1. Name of the medicinal product

Perindopril Erbumine Tablets 2mg Taj Pharma
Perindopril Erbumine Tablets 4mg Taj Pharma
Perindopril Erbumine Tablets 8mg Taj Pharma

2. Qualitative and quantitative composition

a) Each tablet contains:
Perindopril Erbumine ………….2 mg
Excipients ………………………q.s

b) Each tablet contains:
Perindopril Erbumine ………….4 mg
Excipients ………………………q.s

c) Each tablet contains:
Perindopril Erbumine ………….8 mg
Excipients ………………………q.s

For the full list of excipients, see section 6.1.

  1. Pharmaceutical form

Tablet.

  1. Clinical particulars

4.1 Therapeutic indications

Hypertension:

Treatment of hypertension.

Stable coronary artery disease:

Reduction of risk of cardiac events in patients with a history of myocardial infarction and/or revascularization.

4.2 Posology and method of administration

Posology

The dose should be individualized according to the patient profile (see section 4.4) and blood pressure response.

Hypertension

Perindopril erbumine may be used in monotherapy or in combination with other classes of anti-hypertensive therapy (see sections 4.3, 4.4, 4.5 and 5.1).

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 perindopril 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 perindopril erbumine (see section 4.4).

In hypertensive patients in whom the diuretic cannot be discontinued, therapy with perindopril erbumine should be initiated with a 2 mg dose. Renal function and serum potassium should be monitored. The subsequent dosage of perindopril 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 impairment”, below).

Stable coronary artery disease

Perindopril 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 impairment”, 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 (see sections 4.4 and 5.2).

Paediatric population

Efficacy and safety of use in children and adolescents aged below 18 years have not been established. Currently available data are described in section 5.1 but no recommendation on a posology can be made. Therefore, use in children and adolescents is not recommended.

Method of administration

For oral use.

It is recommended that Perindopril Erbumine is taken once daily in the morning, before a meal.

4.3 Contraindications

  • Hypersensitivity to the active substance, to any of the excipients listed in section 6.1 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 (see sections 4.4 and 4.6).
  • Concomitant use of Perindopril Erbumine with aliskiren-containing products in patients with diabetes mellitus or renal impairment (GFR < 60 ml/min/1.73 m2) (see sections 4.5 and 5.1).
  • Extracorporeal treatments leading to contact of blood with negatively charged surfaces (see section 4.5)
  • Significant bilateral renal artery stenosis or stenosis of the artery to a single functioning kidney (see section 4.4).

4.4 Special warnings and precautions for use

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 (see sections 4.5 and 4.8). 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 (see sections 4.2 and 4.8). 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 perindopril 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 Perindopril Erbumine may be necessary.

Aortic and mitral valve stenosis / hypertrophic cardiomyopathy

As with other ACE inhibitors, perindopril 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 (see sections 4.5 and 5.1). 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 (see section 4.2) 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 (see section 4.8).

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 Perindopril 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 Perindopril 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 Perindopril 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 perindopril erbumine in patients with recent kidney transplantation.

Renovascular hypertension:

There is an increased risk of hypotension and renal insufficiency when patients with bilateral renal artery stenosis or stenosis of the artery to a single functioning kidney are treated with ACE inhibitors (see section 4.3). Treatment with diuretics may be a contributory factor. Loss of renal function may occur with only minor changes in serum creatinine even in patients with unilateral renal artery stenosis.

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 perindopril erbumine (see section 4.8). This may occur at any time during therapyIn such cases, Perindopril 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 (see section 4.3).

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) (see section 4.5).

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 (see section 4.8).

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, perindopril 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 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 (see section 4.5).

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 (see section 4.5).

Lithium

The combination of lithium and perindopril is generally not recommended (see section 4.5).

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 (see section 4.5).

Primary aldosteronism:

Patients with primary hyperaldosteronism generally will not respond to anti- hypertensive drugs acting through inhibition of the renin-angiotensin system.

Therefore, the use of this product is 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 (see sections 4.3 and 4.6).

Excipients

Due to the presence of lactose, patients with rare hereditary problems of galactose intolerance, total lactase deficiency or glucose-galactose malabsorption should not take this medicine.

This medicine contains less than 1 mmol sodium (23 mg) per tablet, this is to say essentially ‘sodium free’

4.5 Interaction with other medicinal products and other forms of interaction

Clinical trial data has shown that dual blockade of the renin-angiotensin-aldosterone- system (RAAS) through the combined use of ACE-inhibitors, angiotensin II receptor blockers or aliskiren is associated with a higher frequency of adverse events such as hypotension, hyperkalaemia and decreased renal function (including acute renal failure) compared to the use of a single RAAS-acting agent (see sections 4.3, 4.4 and 5.1).

Drugs inducing hyperkalaemia

Some medicinal products or therapeutic classes may increase the occurrence of hyperkalaemia: aliskiren, potassium salts, potassium-sparing diuretics, ACE inhibitors, angiotensin-II receptors antagonists, NSAIDs, heparins, immunosuppressant agents such as ciclosporin or tacrolimus, trimethoprim. The combination of these drugs increases the risk of hyperkalaemia.

Co-trimoxazole (trimethoprim/sulfamethoxazole)

Patients taking concomitant co-trimoxazole (trimethoprim/sulfamethoxazole) may be at increased risk for hyperkalaemia (see section 4.4).

Concomitant use contraindicated (see section 4.3):

Aliskiren

In diabetic or impaired renal patients, risk of hyperkalaemia, worsening of renal function and cardiovascular morbidity and mortality increase.

Extracorporeal treatments

Extracorporeal treatments leading to contact of blood with negatively charged surfaces such as dialysis or haemofiltration with certain high-flux membranes (e.g. polyacrylonitrile membranes) and low-density lipoprotein apheresis with dextran sulfate due to increased risk of severe anaphylactoid reactions (see section 4.3). If such treatment is required, consideration should be given to using a different type of dialysis membrane or a different class of antihypertensive agent.

Concomitant use not recommended (see section 4.4):

Aliskiren

In patients other than diabetic or impaired renal patients, risk of hyperkalaemia, worsening of renal function and cardiovascular morbidity and mortality increase.

Concomitant therapy with ACE inhibitor and angiotensin-receptor blocker

It has been reported in the literature that in patients with established atherosclerotic disease, heart failure, or with diabetes with end organ damage, concomitant therapy with ACE inhibitor and angiotensin-receptor blocker is associated with a higher frequency of hypotension, syncope, hyperkalaemia, and worsening renal function (including acute renal failure) as compared to use of a single renin-angiotensin- aldosterone system agent. Dual blockade (e.g. by combining an ACE-inhibitor with an angiotensin II receptor antagonist) should be limited to individually defined cases with close monitoring of renal function, potassium levels, and blood pressure.

Racecadotril

ACE inhibitors (e.g. perindopril) are known to cause angioedema. This risk may be elevated when used concomitantly with racecadotril (a drug used against acute diarrhoea).

mTOR inhibitors (e.g. sirolimus, everolimus, temsirolimus)

Patients taking concomitant mTOR inhibitors therapy may be at increased risk for angioedema (see section 4.4)

Estramustine

Risk of increased adverse effects such as angioneurotic oedema (angioedema).

Potassium-sparing diuretics (e.g. triamterene, amiloride), potassium salts

Hyperkalaemia (potentially lethal), especially in conjunction with renal impairment (additive hyperkalaemic effects).

The combination of perindopril with the above-mentioned medicinal products is not recommended (see section 4.4). If concomitant use is nonetheless indicated, they should be used with caution and with frequent monitoring of serum potassium. For use of spironolactone in heart failure, see below.

Lithium

Reversible increases in serum lithium concentrations and toxicity have been reported during concomitant administration of lithium with ACE inhibitors. Use of perindopril with lithium is not recommended, but if the combination proves necessary, careful monitoring of serum lithium levels should be performed (see section 4.4).

Concomitant use which requires special care:

Antidiabetic agents (insulins, oral hypoglycaemic agents)

Epidemiological studies have suggested that concomitant administration of ACE inhibitors and antidiabetic medicinal products (insulins, oral hypoglycaemic agents) may cause an increased blood-glucose lowering effect with risk of hypoglycaemia. This phenomenon appeared to be more likely to occur during the first weeks of combined treatment and in patients with renal impairment.

Baclofen

Increased antihypertensive effect. Monitor blood pressure and adapt antihypertensive dosage if necessary.

Non-potassium sparing diuretics

Patients on diuretics, and especially those who are volume and/or salt depleted, may experience excessive reduction in blood pressure after initiation of therapy with an ACE inhibitor. The possibility of hypotensive effects can be reduced by discontinuation of the diuretic, by increasing volume or salt intake prior to initiating therapy with low and progressive doses of perindopril.

In arterial hypertension, when prior diuretic therapy can have caused salt/volume depletion, either the diuretic must be discontinued before initiating the ACE inhibitor, in which case a non-potassium-sparing diuretic can be thereafter reintroduced or the ACE inhibitor must be initiated with a low dosage and progressively increased.

In diuretic-treated congestive heart failure, the ACE inhibitor should be initiated at a very low dosage, possibly after reducing the dosage of the associated non-potassium- sparing diuretic.

In all cases, renal function (creatinine levels) must be monitored during the first few weeks of ACE inhibitor therapy.

Potassium-sparing diuretics (eplerenone, spironolactone)

With eplerenone or spironolactone at doses between 12.5 mg to 50 mg by day and with low doses of ACE inhibitors:

In the treatment of class II-IV heart failure (NYHA) with an ejection fraction < 40%, and previously treated with ACE inhibitors and loop diuretics, risk of hyperkalaemia, potentially lethal, especially in case of non-observance of the prescription recommendations on this combination.

Before initiating the combination, check the absence of hyperkalaemia and renal impairment.

Close monitoring of the kalaemia and creatinaemia is recommended in the first month of the treatment once a week at the beginning and, monthly thereafter.

Non-steroidal anti-inflammatory medicinal products (NSAIDs), including aspirin ≥3 g/day

When ACE-inhibitors are administered simultaneously with non-steroidal anti- inflammatory drugs (i.e. acetylsalicylic acid at anti-inflammatory dosage regimens, COX-2 inhibitors and non-selective NSAIDs), attenuation of the anti-hypertensive effect may occur. Concomitant use of ACE-inhibitors and NSAIDs may lead to an increased risk of worsening of renal function, including a risk of acute renal failure, and an increase in serum potassium, especially in patients with poor pre-existing renal function. The combination should be administered with caution, especially in the elderly. Patients should be adequately hydrated and consideration should be given to monitoring renal function at the beginning of the treatment and periodically thereafter.

Concomitant use which requires some care:

Anti-hypertensive agents and vasodilators

Concomitant use of these agents may increase the hypotensive effects of perindopril. Concomitant use with nitroglycerin and other nitrates, or other vasodilators, may further reduce blood pressure.

Gliptins (linagliptin, saxagliptin, sitagliptin, vildagliptin)

Increased risk of angioedema, due to dipeptidyl peptidase IV (DPP-IV) decreased activity by the gliptin, in patients co-treated with an ACE inhibitor.

Tricyclic antidepressants/Antipsychotics/Anaesthetics

Concomitant use of certain anaesthetic medicinal products, tricyclic antidepressants and antipsychotics with ACE inhibitors may result in further reduction of blood pressure (see section 4.4).

Sympathomimetics

Sympathomimetics may reduce the anti-hypertensive effects of ACE inhibitors.

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.

4.6 Fertility, pregnancy and lactation

Pregnancy

The use of ACE inhibitors is not recommended during the first trimester of pregnancy (see section 4.4). The use of ACE inhibitors is contraindicated during the 2nd and 3rd trimesters of pregnancy (see sections 4.3 and 4.4).

Epidemiological evidence regarding the risk of teratogenicity following exposure to ACE inhibitors during the first trimester of pregnancy has not been conclusive; however a small increase in risk cannot be excluded. 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.

Exposure to ACE inhibitor therapy during the second and third trimesters is known to induce human foetotoxicity (decreased renal function, oligohydramnios, skull ossification retardation) and neonatal toxicity (renal failure, hypotension, hyperkalaemia) (see section 5.3).

Should exposure to ACE inhibitor have occurred from the second trimester of pregnancy, ultrasound check of renal function and skull is recommended. Infants whose mothers have taken ACE inhibitors should be closely observed for hypotension (see also sections 4.3 and 4.4).

Breast-feeding

Because no information is available regarding the use of perindopril erbumine during breast-feeding, Perindopril Erbumine is not recommended and alternative treatments with better established safety profiles during breast-feeding are preferable, especially while nursing a newborn or preterm infant.

Fertility

There was no effect on reproductive performance or fertility.

4.7 Effects on ability to drive and use machines

Perindopril 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.

4.8 Undesirable effects

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 (≥1/1,000 to <1/100); Rare (≥1/10,000 to <1/1,000); Very rare (<1/10,000); 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 (see section 4.4).

Metabolism and nutrition disorders

Uncommon: hypoglycaemia* (see sections 4.4 and 4.5), hyperkalaemia*, reversible on discontinuation (see section 4.4), hyponatraemia*
Psychiatric disorders
Uncommon: mood or sleep disturbances.
Nervous system disorders
Common: headache, dizziness, vertigo, paresthaesia. Uncommon: somnolence*, syncope*
Very rare: confusion.
Eye disorders
Common: vision disturbance.
Ear and labyrinth disorders
Common: tinnitus.
Cardiac disorders
Uncommon: palpitations*, tachycardia*
Very rare: arrhythmia, angina pectoris (see section 4.4) and myocardial infarction, possibly secondary to excessive hypotension in high-risk patients (see section 4.4).
Vascular disorders
Common: hypotension (and effects related to hypotension). Uncommon: vasculitis*
Very rare: stroke, possibly secondary to excessive hypotension in high-risk patients (see section 4.4).
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 (see section 4.4).
Skin and subcutaneous tissue disorders
Common: rash, pruritus.
Uncommon: angioedema of face, extremities, lips, mucous membranes, tongue, glottis and/or larynx, urticaria (see section 4.4), 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.

Cases of SIADH have been reported with other ACE inhibitors. SIADH can be considered as a very rare but possible complication associated with ACE inhibitor therapy including perindopril.

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.

4.9 Overdose

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 (see section 4.4). Pacemaker therapy is indicated for therapy-resistant bradycardia. Vital signs, serum electrolytes and creatinine concentrations should be monitored continuously.

  1. Pharmacological properties

5.1 Pharmacodynamic properties

Pharmacotherapeutic group: ACE inhibitor, plain.

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 renin angiotensin aldosterone 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.

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.

5.2 Pharmacokinetic properties

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, perindopril 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 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 (see sections 4.2 and 4.4).

5.3 Preclinical safety data

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 foetal development, resulting in foetal 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 either in male or in female rats.

No carcinogenicity has been observed in long-term studies in rats and mice.

  1. Pharmaceutical particulars

6.1 List of excipients

Cellulose, microcrystalline,

Sodium hydrogen carbonate,

Lactose,

Anhydrous colloidal silica,

Magnesium stearate

Aluminium lake of sodium copper chlorophyllin

6.2 Incompatibilities

Not applicable.

6.3 Shelf life

2 years

6.4 Special precautions for storage

Do not store above 25 °C

6.5 Nature and contents of container

Aluminium Blister Pack

Pack sizes: 14, 30, 60, 90, 100 tablets.

Not all pack sizes may be marketed.

7. Manufactured in India by:
TAJ PHARMACEUTICALS LTD.
Mumbai, India
Unit No. 214.Old Bake House,
Maharashtra chambers of  Commerce Lane,
Fort, Mumbai – 400001
at:Gujarat, INDIA.
Customer Service and Product Inquiries:
1-800-TRY-FIRST (1-800-222-434 & 1-800-222-825)
Monday through Saturday 9:00 a.m. to 7:00 p.m. EST
E-mail: tajgroup@tajpharma.com

Perindopril Erbumine Tablets 2mg/4mg/8mg Taj Pharma

Package leaflet: Information for the patient

perindopril tert-butylamine

Read all of this leaflet carefully before you start taking this medicine because it contains important information for you

  • Keep this leaflet. You may need to read it again.
  • If you have any further questions, ask your doctor or pharmacist.
  • This medicine has been prescribed for you only. Do not pass it on to others. It may harm them, even if their signs of illness are the same as yours.
  • If you get any side effects talk to your doctor or pharmacist. This includes any possible side effects not listed in this leaflet. See section 4.

What is in this leaflet:

  1. What Perindopril Erbumine is and what it is used for
  2. What you need to know before you take Perindopril Erbumine
  3. How to take Perindopril Erbumine
  4. Possible side effects
  5. How to store Perindopril Erbumine
  6. Contents of the pack and other information

 

  1. What Perindopril Erbumine is and what it is used for

Perindopril Erbumine Tablets contain the active substance perindopril erbumine which belongs to a group of medicines known as angiotensin converting enzyme (ACE) inhibitors. These work by making your blood vessels wider, which makes it easier for your heart to pump blood through them.

Perindopril Erbumine is used:

  • to treat high blood pressure (hypertension)
  • to reduce the risk of cardiac events, such as heart attack, in patients with stable coronary artery disease (a condition where the blood supply to the heart is reduced or blocked) and who have already had a heart attack and/or an operation to improve the blood supply to the heart by widening the blood vessels supplying it.
  1. What you need to know before you take Perindopril Erbumine

Do not take Perindopril Erbumine:

  • if you are allergic to perindopril, to any other ACE inhibitor or to any of the other ingredients of this medicine (listed in section 6),
  • if you are more than 3 months pregnant (it is also better to avoid perindopril in early pregnancy – see pregnancy section),
  • if you have experienced symptoms such as wheezing, swelling of the face, tongue or throat, intense itching or severe skin rashes with previous ACE inhibitor treatment or if you or a member of your family have had these symptoms in any other circumstances (a condition called angioedema).
  • if you have diabetes or impaired kidney function and you are treated with a blood pressure lowering medicine containing aliskiren.
  • if you are having dialysis or any other type of blood filtration. Depending on the machine that is used, Perindopril erbumine may not be suitable for you.

if you have kidney problems where the blood supply to your kidneys is reduced (renal artery stenosis)

Warnings and precautions

Talk to your doctor or pharmacist before taking Perindopril Erbumine if you:

  • have aortic stenosis (narrowing of the main blood vessel leading from the heart) or hypertrophic cardiomyopathy (heart muscle disease) or renal artery stenosis (narrowing of the artery supplying the kidney with blood),
  • have any other heart problems,
  • have liver problems,
  • have kidney problems or if you are receiving dialysis,
  • have abnormally increased levels of a hormone called aldosterone in your blood (primary aldosteronism),
  • suffer from a collagen vascular disease (disease of the connective tissue) such as systemic lupus erythematosus or scleroderma,
  • have diabetes, and are taking antidiabetic medicines, including insulin to control your diabetes (your blood should be monitored for low blood glucose levels, especially during the first month of treatment)
  • are on a salt restricted diet or use salt substitutes which contain potassium,
  • have recently suffered from diarrhoea or vomiting, or are dehydrated,
  • are of black origin since you may have a higher risk of angioedema and this medicine may be less effective in lowering your blood pressure than in non-black patients.
  • are taking any of the following medicines used to treat high blood pressure:

–           an angiotensin II receptor blocker (ARBs) (also known as sartans – for example valsartan, telmisartan, irbesartan), in particular if you have diabetes-related kidney problems.

–           aliskiren

  • are taking any of the following medicines, the risk of angioedema (rapid swelling under the skin in areas such as the throat) is increased:

–           racecadotril (used to treat diarrhoea)

–           sirolimus, everolimus, temsirolimus and other medicines belonging to the class of mTOR inhibitors (used to avoid rejection of transplanted organs)

Your doctor may check your kidney function, blood pressure, and the amount of electrolytes (e.g. potassium) in your blood at regular intervals.

Angioedema

Angioedema (a severe allergic reaction with swelling of the face, lips, tongue or throat with difficulty in swallowing or breathing) has been reported in patients treated with ACE inhibitors, including perindopril erbumine. This may occur at any time during treatment. If you develop such symptoms you should stop taking Perindopril Erbumine and see a doctor immediately. See also section 4.

See also information under the heading “Do not take Perindopril Erbumine” During treatment tell your doctor or pharmacist:

  • if you develop signs of an infection (e.g. sore throat, fever)
  • if you develop yellowing of the skin or whites of the eyes (jaundice)
  • if you are to undergo anaesthesia and/or major surgery,
  • if you are to undergo LDL apheresis (which is removal of cholesterol from your blood by a machine),
  • if you are going to have desensitisation treatment to reduce the effects of an allergy to bee or wasp stings,
  • if you think that you are (or might become) pregnant. Perindopril Erbumine is not recommended in early pregnancy, and must not be taken if you are more than 3 months pregnant, as it may cause serious harm to your baby if used at that stage (see Pregnancy and breast-feeding section).

Children and adolescents

Perindopril erbumine is not recommended for use in children and adolescents less than 18 years old.

Other medicines and Perindopril Erbumine

Tell your doctor or pharmacist if you are taking, have recently taken or might take any other medicines.

Perindopril erbumine can affect the way some other medicines work and some medicines can have an effect on Perindopril Erbumine. In particular, tell your doctor if you are using any of the following medicines:

  • other medicines for high blood pressure, including diuretics (medicines which increase the amount of urine produced by the kidneys),
  • potassium-sparing medicines (e.g. triamterene, amiloride), potassium supplements or potassium- containing salt substitutes,
  • potassium-sparing medicines used in the treatment of heart failure (e.g. eplerenone, spironolactone at doses between 12.5 mg and 50 mg per day), other medicines which can increase potassium in your body (such as co-trimoxazole also known as trimethoprim/sulfamethoxazole),
  • lithium (a medicine for mental health problems such as mania or depression)
  • non-steroidal anti-inflammatory drugs (e.g. ibuprofen, diclofenac) for pain relief or high dose aspirin,
  • medicines to treat diabetes (such as gliptins, insulin or metformin),
  • baclofen (used to treat muscle stiffness in diseases such as multiple sclerosis)
  • medicines to treat mental disorders such as depression, anxiety or schizophrenia (e.g. tricyclic antidepressants, antipsychotics),
  • immunosuppressants (medicines which reduce the defence mechanism of the body), used for the treatment of auto-immune disorders or following transplant surgery (e.g. ciclosporin, tacrolimus),
  • trimethoprim (used for the treatment of infections)
  • estramustine (used in cancer therapy)
  • medicines for the treatment of gout (e.g. allopurinol),
  • medicines for the treatment of an irregular heart beat (e.g. procainamide),
  • medicines that make the blood vessels become wider (i.e. vasodilators, including nitroglycerin and other nitrates),
  • medicines used to thin blood (e.g. heparin),
  • medicines used for the treatment of low blood pressure, shock or asthma (e.g. ephedrine, noradrenaline or adrenaline).
  • gold salts, especially with intravenous administration (used to treat symptoms of arthritis)

 

Treatment with Perindopril Erbumine can be affected by other medicines. Your doctor may need to change your dose and/or to take other precautions. These include:

  • if you are taking an angiotensin II receptor blocker (ARB) or aliskiren (see also information under the headings “Do not take Perindopril Erbumine” and “Warnings and precautions”).
  • medicines, which is most often used to treat diarrhoea (racecadotril) or avoid rejection of transplanted organs (sirolimus, everolimus, temsirolimus and other medicines belonging to the class of mTOR inhibitors). See section “Warnings and precautions”.

Pregnancy and breast-feeding

If you are pregnant or breast-feeding, think you maybe pregnant or are planning to have a baby ask your doctor or pharmacist for advice before taking this medicine.

Pregnancy

You must tell your doctor if you think you are (or might become) pregnant. Your doctor will normally advise you to stop taking Perindopril Erbumine before you become pregnant or as soon as you know you are pregnant and will advise you to take another medicine instead of Perindopril Erbumine. Perindopril Erbumine is not recommended in early pregnancy, and must not be taken when more than 3 months pregnant, as it may cause serious harm to your baby if used after the third month of pregnancy.

Breast-feeding

Tell your doctor if you are breast-feeding or about to start breast-feeding. Perindopril Erbumine is not recommended for mothers who are breast-feeding, and your doctor may choose another treatment for you if you wish to breast-feed, especially if your baby is newborn, or was born prematurely.

Driving and using machines

Perindopril erbumine usually does not affect alertness but dizziness or weakness due to low blood pressure may occur in certain patients. If you are affected in this way, your ability to drive or to operate machinery may be impaired.

Perindopril Erbumine contains Lactose

Perindopril Erbumine contains lactose. If you have been told by your doctor that you have an intolerance to some sugars, such as lactose, contact your doctor before taking this medicinal product.

This medicine contains less than 1 mmol sodium (23 mg) per tablet, that is to say essentially ‘sodium-free’

  1. How to take Perindopril Erbumine

Always take this medicine exactly as your doctor or pharmacist has told you. Check with your doctor or pharmacist if you are not sure.

Swallow your tablet with a glass of water, preferably at the same time each day, in the morning and before a meal. Your doctor will decide on the correct dose for you. The 4 mg tablet can be divided into equal doses.

The recommended dose for Perindopril Erbumine is:

High blood pressure:

The recommended starting and maintenance dose is 4 mg once daily. After one month, this can be increased to 8 mg once a day if required. The maximum recommended dose for high blood pressure is 8 mg a day.

Elderly patients with high blood pressure:

If you are 65 years old or older, the recommended starting dose is 2 mg once a day. After a month this can be increased to 4 mg once a day and then, if necessary, to 8 mg once daily.

Stable coronary artery disease:

The recommended starting dose is 4 mg once daily. After two weeks, this can be increased to 8 mg once a day, which is the maximum recommended dose for this indication.

Elderly patients with stable coronary artery disease:

If you are 65 years old or older, the recommended starting dose is 2 mg once a day. After a week this can be increased to 4 mg once a day and after a further week, to 8 mg once daily.

Patients with kidney problems:

If you have kidney problems, your doctor will alter the dose depending on how well your kidneys are working.

If you take more Perindopril Erbumine than you should

If you take too many tablets, contact your nearest accident and emergency department or tell your doctor immediately. The most likely effect in case of overdose is low blood pressure, which can make you feel dizzy or faint. If this happens, lying down with the legs raised can help. Other side effects may include: kidney failure, shock, imbalance of minerals in the body, rapid or deep breathing, increase in heart rate, irregular heart-beat, slowing of heart rate, anxiety and cough.

If you forget to take Perindopril Erbumine

It is important to take your medicine every day as regular treatment works better. However, if you forget to take a dose of Perindopril Erbumine, take the next dose at the usual time. Do not take a double dose to make up for a forgotten dose.

If you stop taking Perindopril Erbumine

As the treatment with perindopril erbumine is usually life-long, you should discuss with your doctor before stopping this medicine.

If you have any further questions on the use of this product, ask your doctor or pharmacist.

  1. Possible Side Effects

Like all medicines, this medicine can cause side effects, although not everybody gets them.

If you experience any of the following side effects, stop taking this medicine at once and tell your doctor or go to the nearest hospital casualty department immediately:

Common (may affect up to 1 in 10 people):

  • severe dizziness or fainting due to low blood pressure

Uncommon (may affect up to 1 in 100 people):

  • swelling of the face, lips, mouth, tongue or throat, difficulty in breathing (angioedema),
  • tightening of the chest, wheezing and shortness of breath (bronchospasm),
  • intense itching or severe skin rash, formation of blister clusters over the skin (pemphigoid)
  • producing little or no urine, cloudy urine, pain when passing urine or lower back pain (these may be signs of serious problems with your kidneys)

Very rare (may affect up to 1 in 10,000 people):

  • unusual fast or irregular heart-beat., chest pain (angina) or heart attack
  • weakness of arms or legs, or problems speaking which could be sign of a possible stroke
  • inflamed pancreas which may cause severe abdominal and back pain accompanied with feeling very unwell
  • yellowing of the skin or eyes (jaundice) which could be a sign of liver problems
  • skin rash which often starts with red itchy patches on your face, arms or legs (erythema multiforme)
  • disorders of the blood, such as decreased number of all or certain blood cell types – you may notice a pale skin colour, headache, an increase in infections such as sore throat, mouth ulcers etc. with fever, an increase in unexpected bruising or bleeding, or feel tired, dizzy, breathless and weak.
  • eosinophilic pneumonia (a rare type of pneumonia). You may develop cough, high temperature and have difficulty breathing.

Other possible side effects:

Common (may affect up to 1 in 10 people):

  • headache, dizziness, vertigo, pins and needles,
  • vision disturbances,
  • tinnitus (sensation of noises in the ears),
  • light-headedness due to low blood pressure,
  • cough, shortness of breath,
  • gastro-intestinal disorders (nausea (feeling sick), vomiting (being sick), abdominal pain, taste disturbances, indigestion, diarrhoea, constipation),
  • allergic reactions (such as skin rashes, itching),
  • muscle cramps,
  • feeling of weakness or tiredness.

Uncommon (may affect up to 1 in 100 people):

  • mood swings
  • fast heart rate, thump in the chest
  • sleep disturbances,
  • dry mouth,
  • impotence,
  • excessive sweating
  • excess of eosinophils in the blood (a type of white blood cell). This may show up in blood tests.
  • somnolence
  • fainting
  • vasculitis (inflammation of blood vessels)
  • photosensitivity reaction (increased sensitivity of the skin to sun)
  • arthralgia (joint pain), myalgia (muscle pain)
  • chest pain
  • peripheral oedema (swelling of the hands or feet/ankles)
  • fever
  • fall
  • high level of potassium in the blood (reversible on discontinuation)
  • low level of sodium in the blood
  • hypoglycaemia (very low blood sugar level). This is important in case of diabetic patients.
  • increased blood urea, and increased blood creatinine. These may show up in blood tests.

Rare (may affect up to 1 in 1,000 people):

  • increased level of liver enzymes, high level of serum bilirubin. This may show up in blood tests.
  • psoriasis worsening

Very rare (may affect up to 1 in 10,000 people):

  • confusion,
  • rhinitis (blocked up or runny nose),
  • disorders of the blood such as a lower number of red blood cells, lower haemoglobin, lower number of blood platelets.

Concentrated urine (dark in colour), feel or are sick, have muscle cramps, confusion and fits which may be due to inappropriate ADH (anti-diuretic hormone) secretion. If you have these symptoms contact your doctor as soon as possible.

Reporting of side effects

If you get any side effects talk to your doctor or pharmacist. This includes any possible side effects not listed in this leaflet.

  1. How to store Perindopril Erbumine

Keep this medicine out of the sight and reach of children. Do not store above 25 °C.

Do not use this medicine after the expiry date, which is stated on the carton and blister after EXP. The expiry date refers to the last day of that month.

Do not throw away any medicines via wastewater or household waste. Ask your pharmacist how to throw away medicines you no longer use. These measures will help protect the environment.

  1. Contents of the Pack and Other Information What Perindopril Erbumine contains

The active substance is perindopril tert-butylamine.

One 8 mg tablet contains 8 mg of perindopril tert-butylamine, equivalent to 6.676 mg of perindopril. The other ingredients are:

Lactose See section 2 ‘Perindopril erbumine contains lactose’, magnesium stearate, anhydrous colloidal silica, cellulose, microcrystalline, sodium hydrogen carbonate, aluminium lake of sodium copper chlorophyllin E141.

What Perindopril Erbumine looks like and contents of the pack

Perindopril Erbumine 8 mg tablets are green mottled, round, tablets marked with “PT8” on one side of the tablet and “M” on the other side.

Perindopril Erbumine is available in blisters of 14, 30, 60, 90 and 100 tablets. Not all pack sizes may be marketed.

7. Manufactured in India by:
TAJ PHARMACEUTICALS LTD.
Mumbai, India
Unit No. 214.Old Bake House,
Maharashtra chambers of  Commerce Lane,
Fort, Mumbai – 400001
at:Gujarat, INDIA.
Customer Service and Product Inquiries:
1-800-TRY-FIRST (1-800-222-434 & 1-800-222-825)
Monday through Saturday 9:00 a.m. to 7:00 p.m. EST
E-mail: tajgroup@tajpharma.com