Consumer medicine information

APO-Perindopril Tablets

Perindopril erbumine

BRAND INFORMATION

Brand name

APO-Perindopril

Active ingredient

Perindopril erbumine

Schedule

S4

 

Consumer medicine information (CMI) leaflet

Please read this leaflet carefully before you start using APO-Perindopril Tablets.

What is in this leaflet

This leaflet answers some common questions about perindopril. It does not contain all the available information about this medicine. It does not take the place of talking to your doctor or pharmacist. If you get any side effects, talk to your doctor, pharmacist or nurse. This includes any possible side effects not listed in this leaflet.

All medicines have risks and benefits. Your doctor has weighed the risks of you taking this medicine against the benefits they expect it will have for you.

If you have any concerns about taking this medicine, ask your doctor or pharmacist.

Keep this leaflet with the medicine. You may want to read it again.

What this medicine is used for

Perindopril is used to treat high blood pressure (also known as hypertension), heart failure or coronary artery disease.

Perindopril belongs to a group of medicines called angiotensin converting enzyme (ACE) inhibitors.

High blood pressure

Perindopril helps to lower your blood pressure. Everyone has blood pressure, which helps to circulate blood all around the body. Your blood pressure may be different at different times of the day, depending on how busy or worried you are. You have high blood pressure when your blood pressure stays higher than is needed, even when you are relaxed. There are usually no symptoms of high blood pressure. The only way of knowing that you have it is to have your blood pressure checked on a regular basis. Untreated high blood pressure can lead to serious health problems, such as stroke, heart disease and kidney failure.

Heart failure

Perindopril helps to treat heart failure. Heart failure means that the heart muscle is not pumping blood strongly enough to circulate blood around the body properly. Heart failure is not the same as a heart attack and does not mean that the heart stops working. Heart failure may start off with no symptoms, but as the condition progresses, you may feel short of breath or get tired easily after light physical activity such as walking. Fluid may accumulate in the body, such as swollen ankles and feet. In severe heart failure, symptoms like breathlessness may occur even at rest. If you follow your doctor's advice, your ability to perform daily activities may improve. You may breathe more easily, feel less tired and have less swelling.

Coronary artery disease

Coronary artery disease is the narrowing of the vessels carrying blood to the heart. Perindopril has been shown to reduce some risks of coronary artery disease, including heart attacks.

Ask your doctor if you have any questions about why this medicine has been prescribed for you. Your doctor may have prescribed this medicine for another reason.

This medicine is available only with a doctor's prescription.

This medicine is not addictive.

There is not enough information to recommend the use of this medicine for children. This medicine should not be used in children.

Before you take this medicine

When you must not take it

Do not take this medicine if you have an allergy to:

  • perindopril
  • any of the ingredients listed at the end of this leaflet.

Some of the symptoms of an allergic reaction may include:

  • shortness of breath, wheezing or difficulty breathing
  • swelling of the face, lips, tongue, throat or other parts of the body
  • rash, itching or hives on the skin.

Do not take this medicine if you have or have had any of the following medical conditions:

  • diabetes or kidney impairment and are taking aliskiren to treat high blood pressure
  • undergoing renal dialysis or haemofiltration using polyacrylonitrile membranes
  • unilateral or bilateral renal artery stenosis (narrowing of the blood vessels to one or both kidneys that reduces the blood supply to your kidneys).
  • you have experienced symptoms such as wheezing, swelling of the face, tongue, lips 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 either spontaneously or, in response to another medicine in the past (a rare condition called angioedema)
  • you undergo treatments where your blood is treated outside of the body (also known as extracorporeal treatments) that may increase your risk of allergic reactions, treatments such as: - renal dialysis or haemofiltration using polyacrylonitrile membranes. - low-density lipoprotein (LDL) apheresis, a technique where LDL is 'filtered' out of the blood, using dextran sulphate
  • intolerance or allergy to lactose (this medicine contains lactose)

Do not take this medicine if you are taking a combined medicine called sacubitril/valsartan, used to treat long-term heart failure as the risk of angioedema (rapid swelling under the skin in an area such as the throat) is increased.

Do not take this medicine if you are pregnant or plan to become pregnant. Perindopril may affect your developing baby if you take it during pregnancy.

Do not take this medicine if you are breastfeeding. It is not known if perindopril passes into human breast milk.

Do not take this medicine after the expiry date printed on the pack or if the packaging is torn or shows signs of tampering. If it has expired or is damaged, return it to your pharmacist for disposal.

If you are not sure whether you should start taking this medicine, talk to your doctor.

Before you start to take it

Tell your doctor if you have allergies to any other medicines, foods, preservatives or dyes.

Tell your doctor if you have or have had any of the following medical conditions:

  • aortic stenosis (narrowing of the main blood vessel leading from the heart)
  • kidney disease or if you are on renal dialysis
  • liver disease
  • heart disease, including hypertrophic cardiomyopathy (heart muscle disease)
  • low blood pressure
  • diabetes
  • aortic stenosis (narrowing of the main blood vessel leading from the heart)
  • high or low levels of potassium, sodium or other problems with salt balance
  • systemic lupus erythematous or scleroderma (a disease affecting the skin, joints and kidneys)
  • have abnormally increased levels of a hormone called aldosterone in your blood (primary aldosteronism)

Tell your doctor straight away if:

  • you are on a salt restricted diet or use salt substitutes containing potassium
  • you are undergoing, or you are intending to undergo, treatments where your blood is treated outside of the body (also known as extracorporeal treatments)
  • you are undergoing, or have had an allergic reaction during, previous low-density lipoprotein (LDL) apheresis, a technique where LDL is 'filtered' out of a patient's blood, using dextran sulphate
  • you have recently suffered from diarrhoea or vomiting or are dehydrated.
  • you have an intolerance to some sugars as this medicine contains lactose
  • you are taking lithium (used to treat mania or depression)
  • you are undergoing de-sensitisation treatment or have had an allergic reaction during previous desensitisation treatment (e.g. treatments using bee, wasp or ant venom)
  • you are pregnant or become pregnant while taking this medicine, as it may cause serious harm to your baby

Tell your doctor if you also take an angiotensin II receptor blocker (e.g. valsartan, telmisartan, irbesartan), in particular if you have diabetes-related kidney problems.

Tell your doctor if you are taking aliskiren.

Tell your doctor you are of African origin since you may have a higher risk of angioedema and this medicine is less effective in lowering your blood pressure.

Tell your doctor if you are planning to have surgery, dental treatment or an anaesthetic.

If you have not told your doctor about any of the above, tell them before you start taking this medicine. If you think any of these situations apply to you, or you have any doubts or questions about taking this medication consult your doctor or pharmacist.

Taking other medicines

Tell your doctor if you are taking any other medicines, including any that you get without a prescription from your pharmacy, supermarket or health food shop.

Some medicines may interact with perindopril. These include:

  • some antibiotics and medicines used to treat infection
  • some anti-inflammatory drugs for pain relief (e.g. high dose aspirin, ibuprofen)
  • medicines used to treat mood disorders and some types of depression (e.g. lithium, tricyclic antidepressants, antipsychotics)
  • potassium-sparing diuretics, sources of potassium, like potassium tablets, salt substitutes containing potassium, other drugs which can increase potassium in your body (such as heparin, a medicine used to thin blood to prevent clots, co-trimoxazole also known as trimethoprim/sulfamethoxazole for infections caused by bacteria and ciclosporin, an immunosuppressant medicine used to prevent organ transplant rejection)
  • some treatments where your blood is treated outside of the body, also known as extracorporeal treatments
  • heparin, used to thin the blood
  • immunosuppressants, medicines which reduce the activity of the body's natural defences
  • some medications used to treat high blood pressure (including angiotensin receptor blockers), aliskiren, diuretics (sometimes called "fluid" or "water" tablets because they increase the amount of urine passed each day)
  • medications used to treat fast or irregular heartbeat and other heart conditions vasodilators (e.g. nitrates)
  • medicines used to treat diabetes (tablets and insulin)
  • medicines which may affect the blood cells, such as allopurinol, procainamide
  • baclofen (a medicine used to treat muscle stiffness in diseases such as multiple sclerosis)
  • medicines used for the treatment of low blood pressure, shock or asthma (e.g. ephedrine, noradrenaline or adrenaline (epinephrine))
  • gold salts, especially with intravenous administration (used to treat symptoms of rheumatoid arthritis)
  • medicines which may increase the risk of angioedema (a severe allergic reaction) such as: - mammalian target of rapamycin (mTOR) inhibitors used to avoid rejection of transplanted organs (e.g. temsirolimus, sirolimus, everolimus) - sacubitril (available as fixed- dose combination with valsartan), used to treat long- term heart failure
  • gliptins used to treat diabetes (e.g. linagliptin, saxagliptin, sitagliptin, vildagliptin, alogliptin)

These medicines may be affected by this medicine or may affect how well it works. You may need different amounts of your medicines, or you may need to take different medicines.

Your doctor and pharmacist have more information on medicines to be careful with or avoid while taking this medicine. It is a good idea to remind your doctor of all other medicines you take.

Other medicines not listed above may also interact with perindopril.

How to take this medicine

Follow all directions given to you by your doctor carefully. They may differ to the information contained in this leaflet.

If you do not understand the instructions on the box, ask your doctor or pharmacist for help.

How much to take

Your doctor will tell you how much of this medicine you should take. This will depend on your condition, such as elderly people or severe kidney failure, and whether you are taking any other medicines.

High blood pressure, coronary artery disease
The dose you may need each day will be decided and adjusted by your doctor. This will normally be 2 mg,4 mg or 8 mg once daily.

Heart failure
The dose you may need each day will be decided and adjusted by your doctor. This will normally be 2 mg to 4 mg once daily.

How to take it

Swallow your tablet whole with a glass of water.

When to take it

Take it at about the same time each day, preferably in the morning before a meal. Taking your medicine at the same time each day will have the best effect. It will also help you remember when to take it.

How long to take it for

Continue taking your medicine for as long as your doctor tells you.

Perindopril can help control your condition, but cannot cure it. It is important to keep taking your medicine even if you feel well.

Make sure you have enough to last over weekends and holidays.

If you forget to take it

If it is almost time to take your next dose, skip the dose you missed and take your next dose when you are meant to.

Otherwise, take it as soon as you remember and then go back to taking your medicine as you would normally.

Do not take a double dose to make up for missed doses. This may increase the chance of you experiencing side effects.

If you have trouble remembering to take your medicine, ask your pharmacist for some hints.

If you take too much (overdose)

Immediately telephone your doctor or the Poisons Information Centre (telephone 13 11 26) for advice, or go to Accident and Emergency at your nearest hospital, if you think that you or anyone else may have taken too much of this medicine. Do this even if there are no signs of discomfort or poisoning. You may need urgent medical attention.

If you take too much perindopril, your blood pressure may fall (also known as hypotension), which can make you feel dizzy or faint. If this happens, lying down with the legs elevated can help. Other effects like sickness, cramps, sleepiness, confusion, kidney problems, salt and water disturbances are possible.

While you are taking this medicine

Things you must do

If you are about to be started on any new medicine, remind your doctor and pharmacist that you are taking this medicine.

Tell any other doctors, dentists and pharmacists who are treating you that you take this medicine.

If you become pregnant while taking this medicine, tell your doctor immediately.

Tell your doctor if you are about to have any blood tests.

Tell your doctor if you are going to have surgery or an anaesthetic or are going into hospital.

Keep all of your doctor's appointments so that your progress can be checked. Your doctor may occasionally do tests to make sure the medicine is working and to prevent side effects.

Make sure you drink enough water during exercise and hot weather especially if you sweat a lot. This will help you avoid any dizziness or light-headedness caused by a sudden drop in blood pressure.

Tell your doctor straight away if you have excessive vomiting or diarrhoea while taking this medicine.

Things you must not do

Do not give this medicine to anyone else, even if they have the same condition as you.

Do not take your medicine to treat any other complaint unless your doctor tells you to.

Do not stop taking your medicine or change the dosage without first checking with your doctor.

Do not stop taking your tablets because you are feeling better, unless advised by your doctor.

Things to be careful of

Be careful while driving or operating machinery until you know how perindopril affects you. Dizziness or weakness due to low blood pressure may occur in certain patients. If you have any of these symptoms do not drive or operate machinery or do anything else that could be dangerous.

Side effects

Tell your doctor and pharmacist as soon as possible if you do not feel well while you are taking perindopril.

This medicine helps most people, but it may have unwanted side effects in a few people. All medicines can have side effects. Sometimes they are serious, most of the time they are not. You may need medical attention if you get some of the side effects.

Do not be alarmed by the following lists of side effects. You may not experience any of them.

Ask your doctor or pharmacist to answer any questions you may have.

Angioedema (a severe allergic reaction) has been reported in patients treated with ACE inhibitors. This may occur at any time during treatment. If you experience any of the following, stop taking your medicine and contact your doctor immediately or go to Accident and Emergency at your nearest hospital. These side effects are extremely rare but can become serious:

  • swelling of your extremities (limbs, hands or feet), lips, face, mouth, tongue or throat
  • difficulty breathing, shortness of breath, wheezing
  • purple spots with occasional blisters on the front of your arms, legs, around your neck and ears (Stevens-Johnson Syndrome)
  • severe blisters, skin rash, itching, erythema multiforme or other allergic reactions
  • changes in the rhythm or rate of the heartbeat
  • fast or irregular heartbeat
  • fever, chest pain, shortness of breath, feeling unwell (signs of eosinophilic pneumonia)
  • feeling of tightness, pressure or heaviness in the chest (signs of myocardial infarction, angina)
  • frequent infections, fever, severe chills, sore throat or mouth ulcers (may be caused by a lack of white blood cells)
  • stroke.

These are very serious side effects and you may need urgent medical attention or hospitalisation.

Talk to your doctor or pharmacist if you notice any of the following side effects:

Common (may affect up to 1 in 10 people) side effects can include:

  • Cough, often described as dry and irritating, shortness of breath, discomfort on exertion
  • Headache, dizziness, vertigo, pins and needles
  • Changes in the rhythm or rate of the heart beat, fast or irregular heart beat
  • Feeling tired, lethargic or weak
  • Tinnitus (persistent noise in the ears), vision disturbances
  • Hypotension, flushing, impaired peripheral circulation, vasculitis, nose bleeds
  • Nausea, vomiting, taste disturbances, indigestion, diarrhoea, constipation, stomach pain or discomfort
  • Muscle cramps
  • Rash, pruritus (itching).

Uncommon (may affect up to 1 in 100 people) side effects can include:

  • High levels in the blood of potassium, urea and/or creatine, low sodium levels in the blood
  • Mood disturbance, sleep disturbances (difficulty sleeping, abnormal dreams), feeling sleepy or drowsy, fainting
  • Difficulty breathing or wheezing
  • Dry mouth
  • Swelling of the face, lips, mouth, tongue or throat which may cause difficulty in swallowing or breathing
  • Excessive sweating
  • Increased sensitivity of the skin to sun, skin rash or inflammation of the skin often including blisters that weep and become crusted
  • Increase in some white blood cells
  • Erectile dysfunction
  • Fever or high temperature
  • Chest pain
  • Kidney problems
  • Decreased blood sugar levels
  • Aching muscles, muscle tenderness or weakness, not caused by exercise
  • Generally feeling unwell
  • Falls.

Rare (may affect up to 1 in 1,000 people) side effects can include:

  • Elevation of bilirubin levels in the blood, increases in liver enzymes
  • Worsening of psoriasis
  • Kidney disease
  • Problems with production or passing of urine

Very rare (may affect up to 1 in 10,000 people) side effects can include:

  • Hepatitis
  • Inflammation of the pancreas (pancreatitis)
  • Eosinophilic pneumonia
  • Runny or blocked nose, sneezing, facial pressure or pain
  • Red, often itchy spots, similar to the rash of measles, which starts on the limbs and sometimes on the face and the rest of the body
  • Joint pain
  • Swelling of hands, ankles or feet
  • Bleeding or bruising more easily than normal caused by a low blood platelet count, frequent infections such as fever, severe chills, sore throat or mouth ulcers caused by a lack of white blood cells, pancytopenia (a rare type of anaemia)
  • Illnesses resulting from a lack of red blood cells
  • Stroke, myocardial infarction, angina pectoris (a feeling of tightness, pressure or heaviness in the chest)
  • Changes in the rhythm or rate of the heart beat
  • Confusion, depression or hallucinations

Not known (frequency cannot be estimated from the data available):

  • Discolouration, numbness and pain in fingers or toes (Raynaud’s phenomenon)

Other:

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

Tell your doctor or pharmacist if you notice anything that is making you feel unwell.

Other side effects not listed above may occur in some patients and you should ask your doctor, pharmacist or nurse if you want to know more.

Storage and disposal

Storage

Keep your medicine in the pack until it is time to take it. If you take your medicine out of the pack it may not keep well.

Keep your medicine in a cool, dry place where the temperature stays below 25°C. Do not store your medicine, or any other medicine, in the bathroom or near a sink. Do not leave it on a window sill or in the car. Heat and dampness can destroy some medicines.

Keep this medicine where children cannot reach it. A locked cupboard at least one-and-a-half metres above the ground is a good place to store medicines.

Disposal

If your doctor tells you to stop taking this medicine or the expiry date has passed, ask your pharmacist what to do with any medicine left over.

Product Description

What it looks like

Perindopril 2 mg tablets are white, round, biconvex tablets, engraved "APO" on one side and "PE2" on the reverse.

Blister packs of 30 tablets.
AUST R 151911

Perindopril 4 mg tablets are white, capsule shaped, biconvex tablets, engraved "PE" bisect "4" on one side, and "APO" on the reverse.

Blister packs of 30 tablets.
AUST R 151912

Perindopril 8 mg tablets are white, capsule shaped, biconvex tablets, engraved "PE" bisect "8" on one side, and "APO" on the reverse.

Blister packs of 30 tablets.
AUST R 151913

* Not all strengths may be available.

Ingredients

Each tablet contains 2 mg, 4 mg or 8 mg perindopril erbumine as the active ingredient.

It also contains the following:

  • lactose
  • magnesium stearate

This medicine does not contain gluten, sucrose, tartrazine or any other azo dyes.

Sponsor

Apotex Pty Ltd
16 Giffnock Avenue
Macquarie Park NSW 2113

APO is a registered trade mark of Apotex Inc.

This leaflet was last revised in:
June 2021.

Published by MIMS July 2021

BRAND INFORMATION

Brand name

APO-Perindopril

Active ingredient

Perindopril erbumine

Schedule

S4

 

1 Name of Medicine

Perindopril erbumine.

2 Qualitative and Quantitative Composition

Each tablet contains perindopril erbumine as the active ingredient.

APO-Perindopril tablets.

Each tablet contains 2 mg, 4 mg or 8 mg perindopril erbumine as the active ingredient.

Excipients with known effect.

Sugars as lactose.
For the full list of excipients see Section 6.1 List of Excipients.

3 Pharmaceutical Form

APO-Perindopril tablets.

2 mg tablets.

White, round, biconvex tablets, engraved "APO" on one side and "PE2" on the reverse.

4 mg tablets.

White, capsule shaped, biconvex tablets, engraved "PE" bisect "4" on one side, and "APO" on the reverse.

8 mg tablets.

White, capsule shaped, biconvex tablets, engraved "PE" bisect "8" on one side, and "APO" on the reverse.

4 Clinical Particulars

4.1 Therapeutic Indications

Treatment of hypertension.
Treatment of heart failure.
In such patients it is recommended that perindopril be given with a diuretic and/or digoxin under close medical supervision. (The safety and efficacy of perindopril have not been demonstrated for New York Heart Association category IV patients.)
Patients with established coronary artery disease (see Section 5.1 Pharmacodynamic Properties, Clinical trials), who are stable on concomitant therapy and have no heart failure, to reduce the risk of nonfatal myocardial infarction or cardiac arrest.

4.2 Dose and Method of Administration

APO-Perindopril Tablets are intended for oral administration.

Dosage.

Food intake may reduce hepatic biotransformation of perindopril to perindoprilat. While this effect has not been shown to be clinically significant, it is recommended that perindopril should be taken before meals.

Renal impairment.

In patients with renal failure, treatment should begin with 2 mg daily. Dosage should be adjusted as indicated in Table 1 according to creatinine clearance. Creatinine and potassium levels should be closely monitored.

Hypertension.

The usual starting dose of perindopril is 4 mg once daily, taken in the morning. Optimum control of blood pressure is achieved by increasing the dose, titrating it against the blood pressure to a maximum of 8 mg once daily.
A starting dose of perindopril 2 mg once daily is recommended in the following patients who may be at risk of ACE inhibitor induced hypotension.

Combination with a diuretic.

The administration of perindopril to patients under current treatment with a diuretic may induce hypotension and sometimes, but more rarely, acute renal failure, at the beginning of the treatment. Monitoring of plasma creatinine is recommended during the first month of treatment.

Elderly patients.

Elderly patients with hypertension should start treatment with 2 mg daily, with titration to 4 mg if necessary. It is recommended that renal function be assessed before starting treatment.

Other patients who may be at risk of ACE inhibitor induced hypotension.

Patients with renovascular hypertension, salt and/or volume depletion, or cardiac decompensation may have a strongly activated RAAS. These patients may experience an excessive drop in blood pressure following the first dose of an ACE inhibitor.

Congestive heart failure.

Note.

Treatment of congestive heart failure with perindopril should be initiated under close medical supervision.
The usual starting dose of perindopril is 2 mg once daily, which should be given with a diuretic and/or digitalis. This is increased to 4 mg daily for maintenance.
Patients with severe hepatic or renal impairment and/or severe salt/ volume depletion are particularly sensitive to ACE inhibitors. Doses in these patients should be carefully titrated, as no pharmacokinetic and dose titration studies have been conducted.

Reduction of risk of cardiovascular events.

In patients with stable coronary artery disease, Perindopril should be introduced at a dose of one 4 mg tablet once daily for two weeks, and then increased to one 8 mg tablet once daily, depending on tolerance and renal function.
Elderly patients should receive one 2 mg tablet once daily for one week, then one 4 mg tablet once daily the next week, before increasing the dose up to one 8 mg tablet once daily depending on tolerance and renal function (see Section 4.2 Dose and Method of Administration, Renal impairment, Table 1).

Elderly patients.

Renal insufficiency is commonly observed in elderly people. Care should therefore be taken when prescribing perindopril to elderly patients. The initial dose should always be 2 mg daily and patients should be monitored closely during the initial stages of treatment (see Section 4.4 Special Warnings and Precautions for Use).
Particular care should be taken in elderly patients with congestive heart failure who have renal and/or hepatic insufficiency.

Patients with hepatic impairment.

The small changes in the kinetics of perindoprilat do not justify the need to change the usual dose in most patients with hepatic failure (see Section 4.4 Special Warnings and Precautions for Use).

4.3 Contraindications

Perindopril is contraindicated in the following:
History of previous hypersensitivity to perindopril, ACE-inhibitors or to any component of the formulation.
During pregnancy and for lactating women.
Bilateral or unilateral renal artery stenosis (see Section 4.4 Special Warnings and Precautions for Use).
Patients with a history of hereditary and/or idiopathic angioedema, or angioedema associated with previous treatment with an angiotensin converting enzyme (ACE) inhibitor (see Section 4.4 Special Warnings and Precautions for Use).
In patients receiving 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 such as "AN69") and low density lipoprotein apheresis with dextran sulphate due to increased risk of severe anaphylactoid reactions following treatment with ACE inhibitors. This combination should therefore be avoided, either by use of alternative antihypertensive medicines or alternative membranes (e.g. cuprophane or polysulfone PSF) (see Section 4.4 Special Warnings and Precautions for Use; Section 4.5 Interactions with Other Medicines and Other Forms of Interactions).
Combined use with aliskiren-containing products in patients with diabetes or renal impairment (GFR < 60 mL/min/1.73 m2) (see Section 4.4 Special Warnings and Precautions for Use; Section 4.5 Interactions with Other Medicines and Other Forms of Interactions).
Combined use with sacubitril/valsartan fixed dose combinations - perindopril must not be initiated earlier than 36 hours after the last dose of sacubitril/valsartan (see Section 4.4 Special Warnings and Precautions for Use; Section 4.5 Interactions with Other Medicines and Other Forms of Interactions).

4.4 Special Warnings and Precautions for Use

Hyperkalaemia.

Since ACE inhibitors reduce angiotensin II formation resulting in decreased production of aldosterone, increases in serum potassium have been observed in some patients treated with ACE inhibitors including perindopril. Serum electrolytes (including sodium potassium and urea) should be measured from time to time when ACE inhibitors are given, especially when diuretics are also prescribed.
Hyperkalaemia can cause serious, sometimes fatal, arrhythmias. Risk factors for the development of hyperkalaemia include those with renal insufficiency, worsening of renal function, age (> 70 years), diabetes mellitus, intercurrent 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 medicines associated with increases in serum potassium (e.g. heparin, co-trimoxazole also known as trimethoprim/sulfamethoxazole). Concomitant use of the above mentioned medicines should be used with caution. Frequent monitoring of serum potassium is needed (see Section 4.5 Interactions with Other Medicines and Other Forms of Interactions). In some patients hyponatraemia may co-exist with hyperkalaemia.

Diabetic patients.

Glycaemic control should be closely monitored during the first month of treatment with an ACE inhibitor in patients with diabetes treated with oral medicines or insulin (see Section 4.5 Interactions with Other Medicines and Other Forms of Interactions).

Lithium.

The combination of lithium and perindopril is generally not recommended (see Section 4.5 Interactions with Other Medicines and Other Forms of Interactions).

Potassium sparing medicines, potassium supplements or potassium containing salt substitutes.

The combination of perindopril and potassium sparing medicines, potassium supplements or potassium containing salt substitutes is generally not recommended (see Section 4.5 Interactions with Other Medicines and Other Forms of Interactions).

Angioedema.

Patients with a history of angioedema unrelated to ACE inhibitor treatment may be at increased risk of angioedema while treated with an ACE inhibitor (see Section 4.3 Contraindications).
Life threatening angioedema has been reported with most of the ACE inhibitors. The overall incidence is approximately 0.1 to 0.2%. The aetiology is thought to be non-immunogenic and may be related to accentuated bradykinin activity. Usually the angioedema is non-pitting oedema of the skin, mucous membrane and subcutaneous tissue.
Angioedema of the face, extremities, lips, tongue, mucous membranes, glottis and/or larynx has been reported in patients treated with ACE inhibitors and has been reported uncommonly with perindopril (see Section 4.8 Adverse Effects (Undesirable Effects)). This may occur at any time during treatment. In such cases, perindopril should be promptly discontinued and the patient carefully observed until the swelling disappears.
Where such cases have been described with other ACE inhibitors and swelling has been confined to the face and lips, the condition has generally resolved without treatment although antihistamines have been useful in relieving symptoms. Angioedema associated with laryngeal oedema may be fatal or near fatal. In most cases symptoms occurred during the first week of treatment and the incidence appears to be similar in both sexes or those with heart failure or hypertension.
Where there is involvement of the tongue, glottis or larynx likely to cause airway obstruction, appropriate treatment (e.g. adrenaline (epinephrine) and oxygen) should be given promptly. Treatment of progressive angioedema should be aggressive and, failing a rapid response to medical treatment, mechanical methods to secure an airway should be undertaken before massive oedema complicates oral or nasal intubation.
Patients who respond to medical treatment should be observed carefully for a possible rebound phenomenon. The onset of angioedema associated with the use of ACE inhibitors may be delayed for weeks or months. Patients may have multiple episodes of angioedema with long symptom free intervals. Angioedema may occur with or without urticaria.
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.
ACE inhibitors should not be reintroduced in patients who have a history of angioedema due to rare reports of recurrence.
The combined use of perindopril with sacubitril/valsartan fixed dose combinations is contraindicated due to the increased risk of angioedema (see Section 4.3 Contraindications). Sacubitril/valsartan fixed dose combinations must not be initiated until 36 hours after taking the last dose of perindopril. If treatment with sacubitril/valsartan fixed dose combinations is stopped, perindopril must not be initiated until 36 hours after the last dose of sacubitril/valsartan fixed dose combination (see Section 4.3 Contraindications; Section 4.5 Interactions with Other Medicines and Other Forms of Interactions).
The combined use of perindopril with NEP inhibitors, mammalian target of rapamycin (mTOR) inhibitor (e.g. temsirolimus, sirolimus, everolimus) and gliptins (e.g. linagliptin, saxagliptin, sitagliptin, vildagliptin, alogliptin) may lead to an increased risk of angioedema (e.g. swelling of the airways or tongue, with or without respiratory impairment) (see Section 4.5 Interactions with Other Medicines and Other Forms of Interactions). Caution should be used when starting mTOR inhibitors (e.g. sirolimus, everolimus, temsirolimus) and gliptins (e.g. linagliptin, saxagliptin, sitagliptin, vildagliptin, alogliptin) in a patient already taking an ACE inhibitor.

Anaphylactoid reactions during low density lipoproteins (LDL) apheresis and haemodialysis.

Rarely, patients receiving ACE inhibitors during low density lipoprotein (LDL) apheresis with dextran sulphate have experienced life threatening anaphylactoid reactions. These reactions were avoided by temporarily withholding ACE inhibitor therapy prior to each apheresis.
Anaphylactoid reactions have been reported in patients dialysed with high flux membranes, who are treated with an ACE inhibitor. Extracorporeal treatments leading to contact of blood with negatively charged surfaces (e.g. polyacrylonitrile membranes such as "AN69") are contraindicated. If such treatment is required, consideration should be given to using a different type of dialysis membrane (e.g. cuprophane or polysulfone PSF) or a different class of antihypertensive medicines (see Section 4.3 Contraindications; Section 4.5 Interactions with Other Medicines and Other Forms of Interactions).

Anaphylactic reactions during desensitisation.

Patients treated with ACE inhibitors during desensitisation treatment (e.g. hymenoptera venom) have experienced anaphylactoid reactions. In the same patients, these reactions have been avoided when the ACE inhibitors were temporarily withheld, but they reappeared upon inadvertent rechallenge.

Hypotension.

Hypotension has been reported in patients commencing treatment with ACE inhibitors. Symptomatic hypotension is rarely seen in uncomplicated hypertension but is a potential consequence of perindopril use in patients with salt/ volume depletion, for example, in patients vigorously treated with diuretics, in patients on dialysis, with impaired renal function, following severe diarrhoea or vomiting, in patients on dietary restrictions or those with severe renin dependent hypertension (see Section 4.4 Special Warnings and Precautions for Use; Section 4.5 Interactions with Other Medicines and Other Forms of Interactions; Section 4.8 Adverse Effects (Undesirable Effects)).
Administration of perindopril 2 mg to patients with mild to moderate heart failure was not associated with any significant reduction in blood pressure.
In patients with symptomatic heart failure, with or without associated renal insufficiency, symptomatic hypotension has been observed. This is more likely to occur in those patients with severe heart failure, as reflected by the use of high doses of loop diuretics, hyponatraemia or functional renal impairment. This may be associated with syncope, neurological deficits, oliguria and/or progressive increase in blood nitrogen, and rarely with acute renal failure and/or death. Because of the potential fall in blood pressure in these patients, treatment should be started at low doses under very close supervision. Such patients should be followed closely for the first two weeks of treatment and whenever the dose is increased, or diuretic treatment is commenced or increased.
Patients with ischaemic heart or cerebrovascular disease in whom an excessive fall in blood pressure could result in myocardial infarction or cerebrovascular accident should be closely followed for the first two weeks of treatment and whenever the dose of perindopril and/or diuretic is increased. In all high risk patients it is advisable to initiate treatment with perindopril 2 mg daily.
In some patients with congestive heart failure who have normal or low blood pressure, additional lowering of systemic blood pressure may occur with perindopril. 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 may be necessary.
If hypotension occurs, the patient should be placed in a supine position and if necessary infused with normal saline. A transient hypotensive response is not a contraindication to further doses, which can usually be given without difficulty when blood pressure has increased following volume expansion.

Renovascular hypertension.

If renovascular hypertension is also present treatment should be started under close medical supervision with low doses and careful dose titration. There is an increased risk of severe hypotension and renal insufficiency. 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 treatment. Loss of renal function may occur with only minor changes in serum creatinine even in patients with unilateral renal artery stenosis.

Kidney transplantation.

There is no experience regarding the administration of perindopril in patients with a recent kidney transplantation.

Use in renal impairment.

As a consequence of inhibiting the renin angiotensin aldosterone system (RAAS), changes in renal function may be anticipated in susceptible individuals. In patients with severe congestive heart failure whose renal function may depend on the activity of the RAAS, treatment with ACE inhibitors may be associated with oliguria and/or progressive increase in blood nitrogen, and rarely with acute renal failure and/or death.
In patients with symptomatic heart failure, hypotension following the initiation of treatment with ACE inhibitors may lead to further impairment in renal function. Acute renal failure, usually reversible, has been reported in this situation.
ACE inhibitors should be avoided in patients with known or suspected renal artery stenosis (see Section 4.3 Contraindications).
In clinical studies in patients with hypertension and unilateral or bilateral renal artery stenosis, increases in blood urea nitrogen and serum creatinine were observed in 20% of patients. These increases are usually reversible upon discontinuation. When an ACE inhibitor is given to a patient with stenosis of the renal artery supplying a solitary kidney or bilateral renal artery stenosis, acute renal insufficiency may occur. ACE inhibition may also cause a decrease in renal function. Renal function may also be reduced in patients with stenosis of the artery supplying a transplanted kidney. It is believed that renal artery stenosis reduces the pressure in the afferent glomerular arteriole, and transglomerular hydrostatic pressure is then maintained by angiotensin II induced constriction of the efferent arteriole. When an ACE inhibitor is given, the efferent arteriole relaxes, glomerular filtration pressure falls, and renal failure may result. ACE inhibitors can lead to the thrombotic occlusion of a stenosed renal artery.
If renovascular hypertension is also present, treatment should be started under close medical supervision with low doses and careful dose titration. There is an increased risk of severe hypotension and renal insufficiency. 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 treatment.
Some patients with hypertension and no apparent pre-existing renovascular disease have developed increases in blood urea nitrogen and serum creatinine, which are usually minor and transient, particularly when perindopril has been given in combination with a diuretic. However, increases in blood urea, nitrogen and serum creatinine are more likely to occur in patients with pre-existing renal impairment or those on diuretics. Dosage reduction of the ACE inhibitor and/or discontinuation of the diuretic may be required.
Renal function should always be assessed (see Section 4.2 Dose and Method of Administration). In the case of renal impairment, the initial perindopril dose should be adjusted according to the patient's creatinine clearance (see Section 4.2 Dose and Method of Administration). Routine monitoring of potassium and creatinine are part of normal medical practice for these patients (see Section 4.2 Dose and Method of Administration). If deterioration in renal function has occurred after treatment with one ACE inhibitor, then it is likely to be precipitated by another, and in these patients use of another class of antihypertensive agent would be preferable. Patients with unilateral renal artery disease present a special problem as deterioration of function may not be apparent from measurement of blood urea and serum creatinine.
Some ACE inhibitors have been associated with the occurrence of proteinuria (up to 0.7%) and/or decline in renal function in patients with one or more of the following characteristics: old age, pre-existing renal disease, concomitant treatment with potassium sparing diuretics or high doses of other diuretics, limited cardiac reserve or treatment with a non-steroidal anti-inflammatory drug (NSAID).
Perindopril is dialysable with a clearance of 70 mL/minute.

Renal transplantation.

There is no experience regarding the administration of perindopril in patients with a recent kidney transplantation.

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 treated with 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 Adverse Effects (Undesirable Effects)).

Use in hepatic impairment.

Biotransformation of perindopril to perindoprilat occurs mainly in the liver. Studies in patients with hepatic impairment have shown that kinetic parameters of perindopril were not modified by hepatic failure. With the exception of bioavailability, which was increased, kinetic parameters of perindoprilat (including Tmax) were also unchanged. The increase in bioavailability could be due to inhibition of the formation of perindopril metabolites other than perindoprilat (see Section 5.2 Pharmacokinetic Properties). The administration of perindopril leads to the formation of a glucuronoconjugate derivative of perindoprilat by a hepatic first pass effect. The kinetic parameters of perindoprilat glucuronide are not modified by hepatic failure. The small changes in the kinetics of perindoprilat do not justify the need to change the usual dose in most patients with hepatic failure.

Ethnicity.

ACE inhibitors cause a higher rate of angioedema in patients of indigenous African origin than in patients of other racial origin. As with other ACE inhibitors, perindopril may be less effective in lowering blood pressure in people of indigenous African origin than in people of other racial origin, possibly because of a higher prevalence of low renin states in this population. It is unknown if the same observations have been made in patients of indigenous Australian origin.

Cough.

A persistent dry (non-productive) irritating cough has been reported with most of the ACE inhibitors. The frequency of reports has been increasing since cough was first recognised as a class effect of ACE inhibitor treatment with the incidence of cough varying between 2% and 15% depending upon the medicine, dosage and duration of use.
The cough is often worse when lying down or at night and has been reported more frequently in women (who account for two-thirds of reported cases). Patients who cough may have increased bronchial reactivity compared with those who do not. The observed higher frequency of this side effect in non-smokers may be due to a higher level of tolerance of smokers to cough.
The cough is most likely due to stimulation of the pulmonary cough reflex by kinins (bradykinin) and/or prostaglandins which accumulate because of ACE inhibition. Once a patient has developed intolerable cough, an attempt may be made to switch the patient to another ACE inhibitor; the reaction may recur but this is not invariably the case. A change to another class of medicines may be required in severe cases.

Proteinuria.

Perindopril treatment has occasionally been associated with mild or transient proteinuria (< 1 g per 24 hours). However in the majority of patients with pre-existing proteinuria treated with perindopril, proteinuria disappeared or remained stable. ACE inhibitors have potential to delay the progression of nephropathy in patients with diabetes, or hypertension.

Neutropenia/ agranulocytosis/ thrombocytopenia/ anaemia.

Neutropenia/ agranulocytosis, thrombocytopenia and anaemia have been reported in patients treated with an ACE inhibitor. 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 treatment. 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).

Dermatological reactions.

Dermatological reactions characterised by maculopapular pruritic rashes and sometimes photosensitivity have been reported with another ACE inhibitor. Rare and sometimes severe skin reactions (lichenoid eruptions, psoriasis, pemphigus-like rash, rosacea, Stevens-Johnson syndrome, etc.) have been reported following administration of perindopril and may therefore occur. A causal relationship is difficult to assess.
Patients who develop a cutaneous reaction with one ACE inhibitor might not when switched to another drug of the same class, but there are reports of cross reactivity.

Taste disturbances (dysgeusia).

Taste disturbances were reported to be common (prevalence up to 12.5%) with high doses of one ACE inhibitor. The actual incidence of taste disturbance is probably low (< 0.5%) but data are scarce and difficult to interpret.
Taste disturbances with ACE inhibitors have been described as suppression of taste or a metallic sensation in the mouth. Dysgeusia usually occurs in the first weeks of treatment and may disappear in most cases within one to three months.

Medicines causing renin release.

The effect of perindopril may be enhanced by concomitant administration of antihypertensive medicines which cause renin release.

Dual blockade of the renin angiotensin aldosterone system (RAAS).

As a consequence of inhibiting the RAAS, hypotension, syncope, stroke, hyperkalaemia, and changes in renal function (including acute renal failure) have been reported in susceptible individuals, especially if combining medicines that affect this system. Dual blockade of the RAAS through the combined use of ACE inhibitors, angiotensin II receptor antagonist or aliskiren is therefore not recommended (see Section 4.3 Contraindications; Section 4.5 Interactions with Other Medicines and Other Forms of Interactions; Section 5.1 Pharmacodynamic Properties). If dual blockade therapy is considered absolutely necessary, this should be limited to individually defined cases under specialist supervision with frequent, close monitoring of renal function, electrolytes and blood pressure.
The combination of perindopril with aliskiren is contraindicated in patients with diabetes or renal impairment (GFR < 60 mL/min/1.73 m2) (see Section 4.3 Contraindications; Section 4.5 Interactions with Other Medicines and Other Forms of Interactions).
ACE inhibitors and angiotensin receptor blockers should not be used in combination in patients with diabetic nephropathy.

Surgery and anaesthesia.

Perindopril may block angiotensin II formation secondary to compensatory renin release in patients undergoing major surgery during anaesthesia, with agents that produce hypotension, and cause further reduction in blood pressure. Treatment should be discontinued one day prior to the surgery. Perioperative hypotension can be corrected with volume expansion.

Aortic or mitral valve stenosis/ hypertrophic cardiomyopathy.

There has been some concern on theoretical grounds that patients with mitral valve stenosis and obstruction in the outflow of the left ventricle such as aortic stenosis or with hypertrophic cardiomyopathy might be at particular risk of decreased coronary perfusion when treated with vasodilators, including ACE inhibitors. Vasodilators may tend to drop diastolic pressure, and hence coronary perfusion pressure, without producing the concomitant reduction in myocardial oxygen demand that normally accompanies vasodilatation. The true clinical importance of this concern is uncertain.

Stable coronary artery disease.

If an episode of unstable angina pectoris, regardless of severity, occurs during the first month of perindopril treatment, a careful appraisal of the benefits/ risks of continuing treatment should be performed.

Lactose intolerance.

This medicine contains lactose. Patients with an intolerance to lactose, rare hereditary problems of galactose intolerance, total lactase deficiency or glucose-galactose malabsorption should not take this medicine.

Primary aldosteronism.

Patients with primary hyperaldosteronism will generally not respond to antihypertensive medicines acting through inhibition of the renin-angiotensin system. Therefore, treatment with perindopril is not recommended.

Paediatric use.

Use of perindopril in children is not recommended as no data establishing safety and effectiveness in children are available.

Use in the elderly.

Renal insufficiency is commonly observed in elderly people. Care should therefore be taken when prescribing perindopril to elderly patients. The initial dose should always be 2 mg daily and patients should be monitored closely during the initial stages of treatment (see Section 4.2 Dose and Method of Administration).
In a study of 91 elderly patients with a mean age of 71.9 years, a 6% increase in serum potassium occurred in the first month of treatment and subsequently remained stable. There was no change in the group in blood urea, creatinine or creatinine clearance.
Particular care should be taken in elderly patients with congestive heart failure who have renal and/or hepatic insufficiency.

Effects on laboratory tests.

Increases in blood urea and plasma creatinine, hyperkalaemia reversible on discontinuation may occur, especially in the presence of renal insufficiency, severe heart failure and renovascular hypertension. Elevation of liver enzymes and serum bilirubin have been reported rarely.

4.5 Interactions with Other Medicines and Other Forms of Interactions

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 higher frequency of adverse events such as hypotension, hyperkalaemia and decreased renal function (including acute heart failure) compared to the use of a single RAAS acting agent (see Section 4.3 Contraindications; Section 4.4 Special Warnings and Precautions for Use; Section 5.1 Pharmacodynamic Properties, Clinical trials).

Medicines increasing the risk of angioedema.

The combined use of ACE inhibitors with sacubitril/valsartan is contraindicated as this increases the risk of angioedema (see Section 4.3 Contraindications; Section 4.4 Special Warnings and Precautions for Use). Sacubitril/valsartan must not be started until 36 hours after taking the last dose of perindopril. Perindopril must not be started until 36 hours after the last dose of sacubitril/valsartan (see Section 4.3 Contraindications; Section 4.4 Special Warnings and Precautions for Use). The combined use of ACE inhibitors and mTOR inhibitors (e.g. sirolimus, everolimus, temsirolimus) and gliptins (e.g. linagliptin, saxagliptin, sitagliptin, vildagliptin, alogliptin) may lead to an increased risk for angioedema (see Section 4.4 Special Warnings and Precautions for Use).

Medicines inducing hyperkalaemia.

ACE inhibitors can attenuate potassium loss caused by thiazide diuretics and increase serum potassium when used alone. Although serum potassium usually remains within normal limits, hyperkalaemia may occur in some patients treated with an ACE inhibitor. The combined use of an ACE inhibitor with a potassium sparing diuretic (e.g. spironolactone, triamterene, or amiloride), immunosuppressant (e.g. ciclosporin), angiotensin receptor blocker, NSAID, heparin, potassium supplement, or potassium containing salt substitute can increase the risk of hyperkalaemia. The combination of perindopril with the above mentioned medicines is not recommended (see Section 4.4 Special Warnings and Precautions for Use). If combined use is indicated they should be used with caution and the patient's serum potassium monitored frequently.

Combined use which is contraindicated.

See Section 4.3 Contraindications; Section 4.4 Special Warnings and Precautions for Use.

Aliskiren.

Patients with diabetes or renal impairment (GFR < 60 mL/min/1.73 m2), may be at risk of hypotension, syncope, stroke, hyperkalaemia and changes in renal function (including acute renal failure).

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 such as "AN69") and low density lipoprotein apheresis with dextran sulphate are contraindicated due to increased risk of severe anaphylactoid reactions (see Section 4.3 Contraindications; Section 4.4 Special Warnings and Precautions for Use). If such treatment is required, consideration should be given to using a different type of dialysis membrane (e.g. cuprophane or polysulfone PSF) or a different class of antihypertensive agent.

Sacubitril/valsartan.

The combined use of perindopril with sacubitril/valsartan fixed dose combinations is contraindicated as the concomitant inhibition of neprilysin and ACE may increase the risk of angioedema. Sacubitril/valsartan fixed dose combinations must not be started until 36 hours after taking the last dose of perindopril. Perindopril must not be started until 36 hours after the last dose of sacubitril/valsartan fixed dose combination (see Section 4.3 Contraindications; Section 4.4 Special Warnings and Precautions for Use).

Combined use not recommended.

See Section 4.4 Special Warnings and Precautions for Use.

Aliskiren.

Patients other than those with diabetes or renal impairment may be at risk of hyperkalaemia, worsening of renal function and cardiovascular morbidity, and an increase in mortality (see Section 4.3 Contraindications).

Combined use with ACE inhibitor and angiotensin receptor blocker.

It is reported in the literature that in patients with established atherosclerosis, heart failure, or diabetes with end organ damage, combined use with an ACE inhibitor and an 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 RAAS agent. Dual blockade (e.g. by combining an ACE inhibitor with an angiotensin receptor blocker) should be limited to individually defined cases with close monitoring of renal function, serum potassium, and blood pressure.

Co-trimoxazole (trimethoprim/sulfamethoxazole).

Patients on combined treatment with co-trimoxazole (trimethoprim/sulfamethoxazole) may be at increased risk of hyperkalaemia (see Section 4.4 Special Warnings and Precautions for Use).

Lithium.

Reversible increases in serum lithium concentrations and toxicity have been reported during concomitant administration of lithium with ACE inhibitors. Concomitant use of thiazide diuretics may increase the risk of lithium toxicity and enhance the already increased risk of lithium toxicity with ACE inhibitors. Use of perindopril with lithium is not recommended, but if the combination is necessary, careful monitoring of serum lithium levels should be performed (see Section 4.4 Special Warnings and Precautions for Use).

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

The combined use of perindopril and potassium sparing diuretics may result in potentially lethal hyperkalaemia especially in patients with renal impairment (additive hyperkalaemic effects). The combination of perindopril with the above mentioned medicines is not recommended (see Section 4.4 Special Warnings and Precautions for Use). If the combination is required, it should be used with caution and with frequent monitoring of serum potassium. For use of spironolactone and eplerenone in heart failure, see paragraph under 'Combined use which requires special care'.

Combined use which requires special care.

Medicines to treat diabetes (e.g. insulin, oral hypoglycaemic medicines).

Reported with captopril and enalapril. ACE inhibitors may add to the glucose lowering effect, with risk of hypoglycaemia, in patients with diabetes who are treated with insulin or with oral hypoglycaemic medicines. Hypoglycaemia is very rare and appears to be more likely to occur during the first weeks of combined treatment, and in patients with renal impairment.

Baclofen.

Baclofen may increase the antihypertensive effect of perindopril. Monitor blood pressure and adjust the dose of perindopril if necessary.

Non-potassium sparing diuretics.

Patients treated with diuretics, especially those who are volume and/or salt depleted, may experience excessive reduction in blood pressure after initiation of treatment with an ACE inhibitor. The possibility of hypotensive effects can be reduced by discontinuation of the diuretic or by increasing volume or salt intake prior to commencing treatment with low and progressive doses of perindopril. If it is not possible to discontinue the diuretic, the starting dose of the ACE inhibitor should be reduced. The patient should be closely observed for several hours following the initial dose of the ACE inhibitor and until the blood pressure has stabilised. In arterial hypertension, when prior diuretic treatment has caused salt/ volume depletion, the diuretic must be discontinued before commencing treatment with the ACE inhibitor. A non-potassium sparing diuretic can then be reintroduced, or the ACE inhibitor be commenced at a low dose and progressively increased. In diuretic treated congestive heart failure, the ACE inhibitor should be initiated at a very low dose, possibly after reducing the dose 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 treatment.

Potassium sparing diuretics (eplerenone, spironolactone).

As the combination of perindopril and potassium sparing medicines (e.g. eplerenone and spironolactone), potassium supplements or potassium containing salt substitutes is general not recommended:
Ensure patients do not have hyperkalaemia or renal impairment before commencing treatment with this combination.
There is a risk of potentially lethal hyperkalaemia with this combination in patients treated for NYHA class II-IV heart failure with a reduced ejection fraction, who have been previously treated with ACE inhibitors and loop diuretics. This risk is particularly high when recommendations for use of this combination have not been followed.
Weekly monitoring of serum potassium and creatinine levels is recommended in the first month of the treatment and, monthly thereafter.

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

Medicines with prostaglandin synthetase inhibitor properties (e.g. indometacin) or an NSAID (i.e. acetylsalicylic acid at anti-inflammatory dose regimens, non-selective NSAIDs or COX-2 inhibitors) may diminish the antihypertensive efficacy of concomitantly administered ACE inhibitors. However, clinical studies have not demonstrated any interaction between perindopril and indometacin or other NSAIDs. Combination use of ACE inhibitors and NSAIDs may lead to an increased risk of worsening of renal function, including possible 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 after initiation of concomitant therapy, and periodically thereafter.

Ciclosporin.

Hyperkalaemia may occur during the combined use of ACE inhibitors with ciclosporin. Monitoring of serum potassium is recommended.

Heparin.

Hyperkalaemia may occur during the combined use of ACE inhibitors with heparin. Monitoring of serum potassium is recommended.

Combination use of ACE inhibitors, anti-inflammatory drugs and thiazide diuretics.

The combined use of an ACE inhibiting medicine (ACE inhibitor or angiotensin receptor antagonist), an anti-inflammatory medicine (NSAID or COX-2 inhibitor) and a thiazide diuretic at the same time increases the risk of renal impairment. This includes use in fixed combination products containing more than one class of medicine. The combination of medicines from these three classes should be used with caution particularly in elderly patients or those with pre-existing renal impairment. Combined use of these medications should be accompanied by increased monitoring of serum creatinine, particularly at initiation.

Mammalian target of rapamycin (mTOR) inhibitor (e.g. temsirolimus, sirolimus, everolimus).

Patients on combined treatment with an ACE inhibitor and an mTOR inhibitor may be at increased risk of angioedema (see Section 4.4 Special Warnings and Precautions for Use).

Gliptins (e.g. linagliptin, saxagliptin, sitagliptin, vildagliptin, alogliptin).

When an ACE inhibitor and a gliptin are used in combination, there is an increased risk of angioedema due to the decreased activity of the dipeptidyl peptidase IV (DPP-IV).

Combined use which requires some care.

Gold.

Nitritoid reactions (symptoms include facial flushing, nausea, vomiting and hypotension) have been reported rarely in patients treated with injectable gold (sodium aurothiomalate) and concomitant ACE inhibitor therapy including perindopril.

Antihypertensive agents and vasodilators.

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

Tetracycline and other medicines that interact with magnesium.

The simultaneous administration of tetracycline with an ACE inhibitor may significantly reduce the absorption of tetracycline, possibly due to the magnesium content in the ACE inhibitor tablets. This interaction should be considered if co-prescribing an ACE inhibitor and tetracycline or other medicines that interact with magnesium.

Medicines affecting sympathetic activity.

As the sympathetic nervous system plays an important part in physiological blood pressure regulation, caution should be exercised with concomitant administration of a medicine with sympathetic activity and perindopril. Sympathomimetics may reduce the antihypertensive effects of ACE inhibitors.

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 Special Warnings and Precautions for Use).

4.6 Fertility, Pregnancy and Lactation

Effects on fertility.

Studies in rats showed no impairment of male or female fertility at oral perindopril erbumine doses up to 10 mg/kg/day.
(Category D)
The use of ACE inhibitors is contraindicated during pregnancy (see Section 4.3 Contraindications).
As with all ACE inhibitors, perindopril should not be taken during pregnancy. Pregnancy should be excluded before starting treatment and avoided during treatment. Unless continued treatment with an ACE inhibitor is considered essential, patients planning pregnancy should be changed to alternative antihypertensive treatments which have an established safety profile for use in pregnancy. If a patient intends to become pregnant, treatment with ACE inhibitors must be discontinued and replaced by another form of treatment.
If a patient becomes pregnant while on ACE inhibitors, she must immediately inform her doctor to discuss a change in medication and further management.
Perindopril or its metabolites have been shown to cross the placenta and distribute to the foetus in pregnant animals.
There are no adequate and well controlled studies of ACE inhibitors in pregnant women, but foetotoxicity is well documented in animal models. Data, however, show that ACE inhibitors cross the human placenta. Post-marketing experience with all ACE inhibitors suggests that exposure in utero may be associated with hypotension and decreased renal perfusion in the foetus. ACE inhibitors have also been associated with foetal death in utero.
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.
A historical cohort study in over 29,000 infants born to non-diabetic mothers has shown 2.7 times higher risk for congenital malformations in infants exposed to any ACE inhibitor during first trimester compared to no exposure. The risk ratios for cardiovascular and central nervous system malformations were 3.7 times (95% confidence interval 1.89 to 7.3) and 4.4 times (95% confidence interval 1.37 to 14.02) respectively, compared to no exposure.
When ACE inhibitors have been used during the second and third trimesters of pregnancy, there have been reports of foetal and neonatal toxicity: hypotension, hyperkalaemia, renal failure, skull hypoplasia, oligohydramnios and death.
Oligohydramnios has been reported, presumably resulting from decreased foetal renal function; oligohydramnios has been associated with foetal limb contractures, craniofacial deformities, hypoplastic lung development and intrauterine growth retardation. Prematurity and patent ductus arteriosus have been reported, however it is not clear whether these events were due to ACE inhibitor exposure or to the mother's underlying disease.
Infants exposed in utero to ACE inhibitors should be closely observed for hypotension, oliguria and hyperkalaemia. Should exposure to ACE inhibitors occur from the second trimester of pregnancy, ultrasound check of renal function and skull is recommended. If such complications arise, appropriate medical treatment should be initiated to support blood pressure and renal perfusion.
Animal studies have shown that perindopril and its metabolites are excreted in milk during lactation, but there are no human data. It is therefore recommended that perindopril should not be given to lactating women as the possible effect on the newborn is unknown. Alternative treatments with better established safety profiles during breast feeding are preferable, especially while nursing a newborn or preterm infant.

4.7 Effects on Ability to Drive and Use Machines

The antihypertensive effect in individual cases may be symptomatic. Treatment with any blood pressure lowering agent may, therefore, affect the ability to drive, cross the road safely or operate machinery, especially at the start of treatment or when changing over from other preparations, or during concomitant use of alcohol.

4.8 Adverse Effects (Undesirable Effects)

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, pruritus, rash, muscle cramps, and asthenia.
Adverse events that have been observed during clinical trials and/or post-marketing use of perindopril and ranked under the following frequency: very common (> 1/10); common (> 1/100, < 1/10); uncommon (> 1/1000, < 1/100); rare (> 1/10,000, < 1/1000); very rare (< 1/10,000 and including isolated reports).

Blood and the lymphatic system disorders.

Uncommon: eosinophilia#.
Very rare: decreases in haemoglobin and haematocrit, thrombocytopenia, leucopenia/ neutropenia, agranulocytosis or pancytopenia. An unexplained change in prothrombin ratio was reported in one patient. Haemolytic anaemia has been reported in patients with congenital G-6PDH deficiency (see Section 4.4 Special Warnings and Precautions for Use).

Metabolism and nutrition disorders.

Uncommon: hypoglycaemia# (see Section 4.4 Special Warnings and Precautions for Use; Section 4.5 Interactions with Other Medicines and Other Forms of Interactions), hyperkalaemia#, reversible on discontinuation (see Section 4.4 Special Warnings and Precautions for Use), hyponatraemia#.

Psychiatric disorders.

Uncommon: mood disturbances, sleep disorders (insomnia, dream abnormality).

Nervous system disorders.

Common: headache, dizziness, drowsiness, vertigo, paraesthesia.
Uncommon: syncope#, somnolence#.
Very rare: confusion, depression, hallucinations.

Eye disorders.

Common: vision disturbance.

Ear disorders.

Common: tinnitus.

Cardiac disorders.

Common: palpitations.
Uncommon: tachycardia#.
Very rare: arrhythmia, angina pectoris (see Section 4.4 Special Warnings and Precautions for Use), myocardial infarction - possibly secondary to excessive hypotension in high risk patients (see Section 4.4 Special Warnings and Precautions for Use).

Vascular disorders.

Common: hypotension (and effects related to hypotension), vasculitis, flushing, impaired peripheral circulation.
Very rare: stroke - possibly secondary to excessive hypotension in high risk patients (see Section 4.4 Special Warnings and Precautions for Use).
Not known: Raynaud's phenomenon.

Respiratory, thoracic and mediastinal disorders.

Common: cough, dyspnoea, epistaxis, discomfort on exertion.
Uncommon: bronchospasm.
Very rare: eosinophilic pneumonia, rhinitis.

Gastrointestinal disorders.

Common: nausea, vomiting, abdominal pain, dysgeusia, diarrhoea, dyspepsia, constipation.
Uncommon: dry mouth.
Very rare: pancreatitis.

Hepatobiliary disorders.

Very rare: hepatitis, either cytolytic or cholestatic (see Section 4.4 Special Warnings and Precautions for Use).

Skin and subcutaneous tissue disorders.

Common: rash, pruritus.
Uncommon: urticaria (see Section 4.4 Special Warnings and Precautions for Use), angio-oedema of face, extremities, lips, mucous membranes, tongue, glottis and/or larynx (see Section 4.4 Special Warnings and Precautions for Use), hyperhidrosis, photosensitivity reactions#, pemphigoid#, eczema#.
Rare: psoriasis aggravation#.
Very rare: erythema multiforme.

Musculoskeletal, connective tissue and bone disorders.

Common: muscle cramps.
Uncommon: arthralgia#, myalgia#.

Renal and urinary disorders.

Uncommon: renal insufficiency.
Rare: acute renal failure#, anuria/oliguria#.

Reproductive system and breast disorders.

Uncommon: erectile dysfunction.

General disorders and administration site conditions.

Common: asthenia.
Uncommon: sweating, chest pain#, atypical chest pain, malaise#, oedema peripheral#, pyrexia#.

Investigations.

Uncommon: blood urea increased#, blood creatinine increased#.
Rare: blood bilirubin elevation, hepatic enzyme increases.

Injury, poisoning and procedural complications.

Uncommon: fall#.
# Frequency of these adverse events detected from spontaneous reports is calculated from clinical trial data.

Syndrome of inappropriate antidiuretic hormone secretion (SIADH).

Cases 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.

Withdrawals.

In total, 56 of 1,275 patients studied (4.4%) stopped treatment because of adverse reactions. In a specific study of 632 patients in which 36 patients (5.7%) withdrew because of adverse events. A plausible or probable relationship with perindopril treatment was considered to exist in 19 cases (3%).

Reporting suspected adverse effects.

Reporting suspected adverse reactions after registration 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 at www.tga.gov.au/reporting-problems and contact Apotex Medical Information Enquiries/Adverse Drug Reaction Reporting on 1800 195 055.

4.9 Overdose

Limited data are available for overdose in humans.

Symptoms.

Symptoms associated with overdose of ACE inhibitors may include hypotension, circulatory shock, electrolyte disturbances, renal failure, hyperventilation, tachycardia, palpitations, bradycardia, dizziness, anxiety and cough.

Treatment.

The recommended treatment of overdose is intravenous infusion of normal saline solution. If hypotension occurs, the patient should be placed in the shock position. If available, treatment with intravenous catecholamines may also be considered. Perindopril may be removed from the general circulation by haemodialysis (see Section 4.4 Special Warnings and Precautions for Use). Vital signs, serum electrolytes and creatinine concentrations should be monitored continuously.
For information on the management of overdose, contact the Poisons Information Centre on 131126 (Australia).

5 Pharmacological Properties

5.1 Pharmacodynamic Properties

Mechanism of action.

Perindopril (prodrug), following hydrolysis to perindoprilat, inhibits angiotensin converting enzyme (ACE) both in vitro and in vivo. It is thought that ACE inhibitors reduce blood pressure by inhibiting the enzyme which catalyses the conversion of angiotensin I to angiotensin II. Decreased plasma angiotensin II leads to increased plasma renin activity and a decrease in aldosterone. In addition to its effects on circulating ACE, perindopril binds to and inhibits tissue converting enzyme, predominantly in the kidney and vascular wall. The contribution of this mechanism to the overall antihypertensive effect of perindopril is unknown. Animal studies have demonstrated reversal of vascular hypertrophy and an improvement in the ratio of elastin to collagen in the vessel wall. Studies in humans have demonstrated an improvement in the viscoelastic properties of large vessels and in compliance. Studies in animals and humans suggest that specific and competitive suppression of the renin angiotensin aldosterone system is the main mechanism by which blood pressure is reduced. However, antihypertensive activity has also been observed in patients with low renin activity. Perindopril may also inhibit the degradation of the potent vasodepressor peptide bradykinin and this action may contribute to its antihypertensive action. Perindopril appears to reduce peripheral resistance and may influence arterial compliance.
Studies carried out in animal models of hypertension have shown that perindopril is a specific competitive angiotensin I converting enzyme inhibitor. The administration of perindopril to patients with essential hypertension results in a reduction in supine and standing blood pressure without any significant effect on heart rate. Abrupt withdrawal of perindopril has not been associated with a rebound rise in blood pressure. Single dose studies have demonstrated that peak inhibition of ACE activity and peak reduction in blood pressure occurs four to six hours after administration. The duration of these effects are dose related and, at the recommended dose range, both effects have been shown to be maintained over a 24 hour period.
In haemodynamic studies carried out in animal models of hypertension, blood pressure reduction after perindopril administration was accompanied by a reduction in peripheral arterial resistance and improved arterial wall compliance. In studies carried out in patients with essential hypertension the reduction in blood pressure was accompanied by a reduction in peripheral resistance with no change or a small increase in renal blood flow, and no change in glomerular filtration rate. An increase in the compliance of large arteries was also observed. When perindopril is administered together with a thiazide type diuretic, the antihypertensive activity of perindopril may be potentiated in some patients and this effect is evident after four weeks of treatment. Perindopril, like other ACE inhibitors, may compensate for thiazide induced hypokalaemia.
In one study of 48 patients when low dose perindopril (2.0 mg) was compared with correspondingly low doses of enalapril (2.5 mg) or captopril (6.25 mg) in patients with congestive heart failure, significantly different blood pressure responses were noted. Blood pressure fell significantly with captopril and enalapril following the first dose. However, while perindopril inhibited plasma ACE comparably with enalapril, the blood pressure changes were insignificant and similar to placebo for up to ten hours of regular observation. Data regarding the possibility of a late hypotensive response are not available for perindopril.

Clinical trials.

Patients with stable coronary artery disease.

The effects of perindopril were compared to placebo in patients with stable coronary artery disease with no clinical signs of heart failure. The EUROPA (European trial on Reduction Of cardiac events with Perindopril in stable coronary Artery disease) study was a multicentre, international, randomised, double blind, placebo controlled clinical trial lasting 4 years. 12,218 patients aged over 18 were randomised: 6,110 patients to high dose perindopril 8 mg and 6108 patients to placebo.
The primary endpoint was the composite of cardiovascular mortality, non-fatal myocardial infarction, and/or cardiac arrest with successful resuscitation.
The trial population had evidence of coronary artery disease documented by previous myocardial infarction at least 3 months before screening, coronary revascularisation at least 6 months before screening, angiographic evidence of stenosis (at least 70% narrowing of one or more major coronary arteries), or positive stress test in men with a history of chest pain.
Study medication was added to conventional treatment, including medication used for the management of hyperlipidaemia, hypertension and diabetes mellitus. Patients randomised to perindopril were initiated on perindopril 2 mg or perindopril 4 mg for 2 weeks, and then titrated up to perindopril 8 mg during the 2 following weeks. Perindopril 8 mg was then maintained for the whole duration of the study. If this dose was not well tolerated, it could be reduced to perindopril 4 mg once daily.
Most of the patients also received platelet inhibitors, lipid lowering medicines and beta-blockers. At the end of the study, the proportions of patients treated with a combination of these medications were 91%, 69% and 63% respectively.
The results of the EUROPA study, specifically the primary endpoint and its components (cardiovascular mortality, non-fatal myocardial infarction or resuscitated cardiac arrest) for the intention to treat (ITT) population are presented in Table 2.
The reduction in the primary composite endpoint was mainly due to a reduction in the number of non-fatal myocardial infarctions. There was no significant reduction in the rate of cardiovascular mortality or total mortality in patients taking perindopril compared to those taking placebo.
After a mean follow-up of 4.2 years, treatment with perindopril erbumine 8 mg once daily resulted in a significant relative risk reduction of 20% (95% CI: 9-29) in the primary combined endpoint: 488 patients (8.0%) reported events in the perindopril group compared to 603 patients (9.9%) in the placebo group (p = 0.0003). Improvements in the primary composite endpoint achieved statistical significance after 3 years of continuous treatment on perindopril.

5.2 Pharmacokinetic Properties

Absorption.

Following oral administration, perindopril is rapidly absorbed with a bioavailability of 61-85%. Elimination is rapid, occurring predominantly via the urine. Plasma half-life is approximately one hour. Bioavailability of the active metabolite perindoprilat is approximately 20%.

Distribution.

Peak plasma concentrations of perindoprilat occur three to four hours after oral administration of perindopril and protein binding of perindoprilat is below 30%, principally to ACE. When perindopril is administered chronically, steady state of perindoprilat concentration is reached within four days, and perindoprilat does not accumulate.

Metabolism.

Apart from perindoprilat, the administration of perindopril leads to the formation of five other metabolites, all of which are inactive and exist in very low quantities. One of these is the glucuronoconjugate of perindoprilat which is formed by a hepatic first pass effect. This effect does not appear to have any influence on the kinetics of perindoprilat. Food intake may reduce hepatic biotransformation to perindoprilat.

Excretion.

Perindoprilat binds to plasma and tissue ACE and free perindoprilat is eliminated through the urine. The terminal half-life of the unbound fraction is between three to five hours.
The terminal half-life, which corresponds to the disassociation of perindoprilat from ACE, is approximately 25 to 30 hours.
The elimination of perindoprilat is reduced in elderly patients and in patients with cardiac and renal failure (see Section 4.2 Dose and Method of Administration).

5.3 Preclinical Safety Data

Genotoxicity.

Results from a broad set of assays for gene mutation and chromosomal damage with perindopril suggest no genotoxic potential at clinical doses.

Carcinogenicity.

No evidence of carcinogenic activity was observed in mice and rats when perindopril erbumine was administered via drinking water at levels up to 7.5 mg/kg/day for 2 years. At least one ACE inhibitor has caused an increase in the incidence of oxyphilic renal tubular cells and oncocytomas in rats. The potential of ACE inhibitors to cause this effect in humans is unknown. Moreover, the progression of oxyphilic cells to oncocytomas is rare in humans and when this occurs, it is considered benign.

6 Pharmaceutical Particulars

6.1 List of Excipients

Lactose, magnesium stearate.

6.2 Incompatibilities

Incompatibilities were either not assessed or not identified as part of the registration of this medicine.

6.3 Shelf Life

In Australia, information on the shelf life can be found on the public summary of the Australian Register of Therapeutic Goods (ARTG). The expiry date can be found on the packaging.

6.4 Special Precautions for Storage

Store below 25°C. Protect from light and moisture.

6.5 Nature and Contents of Container

APO-Perindopril tablets.

2 mg tablets.

Blister packs (Aluminium/Aluminium silver foil) of 30 tablets (AUST R 151911).

4 mg tablets.

Blister packs (Aluminium/Aluminium silver foil) of 30 tablets (AUST R 151912).

8 mg tablets.

Blister packs (Aluminium/Aluminium silver foil) of 30 tablets (AUST R 151913).
APO and APOTEX are registered trade marks of Apotex Inc.
Not all strengths and/or pack sizes may be available.

6.6 Special Precautions for Disposal

In Australia, any unused medicine or waste material should be disposed of by taking to your local pharmacy.

6.7 Physicochemical Properties

Perindopril is a dipeptide monoacid monoester with a perhydroindole group and no sulfhydryl radical. Perindopril erbumine is a white powder, readily soluble in purified water, 95% ethanol and chloroform. Perindopril has five asymmetric centres and is synthesised stereoselectively so that it is a single enantiomer (all S stereochemistry).
Perindopril erbumine is an angiotensin converting enzyme inhibitor.

Chemical structure.


Chemical Name: 2-methylpropan-2-amine (2S,3aS,7aS)-1-[(2S)-2-[[(1S)-1-(ethoxycarbonyl)butyl]amino]propanoyl]octahydro-1H-indole-2-carboxylate.
Molecular Formula: C19H32N2O5,C4H11N.

CAS number.

107133-36-8.

7 Medicine Schedule (Poisons Standard)

S4 - Prescription Only Medicine.

Summary Table of Changes