated with a non-potassium-sparing diuretic and/or digoxin and/or a beta-blocker, be introduced under close medical supervision with a recommended starting dose of 2 mg taken in the morning. This dose may be increased after 2 weeks to 4 mg once daily, if tolerated.
The dose adjustment should be based on the clinical response of the individual patient.
In severe heart failure and in other patients considered to be at high risk (patients with impaired renal function and a tendency to have electrolyte disturbances, patients receiving simultaneous treatment with diuretics and/or treatment with vasodilating agents), treatment should be initiated under careful supervision.
Patients at high risk of symptomatic hypotension, e.g. patients with salt depletion, with or without hyponatraemia, patients with hypovolaemia or patients who have been receiving vigorous diuretic therapy, should have these conditions corrected, if possible, prior to therapy with Coverene. Blood pressure, renal function and serum potassium should be monitored closely, both before and during treatment with Coverene.
Stable coronary artery disease
Coverene should be introduced at a dose of 4 mg once daily for two weeks, then increased to 8 mg once daily, depending on renal function and provided that the 4 mg dose is well tolerated.
Elderly patients should receive 2 mg once daily for one week, then 4 mg once daily the next week, before increasing the dose up to 8 mg once daily, depending on renal function (see Table 1 “Dosage adjustment in renal impairmentâ€, below). The dose should be increased only if the previous lower dose is well tolerated.
Special populations
Renal impairment
Dosage in patients with renal impairment should be based on creatinine clearance as outlined in table 1 below:
Table 1: dosage adjustment in renal impairment
| Creatinine clearance (ml/min) | Recommended dose |
| ClCR > 60 | 4 mg per day |
| 30 < ClCR < 60 | 2 mg per day |
| 15 < ClCR < 30 | 2 mg every other day |
| Haemodialysed patients * | |
| ClCR < 15 | 2 mg on the day of dialysis |
* Dialysis clearance of perindoprilat is 70 ml/min.
For patients on haemodialysis, the dose should be taken after dialysis.
Hepatic impairment
No dosage adjustment is necessary in patients with hepatic impairment.
Paediatric population
Efficacy and safety of use in children and adolescents aged below 18 years have not been established. Therefore, use in children and adolescents is not recommended.
Method of administration
For oral use.
It is recommended that Coverene is taken once daily in the morning, before a meal.
No special requirements for disposal.
