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Coversyl Plus (Perindopril and indapamide) - Dose, Side effects

Perindopril and Indapamide are two different medications that are often prescribed together for the treatment of hypertension (high blood pressure). They are sometimes combined into a single tablet for convenience, known as a fixed-dose combination, and can also be prescribed separately.

For the treatment of mild to moderate hypertension, Coversyl Plus (perindopril and indapamide) combines two medications (an ACE-inhibitor and a thiazide diuretic).

Coversyl Plus (Perindopril and Indapamide) Indications:

Hypertension: Management of mild to moderate hypertension.

Note: Arcosyl Plus LD or Coversyl Plus LD may be used initially; Arcosyl Plus, Coversyl Plus, and Coversyl Plus HD are not usually indicated in the initial stages. It is not approved in the US.

Coversyl Plus (Perindopril and indapamide) dose in adults:

Coversyl Plus Treatment dose in Hypertension:

Arcosyl:

Start with: 2.5 mg of Perindopril and 0.625 mg of Indapamide every day.
Adjust if needed: Up to 5 mg of Perindopril and 1.25 mg of Indapamide every day.
Regular dose: Between 2.5-10 mg of Perindopril and 0.625-2.5 mg of Indapamide daily.

Coversyl:

Start with: 2 mg of Perindopril and 0.625 mg of Indapamide every day.
Adjust if needed: Up to 4-8 mg of Perindopril and 1.25 mg of Indapamide every day.
Regular dose: Between 2-8 mg of Perindopril and 0.625-2.5 mg of Indapamide daily.

Coversyl Plus (Perindopril and indapamide) dose in Childrens

Not recommended for children.

Pregnancy Risk Category: D

Warning: These drugs can harm or even cause death to an unborn baby. Stop taking them immediately if you find out you're pregnant.
Also, check the warnings for each specific drug in this category.

Use when Patient is Breastfeeding:

We don't know if perindopril or indapamide pass into breast milk.
Breastfeeding women shouldn't use them.
Also, check the details for each specific drug.

Perindopril and indapamide (Coversyl Plus) Dose adjustment in renal disease:

GFR ≥60 mL/minute/1.73 m: No need to adjust the dosage. You can take the standard dose.
GFR 30 to 59 mL/minute/1.73 m: There are no specific dosage recommendations in the instructions, but be cautious and consider using lower doses. Perindoprilat exposure might increase. Don't use certain high-dose combinations (8 mg perindopril/1.25 mg indapamide, 8 mg perindopril/2.5 mg indapamide, and 10 mg perindopril/2.5 mg indapamide).
GFR <30 mL/minute/1.73 m: Using these drugs is not allowed because of your kidney function.
Hemodialysis: You can use these drugs, and they can be removed from your body through dialysis.

Coversyl Plus Dose adjustment in liver disease:

The manufacturer doesn't give specific dosage changes for liver problems.
However, be careful because the amount of perindoprilat in the body can be higher if you have liver issues.
People with severe liver problems or brain complications from liver disease shouldn't use this drug.

Also see individual agents (Perindopril and indapamide)

Side Effects of Coversyl Plus (Perindopril and indapamide):

Central Nervous System:
- Headache And Dizziness
Endocrine & Metabolic:
- Hypokalemia and Hyperkalemia
Gastrointestinal:
- Nausea And Vomiting and Dyspepsia
Neuromuscular & Skeletal:
- Arthralgia
Renal:
- Increased Blood Urea Nitrogen
Respiratory:
- Cough
- Upper Respiratory Tract Infection
- Bronchitis

Rare Side effects of Perindopril and indapamide (Coversyl Plus):

Cardiovascular:
- Transient Ischemic Attacks
Central Nervous System:
- Loss Of Consciousness
Renal:
- Renal Colic

Contraindications to Coversyl Plus (Perindopril and indapamide):

People should NOT take this drug if they have:

Allergies to perindopril, indapamide, ingredients in the drug, or drugs derived from sulfonamides.
A history of swelling attacks not caused by allergies or related to a previous ACE inhibitor.
Very low potassium levels.
Severe liver problems or brain issues from liver disease.
Pregnancy, planning to get pregnant, or not using effective birth control.
Breastfeeding.
Moderate kidney issues (specific for Arcosyl Plus, Coversyl Plus, and Coversyl Plus HD).
Severe kidney issues.
Diabetes or kidney issues and are taking aliskiren.
Taking certain heart rhythm drugs that can cause heart rhythm issues.
Taking sacubitril/valsartan.
Rare sugar problems like galactose intolerance or issues absorbing glucose-galactose.
Treatments where blood contacts negatively charged surfaces.
Narrowing of one or both kidney arteries.

It's also noted that if someone is allergic to one ACE inhibitor, they might be allergic to others. But it's not fully confirmed.

And while the drug label says to avoid with other sulfonamide drugs, this claim is debated. The warnings section has more details.

Warnings and precautions

Angioedema

Angioedema, or swelling deep under the skin, can happen during treatment, especially after the first dose.
It can affect the head and neck, which might block the airway, or the intestines, causing stomach pain.
People who are Black, have a family history or unknown cause of angioedema, or had angioedema from using ACE inhibitors before might be at a higher risk.
The risk can be higher if someone is also taking certain other drugs like everolimus, sitagliptin, or sacubitril.
If the swelling involves the tongue, voice box, or windpipe, it's very dangerous because it can block breathing. People who've had throat surgery might have an even higher risk.
Quick and correct treatment is vital.
Those with a history of angioedema or unknown cause should not take this drug.

Cholestatic jaundice

ACE inhibitors can rarely cause a liver issue called cholestatic jaundice.
This issue might get worse, leading to severe liver damage, and sometimes can be deadly.
Stop the medication if there are significant increases in liver enzymes or if you notice yellowing of the skin or eyes (jaundice).
If you feel unwell, have muscle pain, a fever, a rash, or other signs of liver problems within the first few weeks to months of taking the drug, think about stopping the medicine.

CNS depression:

Perindopril might make you feel drowsy or less alert.
Be careful when doing things that need your full attention, like using machines or driving a car.

Cough:

Taking an ACE inhibitor can cause a persistent, dry cough.
This cough typically starts within the first few months of using the medication.
It usually goes away 1 to 4 weeks after stopping the ACE inhibitor.
Before stopping the medicine because of the cough, other reasons for the cough, like lung issues in heart failure patients, should be checked and ruled out.

Dermatologic reactions

ACE inhibitors can cause itchy rashes with red spots or bumps. If you switch to a different ACE inhibitor, the rash might or might not come back.
Rarely, ACE inhibitors can cause severe skin reactions like lichen-like rashes, worsening psoriasis, blistery rashes, redness, or the serious Stevens-Johnson syndrome.
Indapamide, another drug, has also caused severe skin reactions. These usually get better about 2 weeks after stopping indapamide.

Dysgeusia:

High doses of ACE inhibitors can sometimes cause taste problems or a metallic feeling in the mouth.
This usually starts within the first few weeks of taking the medicine.
It often goes away on its own in 1 to 3 months.

Electrolyte disturbances:

ACE inhibitors can lead to high potassium levels in the blood (hyperkalemia). This is more likely in older patients, those with kidney problems, diabetes, dehydration, heart issues, acid buildup in the body, and when taken with other medicines or supplements that also increase potassium. If you're using these, monitor potassium levels closely.
Indapamide, on the other hand, can lead to low levels of potassium, chloride, sodium, and phosphate, but high calcium levels in the blood. Don't use it if you already have low potassium levels. Also, people with an extended QT interval on their heart tracing (due to birth defect or other medicines) can be at risk from the low potassium.

Hematologic effects

Some ACE inhibitors, like captopril, have been linked to a condition called neutropenia, where a type of white blood cell (neutrophil) is too low. This can lead to anemia (low red blood cells) and low platelet counts (thrombocytopenia).
People with kidney problems are at higher risk for neutropenia.
Those with both kidney issues and autoimmune diseases like lupus are at an even higher risk for neutropenia.
To watch for these issues, doctors should regularly check the blood counts of these patients (CBC with differential).

Hypersensitivity reactions

Severe allergic reactions (anaphylactic or anaphylactoid) can happen with ACE inhibitors.
These strong reactions might happen during certain treatments like:
- Hemodialysis with specific filters (like PAN).
- Procedures to lower cholesterol using dextran sulfate cellulose.
There have been rare cases where people getting allergy treatments for bee or wasp stings have strong reactions when also on ACE inhibitors.

Syncope and hypotension:

ACE inhibitors can cause a significant drop in blood pressure, sometimes leading to fainting, especially after the first few doses.
This is more likely if you're dehydrated or low on fluids. It's best to correct this before starting the medication.
When starting or increasing the dose, close monitoring is essential to ensure the patient's safety.
Even if the blood pressure drops too much, the dose might just need adjusting. Stopping the ACE inhibitor isn't always necessary, especially in heart failure patients where a drop in blood pressure can be a good sign.

Photosensitivity

The medicine can make your skin more sensitive to sunlight, increasing the risk of sunburn.

Proteinuria:

A small number of users (less than 1%) taking ACE inhibitors might have increased protein in their urine (less than 1 gram/day).
Of those, about one-fifth might develop a condition where they lose too much protein in their urine, called nephrotic syndrome.
In most cases, this increase in urine protein goes away or gets better within six months, regardless of whether the patient continues the ACE inhibitor or not.

Renal function deterioration:

The medication can sometimes lead to worsening kidney function, noticeable by increased levels of certain blood markers (BUN and serum creatinine).
This is more likely in people with certain conditions where the kidney's blood flow is already reduced, like narrowed kidney arteries or heart failure.
Worsened kidney function can lead to reduced urine output, acute kidney failure, or increased waste products in the blood.
A small rise in serum creatinine after starting the medicine can happen. Only consider stopping the medication if the kidney function worsens significantly.

Allergy to sulfonamide ("sulfa")

Many drugs with a sulfonamide structure come with warnings against use in people who've had allergic reactions to sulfonamides.
There's a chance of having an allergic reaction between similar sulfonamides (like two antibiotic sulfonamides).
But the idea that all sulfonamide drugs might cause allergic reactions, even if they're in different drug classes, is being reevaluated. Most experts now believe that the risk of an allergic reaction between an antibiotic sulfonamide and a non-antibiotic sulfonamide is very low or might not even exist.
While reactions caused by antibodies (like anaphylaxis) are unlikely with non-antibiotic sulfonamides, other types of reactions (like certain rashes) aren't fully understood.
If someone had a very severe reaction in the past (like Stevens-Johnson syndrome), some doctors may advise avoiding all drugs with the sulfonamide structure to be safe.

Aldosteronism:

If you have primary aldosteronism (a condition where the adrenal gland produces too much of the hormone aldosterone), this drug might not work for you.
People with this condition usually don't respond well to blood pressure drugs that work by affecting the renin-angiotensin system, like ACE inhibitors.

Aortic stenosis

If you have a narrowed aortic valve (aortic stenosis) or a problem with your mitral valve, use perindopril carefully.
The drug might reduce blood flow to the heart muscle, leading to reduced oxygen supply (ischemia).

Bariatric surgery

After weight loss surgery (bariatric surgery), don't take diuretics (water pills) right away.
Using them too soon can cause dehydration and problems with salts in your body.
Once you're able to drink enough liquids again, diuretics can be considered if needed.

Cardiovascular disease

Starting perindopril in people with heart or brain blood vessel problems needs close monitoring because a sudden drop in blood pressure can lead to heart attack or stroke.
If blood pressure drops too much, replacing fluids might help fix it, and then the medication can be considered again.
If low blood pressure keeps happening, it might be best to stop the drug.
For those with heart failure, starting with a lower dose of perindopril is suggested because the drug's active part stays in the body longer.
Perindopril isn't recommended for those with certain kidney-related high blood pressure or heart failure.

Collagen vascular disease:

Be careful with perindopril in patients with diseases affecting connective tissues (like lupus or scleroderma), especially if they also have kidney problems. They might have a higher risk of blood-related side effects.
Indapamide, another drug, might make systemic lupus erythematosus (SLE) worse or trigger its onset.

Diabetes:

If you have prediabetes or diabetes, use the medication carefully. It might affect your blood sugar levels.

Gout

Indapamide can increase uric acid levels in the blood.
If you have a history of gout, are prone to it because of family history, or have chronic kidney problems, indapamide might trigger a gout attack.

Hepatic impairment

Be cautious using the medication in people with liver problems. Perindopril has been linked to increased liver enzymes and bilirubin levels.
Before starting the drug, check baseline levels of liver enzymes and bilirubin.
In people with cirrhosis, avoid imbalances that might cause brain complications (hepatic encephalopathy).
Don't use the medication in people with severe liver problems or those experiencing brain complications from liver disease.

Hypertrophic cardiomyopathy with outflow tract obstruction (HCM)

Be cautious when using the drug in patients with hypertrophic cardiomyopathy (a thickened heart muscle) and an obstruction in the outflow of blood.
Reducing the resistance the heart works against might make the symptoms of this condition worse.

Renal artery stenosis

Don't use the medication in people with narrowed arteries (either one or both) leading to the kidneys.

Renal impairment

Be careful when using the medication in people with kidney problems. You might need to adjust the dose.
Increasing the dose too quickly could make kidney problems worse.
People with kidney issues might also have a higher risk of blood-related side effects.
The medication might not be safe for those with moderate to severe kidney problems. Always check the list of conditions that would advise against using the drug.

Perindopril and indapamide (United States: Not available): Drug Interaction

Risk Factor C (Monitor therapy)
Ajmaline	Sulfonamides might make ajmaline more harmful or poisonous. In particular, there may be an elevated risk for cholestasis.
Alcohol (Ethyl)	Increases the effectiveness of thiazide and thiazide-like diuretics in lowering orthostatic blood pressure.
Alfuzosin	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Aminolevulinic Acid (Topical)	Aminolevulinic Acid's photosensitizing impact may be enhanced by photosensitizing agents (Topical).
Amphetamines	May lessen the effectiveness of antihypertensive agents.
Angiotensin II	The therapeutic efficacy of angiotensin II may be enhanced by angiotensin-converting enzyme inhibitors.
Angiotensin-Converting Enzyme Inhibitors	Angiotensin-Converting Enzyme Inhibitors' hypotensive effects may be enhanced by thiazide and thiazide-like diuretics. Angiotensin-Converting Enzyme Inhibitors' nephrotoxic effects may be increased by thiazide and thiazide-like diuretics.
Anticholinergic Agents	May raise the levels of thiazide and thiazide-like diuretics in the blood.
Antidiabetic Agents	The therapeutic value of anti-diabetic agents may be diminished by thiazide and thiazide-like diuretics.
Antidiabetic Agents	The therapeutic benefit of anti-diabetic agents may be reduced by hyperglycemia-associated agents.
Antipsychotic Agents (Second Generation [Atypical])	Antipsychotic drugs' hypotensive effects may be enhanced by blood pressure-lowering medications (Second Generation [Atypical]).
Aprotinin	Angiotensin-Converting Enzyme Inhibitors may intensify their hyperkalemic effects.
AzaTHIOprine	AzaTHIOprine's myelosuppressive effects may be enhanced by angiotensin-converting enzyme inhibitors.
Barbiturates	Increases the effectiveness of thiazide and thiazide-like diuretics in lowering orthostatic blood pressure.
Barbiturates	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Benperidol	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Beta2-Agonists	Thiazide and Thiazide-Like Diuretics might have an enhanced hypokalemic impact.
Brigatinib	May lessen the effectiveness of antihypertensive agents. Antihypertensive Agents' bradycardic action may be strengthened by brutinib.
Brimonidine (Topical)	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Calcium Salts	The excretion of calcium salts may be decreased by thiazide and thiazide-like diuretics. Metabolic alkalosis can also be brought on by continued concurrent usage.
CarBAMazepine	Thiazide and Thiazide-Like Diuretics may intensify CarBAMazepine's negative/toxic effects. Particularly, there could be a higher risk of hyponatremia.
Cardiac Glycosides	Cardiac Glycosides may have an increased negative or toxic effect when used with thiazide and thiazide-Like Diuretics. Particularly, the hypokalemic and hypomagnesemic impact of thiazide diuretics may worsen cardiac glycoside toxicity.
Corticosteroids (Orally Inhaled)	.Could intensify the hypokalemic effects of thiazide and make diuretics like thiazide more potent.
Corticosteroids (Systemic	Thiazide and Thiazide-Like Diuretics might have an enhanced hypokalemic impact.
Cyclophosphamide	Thiazide and Thiazide-Like Diuretics may intensify Cyclophosphamide's harmful or hazardous effects. Particularly, granulocytopenia could be worsened.
Dapoxetine	May increase the angiotensin-converting enzyme inhibitors' orthostatic hypotensive effects.
Dexketoprofen	Can lessen an antihypertensive drug's therapeutic impact.
Dexmethylphenidate	Could make diuretics' therapeutic effects stronger. Particularly, there may be a higher chance of hypokalemia or dehydration.
Diacerein	Thiazide and Thiazide-Like Diuretics may intensify Diazoxide's harmful or toxic effects.
Diazoxide	Thiazide and Thiazide-Like Diuretics may intensify Diazoxide's harmful or toxic effects.
Diazoxide	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Dipeptidyl Peptidase-IV Inhibitors	May worsen angiotensin-converting enzyme inhibitors' toxic or severe effects. Particularly, there may be a higher incidence of angioedema.
Drospirenone	Drospirenone's hyperkalemic impact may be enhanced by angiotensin-converting enzyme inhibitors.
DULoxetine	The hypotensive impact of DULoxetine may be enhanced by blood pressure lowering medications.
Eplerenone	Angiotensin-Converting Enzyme Inhibitors may intensify their hyperkalemic effects.
Everolimus	May intensify angiotensin-converting enzyme inhibitors' harmful or hazardous effects. Particularly, there may be a higher incidence of angioedema.
Ferric Gluconate	Angiotensin-Converting Enzyme Inhibitors might make ferric gluconate more harmful or poisonous.
Ferric Hydroxide Polymaltose Complex	Ferric Hydroxide Polymaltose Complex may have a more negative or toxic effect when taken with angiotensin-converting enzyme inhibitors. In particular, there may be an elevated risk for angioedema or allergic responses.
Gelatin (Succinylated)	Gelatin's harmful or toxic effects may be increased by angiotensin-converting enzyme inhibitors (Succinylated). Particularly, there may be a higher chance of a paradoxical hypotensive reaction.
Gold Sodium Thiomalate	Gold Sodium Thiomalate may have a more negative or toxic effect when used with angiotensin-converting enzyme inhibitors. Nitritoid responses are more likely now, it has been noted.
Heparin	Angiotensin-Converting Enzyme Inhibitors may intensify their hyperkalemic effects.
Heparins (Low Molecular Weight)	Angiotensin-Converting Enzyme Inhibitors may have an enhanced hyperkalemic impact.
Herbs (Hypertensive Properties)	May lessen the effectiveness of antihypertensive agents.
Herbs (Hypotensive Properties)	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Hypotension-Associated Agents	The hypotensive action of hypotension-associated agents may be strengthened by blood pressure lowering medications.
Icatibant	May lessen the effectiveness of angiotensin-converting enzyme inhibitors in treating hypertension.
Ipragliflozin	The toxic and harmful effects of thiazide and thiazide-like diuretics may be increased. In particular, there may be an elevated risk for intravascular volume depletion.
Ivabradine	The arrhythmogenic impact of ivabradine may be enhanced by thiazide and thiazide-like diuretics.
Levodopa-Containing Products	Levodopa-Containing Products' hypotensive effects may be strengthened by blood pressure-lowering medications.
Licorice	Thiazide and Thiazide-Like Diuretics might have an enhanced hypokalemic impact.
Loop Diuretics	May strengthen angiotensin-converting enzyme inhibitors' hypotensive effects. Angiotensin-Converting Enzyme Inhibitors' nephrotoxic effects may be increased by loop diuretics.
Lormetazepam	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Methylphenidate	May lessen the effectiveness of antihypertensive agents.
Molsidomine	Angiotensin-Converting Enzyme Inhibitors may intensify their hyperkalemic effects.
Multivitamins/Fluoride (with ADE)	May intensify the effects of thiazide and thiazide-like diuretics on hypercalcemia.
Multivitamins/Minerals (with ADEK, Folate, Iron)	The effect of multivitamins and minerals on hypercalcemia may be enhanced by thiazide and thiazide-like diuretics (with ADEK, Folate, Iron).
Multivitamins/Minerals (with AE, No Iron)	The serum concentration of multiple vitamins and minerals may rise after taking thiazide and thiazide-like diuretics (with AE, No Iron). Particularly, thiazide diuretics may reduce calcium excretion, and long-term concurrent usage may result in metabolic alkalosis.
Naftopidil	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Neuromuscular-Blocking Agents (Nondepolarizing)	The neuromuscular-blocking action of neuromuscular-blocking agents may be enhanced by thiazide and thiazide-like diuretics (Nondepolarizing).
Nicergoline	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Nicorandil	The effects of angiotensin-converting enzyme inhibitors on hyperkalemia may be enhanced.
Nicorandil	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Nitroprusside	Nitroprusside's hypotensive impact may be strengthened by blood pressure-lowering medications.
Nonsteroidal Anti-Inflammatory Agents	Nonsteroidal Anti-Inflammatory Agents' negative/toxic effects may be increased by angiotensin-converting enzyme inhibitors. In particular, the combination may cause a marked decline in renal function. Angiotensin-Converting Enzyme Inhibitors' antihypertensive effects may be lessened by nonsteroidal anti-inflammatory drugs.
Nonsteroidal Anti-Inflammatory Agents	Nonsteroidal Anti-Inflammatory Agents' nephrotoxic effects may be intensified by thiazide and thiazide-like diuretics. Thiazide and Thiazide-Like Diuretics may have less of a therapeutic impact when used with nonsteroidal anti-inflammatory drugs.
Opioid Agonists	Could make diuretics' harmful or toxic effects worse. Opioid antagonists may reduce diuretics' therapeutic benefit.
Oxcarbazepine	Thiazide and Thiazide-Like Diuretics may intensify OXcarbazepine's negative/toxic effects. Particularly, there could be a higher risk of hyponatremia.
Pentoxifylline	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Pholcodine	Pholcodine's hypotensive impact may be strengthened by blood pressure lowering medications.
Phosphodiesterase 5 Inhibitors	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Potassium Salts	Angiotensin-Converting Enzyme Inhibitors may intensify their hyperkalemic effects.
Potassium-Sparing Diuretics	Angiotensin-Converting Enzyme Inhibitors may intensify their hyperkalemic effects.
Pregabalin	Angiotensin-Converting Enzyme Inhibitors may intensify Pregabalin's negative/toxic effects. Particularly, there may be a higher incidence of angioedema.
Prostacyclin Analogues	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Quinagolide	The hypotensive effects of blood pressure-lowering medications may be strengthened.
Racecadotril	May intensify angiotensin-converting enzyme inhibitors' harmful or hazardous effects. In particular, this combination may make angioedema more likely.
Ranolazine	Angiotensin-Converting Enzyme Inhibitors may intensify their hyperkalemic effects.
Reboxetine	Thiazide and Thiazide-Like Diuretics might have an enhanced hypokalemic impact.
Salicylates	May intensify angiotensin-converting enzyme inhibitors' nephrotoxic effects. The therapeutic benefit of angiotensin-converting enzyme inhibitors may be reduced by salicylates.
Selective Serotonin Reuptake Inhibitors	The hyponatremic effects of thiazide and thiazide-like diuretics may be enhanced.
Sirolimus	Angiotensin-Converting Enzyme Inhibitors may intensify their hyperkalemic effects.
Tacrolimus (Systemic)	Tacrolimus's effect of making you more hyperkalemic may be enhanced by angiotensin-converting enzyme inhibitors (Systemic).
Temsirolimus	Angiotensin-Converting Enzyme Inhibitors may intensify their hyperkalemic effects.
Thiazide and Thiazide-Like Diuretics	May increase the angiotensin-converting enzyme inhibitors' hypotensive effects. Angiotensin-Converting Enzyme Inhibitors' nephrotoxic effects may be increased by thiazide and thiazide-like diuretics.
TiZANidine	Angiotensin-Converting Enzyme Inhibitors may intensify their hyperkalemic effects.
Tolvaptan	The effects of angiotensin-converting enzyme inhibitors on hyperkalemia may be enhanced.
Toremifene	Toremifene's hypercalcemic impact may be enhanced by thiazide and thiazide-like diuretics.
Trimethoprim	Angiotensin-Converting Enzyme Inhibitors may intensify their hyperkalemic effects.
Verteporfin	Toremifene's hypercalcemic impact may be enhanced by thiazide and thiazide-like diuretics.
Vitamin D Analogs	The hypercalcemic impact of vitamin D analogues may be enhanced by thiazides and thiazide-like diuretics.
Yohimbine	May lessen the effectiveness of antihypertensive agents.
Risk Factor D (Consider therapy modification)
Aliskiren	Angiotensin-Converting Enzyme Inhibitors may intensify their hyperkalemic effects. Angiotensin-Converting Enzyme Inhibitors' hypotensive effects may be strengthened by aliskiren. Angiotensin-Converting Enzyme Inhibitors' nephrotoxic effects may be made worse by aliskiren. Treatment: It is not advised for diabetic patients to take aliskiren along with ACEIs or ARBs. Combination therapy should be avoided in other patients, especially when CrCl is less than 60 mL/min. If combined, keep a close eye on your blood pressure, potassium, and creatinine levels.
Allopurinol	Angiotensin-Converting Enzyme Inhibitors might make Allopurinol more likely to cause allergic or hypersensitive reactions.
Amifostine	Amifostine's hypotensive impact may be strengthened by blood pressure lowering medications. Treatment: Blood pressure-lowering drugs need to be avoided for 24 hours before amifostine is administered when used at chemotherapeutic doses. Amifostine should not be given if blood pressure lowering treatment cannot be stopped.
Angiotensin II Receptor Blockers	May worsen angiotensin-converting enzyme inhibitors' toxic or severe effects. Angiotensin-Converting Enzyme Inhibitors' serum levels may rise in response to angiotensin II receptor blockers. Management: According to US labelling, it is not advisable to take telmisartan and ramipril. It is unclear whether another ACE inhibitor and ARB combo would be any safer. When possible, take into account alternatives to the mix.
Bile Acid Sequestrants	The absorption of thiazide and thiazide-like diuretics may be reduced. Also reduced is the diuretic reaction.
Dofetilide	The QTc-prolonging action of dofetilide may be enhanced by thiazide and thiazide-like diuretics. The blood concentration of Dofetilide may rise in response to thiazide and thiazide-like diuretics. Management: Despite the fact that hydrochlorothiazide is clearly listed as being contraindicated, the risk certainly applies to all thiazide and thiazide-like diuretics and may even be larger when using chlorthalidone or bendroflumethiazide. When feasible, take into account alternatives.
Grass Pollen Allergen Extract (5 Grass Extract	Grass pollen allergen extract may have a more negative or toxic effect if angiotensin-converting enzyme inhibitors are used (5 Grass Extract). With regard to grass pollen allergen extract, ACE inhibitors may specifically enhance the likelihood of a severe allergic reaction (5 Grass Extract).
Iron Dextran Complex	Angiotensin-Converting Enzyme Inhibitors might make Iron Dextran Complex more harmful or poisonous. Patients taking an ACE inhibitor may be more susceptible to events of the anaphylactic variety. Management: Adhere strictly to the instructions for iron dextran administration, including the use of a test dose before the initial therapeutic dose and the availability of resuscitation tools and qualified people.
Lanthanum	May lower angiotensin-converting enzyme inhibitors' serum concentration. Angiotensin-converting enzyme inhibitors should be given at least two hours before or after lanthanum.
Lithium	The excretion of lithium may be reduced by thiazide and thiazide-like diuretics.
Lithium	The serum concentration of lithium may rise in response to angiotensin-converting enzyme inhibitors. Management: After adding an ACE inhibitor, lithium dosage decreases will probably be required. Following the addition or discontinuation of concurrent ACE inhibitor therapy, carefully monitor the patient's response to lithium.
Obinutuzumab	The hypotensive effects of blood pressure-lowering medications may be strengthened. Management: Take into account temporarily stopping blood pressure-lowering drugs 12 hours before the start of the obinutuzumab infusion and keeping them off until 1 hour after the infusion is finished.
Sodium Phosphates	The nephrotoxic impact of sodium phosphates may be enhanced by angiotensin-converting enzyme inhibitors. In particular, there may be an increased risk of acute phosphate nephropathy. Treatment: You might want to temporarily stop taking ACEIs or look into alternatives to the oral sodium phosphate bowel preparation in order to prevent this combo. Maintaining appropriate hydration and properly monitoring renal function should be done if the combination cannot be avoided.
Sodium Phosphates	The nephrotoxic effects of sodium phosphates may be increased by diuretics. In particular, there may be an increased risk of acute phosphate nephropathy. Treatment: You might want to temporarily stop taking diuretics or look for an alternative to the oral sodium phosphate bowel preparation in order to prevent this combo. If the combination cannot be avoided, drink well and keep an eye on your kidney and fluid levels.
Topiramate	The hypokalemic impact of topiramate may be enhanced by thiazide and thiazide-like diuretics. The blood concentration of topiramate may rise in response to thiazide and thiazide-like diuretics. When using a thiazide diuretic, monitor for elevated topiramate levels and any negative consequences (such as hypokalemia). Serum potassium levels should be closely watched when receiving concurrent treatment. There may be a need to lower topiramate dosage.
Urapidil	Angiotensin-Converting Enzyme Inhibitors may interact with them through an unidentified method. Avoid taking urapidil and ACE inhibitors simultaneously as a management strategy.
Risk Factor X (Avoid combination)
Aminolevulinic Acid (Systemic)	Aminolevulinic Acid's photosensitizing impact may be enhanced by photosensitizing agents (Systemic).
Bromperidol	The hypotensive impact of bromperidol may be enhanced by blood pressure lowering medications. Blood Pressure Lowering Agents' hypotensive effects may be lessened by bromperidol.
Levosulpiride	Thiazide and Thiazide-Like Diuretics may intensify Levosulpiride's negative/toxic effects.
Mecamylamine	.Sulfonamides may intensify Mecamylamine's harmful or hazardous effects.
Promazine	Promazine's ability to prolong QTc may be enhanced by thiazide and thiazide-like diuretics.
Sacubitril	The negative or hazardous effects of sacubitril may be increased by angiotensin-converting enzyme inhibitors. In particular, this combination may raise the risk of angioedema.

Monitoring parameters:

Blood Pressure:
- Check regularly.
Kidney Tests:
- BUN and serum creatinine: Monitor routinely.
- Electrolytes: Check regularly.
Liver Health:
- Test hepatic function: At the start and then as needed based on the patient's condition.
Other Tests:
- Uric acid: Monitor if needed.
- Glucose: Monitor as appropriate.
- Urea: Especially when using drugs/supplements that can increase potassium or when using other Renin-Angiotensin-Aldosterone System (RAAS) inhibitors.
Special Considerations:
- If a patient has collagen vascular disease or kidney issues, periodically check their complete blood count (CBC) with a breakdown of different cell types (differential).

How to administer Perindopril and indapamide (Coversyl Plus)?

Take it in the morning before eating.

Mechanism of action of Perindopril and indapamide (Coversyl Plus):

Perindopril:

Prevents angiotensin I from turning into angiotensin II.
Angiotensin II makes blood vessels narrow (vasoconstriction).
Lowering angiotensin II levels increases plasma renin activity and reduces aldosterone secretion.

Indapamide:

Increases the removal of sodium, chloride, and water from the body.
Does this by messing with sodium ions in the kidneys.
Works mainly in a part of the kidney called the proximal segment of the distal tubule.

For more detailed information about each of these medications, please refer to their individual descriptions.

International Brands of Perindopril and indapamide: