This may lead to fainting. It is more common after the first or second dose, when the dose is increased, or when a person is dehydrated. To reduce the risk of dizziness, get up slowly from a lying down or sitting position. If low blood pressure causes you to faint or feel lightheaded, contact your doctor. Indapamide may make it more difficult for people with diabetes to control their blood sugar. Your doctor will monitor you while you are taking this medication and may need to adjust your doses of antidiabetes medications.
Fluid and electrolyte balance: Your levels of electrolytes, such as potassium, sodium, calcium, magnesium, and chloride, may change due to this medication. Your doctor may periodically ask for tests to check that these are in balance. If you experience symptoms of fluid and electrolyte imbalance such as muscle pains or cramps; dry mouth; numb hands, feet, or lips; or racing heartbeat, contact your doctor as soon as possible.
Salt substitutes containing potassium should be avoided. High levels of uric acid may occur in the blood or gout a type of arthritis that causes sudden, severe attacks of joint pain with redness, warmth, and swelling in the affected area may be brought on in certain people receiving indapamide.
The most likely effect in case of overdose is low blood pressure which can make you feel dizzy. If this happens, lying down with the legs elevated can help. Other effects like, nausea, vomiting, cramps, sleepiness, confusion changes in the amount of urine produced by the kidney are possible. You may require urgent medical attention.
Telephone your doctor or the Poisons Information Centre 13 11 26 in Australia; 03 in New Zealand , or go to the Accident and Emergency department at your nearest hospital. Do this even if there are no signs of discomfort or poisoning. Otherwise you may not get the benefits from treatment.
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. This is because your blood pressure is falling. If you have these symptoms when standing up or getting out of bed then getting up more slowly can help.
Calcium levels Thiazide diuretics and thiazide-related diuretics may reduce urinary excretion of calcium and cause a mild and transient increase in plasma calcium levels. Markedly raised levels of calcium may be related to undiagnosed hyperparathyroidism.
In such cases the treatment should be stopped before investigating the parathyroid function. Blood glucose Monitoring of blood glucose is important in diabetic patients, particularly when potassium levels are low. Uric acid Tendency to gout attacks may be increased in hyperuricaemic patients.
In the elderly the value of plasma creatinine levels should be adjusted to take account of the age, weight and sex of the patient, according to the Cockcroft formula: Hypovolaemia, resulting from the loss of water and sodium caused by the diuretic at the start of treatment, causes a reduction in glomerular filtration.
It may result in an increase in blood urea and creatinine levels. This transitory functional renal insufficiency is of no adverse consequence in patients with normal renal function but may however worsen a pre-existing renal impairment.
Athletes Athletes should note that this product contains an active substance which may cause a positive reaction in doping tests.
Acute myopia and secondary angle-closure glaucoma Sulfonamide, or sulfonamide derivative, drugs can cause an idiosyncratic reaction resulting in transient myopia and acute angle-closure glaucoma.
Untreated acute angle-closure glaucoma can lead to permanent vision loss. The primary treatment is to discontinue drug intake as rapidly as possible.
Prompt medical or surgical treatments may need to be considered if the intraocular pressure remains uncontrolled. Risk factors for developing acute angle-closure glaucoma may include a history of sulfonamide or penicillin allergy. Concomitant use not recommended: Use of perindopril combined with indapamide with lithium is not recommended, but if the combination proves necessary, careful monitoring of serum lithium levels should be performed see section 4.
Concomitant use which requires special care: Monitor blood pressure and adapt antihypertensive dosage if necessary. Concomitant 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. Concomitant use which requires some care: Increased antihypertensive effect and increased risk of orthostatic hypotension additive effect. Clinical trial data has shown that dual blockade of the renin-angiotensin-aldosterone-system RAAS through the combined use of ACE-inhibitors, angiotensin II receptor blockers or aliskiren is associated with a higher frequency of adverse events such as hypotension, hyperkalaemia and decreased renal function including acute renal failure compared to the use of a single RAAS-acting agent see sections 4.
Drugs inducing hyperkalaemia Some drugs or therapeutic classes may increase the occurrence of hyperkalaemia: The combination of these drugs increases the risk of hyperkalaemia. Concomitant use contra-indicated see section 4. In diabetic or impaired renal patients, risk of hyperkalaemia, worsening of renal function and cardiovascular morbidity and mortality increase. In patients other than diabetic or impaired renal patients, risk of hyperkalaemia, worsening of renal function and cardiovascular morbidity and mortality increase see section 4.
It has been reported in the literature that in patients with established atherosclerotic disease, heart failure, or with diabetes with end organ damage, concomitant therapy with 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 renin-angiotensin-aldosterone system agent.
Risk of increased adverse effects such as angioneurotic oedema angioedema. Hyperkalaemia potentially lethal , especially in conjunction with renal impairment additive hyperkalaemic effects. The combination of perindopril with the above-mentioned drugs is not recommended see section 4. If concomitant use is nonetheless indicated, they should be used with caution and with frequent monitoring of serum potassium. Epidemiological studies have suggested that concomitant administration of ACE inhibitors and antidiabetic medicines insulins, oral hypoglycaemic agents may cause an increased blood-glucose lowering effect with risk of hypoglycaemia.
This phenomenon appeared to be more likely to occur during the first weeks of combined treatment and in patients with renal impairment. The possibility of hypotensive effects can be reduced by discontinuation of the diuretic, by increasing volume or salt intake prior to initiating therapy with low and progressive doses of perindopril. In diuretic-treated congestive heart failure, the ACE inhibitor should be initiated at a very low dosage, possibly after reducing the dosage of the associated non-potassium-sparing diuretic.
In all cases, renal function creatinine levels must be monitored during the first few weeks of ACE inhibitor therapy. With eplerenone or spironolactone at doses between Before initiating the combination, check the absence of hyperkalaemia and renal impairment.
Close monitoring of the kalaemia and creatininaemia is recommended in the first month of the treatment once a week at the beginning and, monthly thereafter. In such cases perindopril should be discontinued promptly and appropriate monitoring should be instituted to ensure complete resolution of symptoms prior to dismissing the patient.
In those instances where swelling has been confined to the face and lips the condition generally resolved without treatment, although antihistamines have been useful in relieving symptoms. Angioedema associated with laryngeal oedema may be fatal.
Where there is involvement of the tongue, glottis or larynx, likely to cause airway obstruction, appropriate therapy, which may include subcutaneous epinephrine solution 1: Black patients receiving ACE inhibitors have been reported to have a higher incidence of angioedema compared to non-blacks. Patients with a history of angioedema unrelated to ACE inhibitor therapy may be at increased risk of angioedema while receiving an ACE inhibitor see section 4.
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. There have been isolated reports of patients experiencing sustained, life-threatening anaphylactoid reactions while receiving ACE inhibitors during desensitisation treatment with hymenoptera bees, wasps venom.
ACE inhibitors should be used with caution in allergic patients treated with desensitisation, and avoided in those undergoing venom immunotherapy. However these reactions could be prevented by temporary withdrawal of ACE inhibitor for at least 24 hours before treatment in patients who require both ACE inhibitors and desensitisation. Anaphylactoid reactions during LDL apheresis: Rarely, patients receiving ACE inhibitors during low density lipoprotein LDL -apheresis with dextran sulfate have experienced life-threatening anaphylactoid reactions.
These reactions were avoided by temporarily withholding ACE-inhibitor therapy prior to each apheresis. Anaphylactoid reactions have been reported in patients dialysed with high-flux membranes e. In these patients consideration should be given to using a different type of dialysis membrane or a different class of antihypertensive agent.
The combination of perindopril and potassium-sparing diuretics, potassium salts is usually not recommended see section 4.
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