. . . . . . . . . . . . . . . . . . . . . "Zvl\u00E1\u0161tn\u00ED upozorn\u011Bn\u00ED\nSpole\u010Dn\u00E1 pro perindopril a indapamid:\nLithium:\nKombinace lithia s kombinac\u00ED perindoprilu a indapamidu se obvykle nedoporu\u010Duje (viz bod 4.5).\nSouvisej\u00EDc\u00ED s\u00A0perindoprilem:\nNeutropenie/agranulocyt\u00F3za u imunosuprimovan\u00FDch pacient\u016F:\nZd\u00E1 se, \u017Ee v\u00FDskyt neutropenie je spojen s\u00A0typem a d\u00E1vkou inhibitoru ACE, stejn\u011B jako i s\u00A0klinick\u00FDm stavem pacienta. Je vz\u00E1cn\u011B pozorov\u00E1n u nekomplikovan\u00FDch p\u0159\u00EDpad\u016F, m\u016F\u017Ee ale ovlivnit pacienty s\u00A0vaskul\u00E1rn\u00EDmi kolagenn\u00EDmi poruchami (nap\u0159. syst\u00E9mov\u00FDm lupus erythematodes, sklerodermi\u00ED) a doprovodnou dysfunkc\u00ED ledvin nebo pacienty l\u00E9\u010Den\u00FDmi imunosupresivy. Po vysazen\u00ED inhibitor\u016F ACE p\u0159\u00EDznaky vymiz\u00ED.\nMetodou volby pro p\u0159edch\u00E1zen\u00ED t\u011Bchto p\u0159\u00EDhod je p\u0159\u00EDsn\u00E9 dodr\u017Eov\u00E1n\u00ED d\u00E1vkov\u00E1n\u00ED. Je-li v\u0161ak u t\u011Bchto skupin pacient\u016F zva\u017Eov\u00E1no pou\u017Eit\u00ED inhibitoru ACE, je t\u0159eba p\u0159esto pe\u010Dliv\u011B zv\u00E1\u017Eit riziko a p\u0159\u00EDnos.\nAngioed\u00E9m (Quinckeho ed\u00E9m)\nU pacient\u016F l\u00E9\u010Den\u00FDch inhibitory ACE, v\u010Detn\u011B perindoprilu, byly vz\u00E1cn\u011B hl\u00E1\u0161eny p\u0159\u00EDpady angioed\u00E9mu tv\u00E1\u0159e, kon\u010Detin, rt\u016F, sliznic, jazyka, hlasivkov\u00E9 \u0161t\u011Brbiny a/nebo hrtanu. V\u00A0t\u011Bchto p\u0159\u00EDpadech je t\u0159eba l\u00E9\u010Dbu perindoprilem ihned p\u0159eru\u0161it a pacient by m\u011Bl b\u00FDt pod dohledem a\u017E do \u00FApln\u00E9ho vymizen\u00ED p\u0159\u00EDznak\u016F. Otoky omezen\u00E9 na obli\u010Dej a rty obvykle vymiz\u00ED bez l\u00E9\u010Dby, a\u010Dkoliv k \u00FAlev\u011B symptom\u016F lze pod\u00E1vat antihistaminika. \nAngioed\u00E9m spojen\u00FD s\u00A0otokem hrtanu m\u016F\u017Ee b\u00FDt fat\u00E1ln\u00ED, proto\u017Ee zasa\u017Een\u00ED jazyka, hlasivkov\u00E9 \u0161t\u011Brbiny nebo hrtanu m\u016F\u017Ee v\u00E9st k\u00A0obstrukci d\u00FDchac\u00EDch cest. V\u00A0t\u011Bchto p\u0159\u00EDpadech je t\u0159eba okam\u017Eit\u011B podat subkut\u00E1nn\u011B 0,3-0,5 ml roztoku adrenalinu (1:1000) a prov\u00E9st dal\u0161\u00ED p\u0159\u00EDslu\u0161n\u00E1 opat\u0159en\u00ED. \nL\u00E9\u010Dbu inhibitory ACE je t\u0159eba u takov\u00FDch pacient\u016F ukon\u010Dit (viz bod 4.3). \nPacienti, je\u017E maj\u00ED v anamn\u00E9ze Quinckeho ed\u00E9m nesouvisej\u00EDc\u00ED s\u00A0l\u00E9\u010Dbou inhibitorem ACE, mohou p\u0159i pod\u00E1v\u00E1n\u00ED inhibitoru ACE vykazovat zv\u00FD\u0161en\u00E9 riziko vzniku angioed\u00E9mu.\nAnafylaktick\u00E9 reakce v\u00A0pr\u016Fb\u011Bhu desenzibilizace\nU pacient\u016F l\u00E9\u010Den\u00FDch inhibitory ACE a podstupuj\u00EDc\u00EDch desenzibiliza\u010Dn\u00ED reakci jedem \u0159\u00E1du Hymenoptera (vosy, v\u010Dely) byly hl\u00E1\u0161eny jednotliv\u00E9 p\u0159\u00EDpady \u017Eivot ohro\u017Euj\u00EDc\u00ED p\u0159etrv\u00E1vaj\u00EDc\u00ED anafylaktick\u00E9 reakce z p\u0159ecitliv\u011Blosti. Proto by inhibitory ACE m\u011Bly b\u00FDt pou\u017E\u00EDv\u00E1ny u alergick\u00FDch pacient\u016F podstupuj\u00EDc\u00EDch desenzibilizaci s\u00A0opatrnost\u00ED a v\u00A0pr\u016Fb\u011Bhu imunoterapie jedem by m\u011Bly b\u00FDt zcela vylou\u010Deny. T\u011Bmto anafylaktick\u00FDm reakc\u00EDm lze zabr\u00E1nit vysazen\u00EDm l\u00E9\u010Dby inhibitorem ACE 24 hodin p\u0159ed desenzibilizac\u00ED.\nAnafylaktick\u00E9 reakce v\u00A0pr\u016Fb\u011Bhu dial\u00FDzy p\u0159es membr\u00E1ny s\u00A0vysok\u00FDm pr\u016Ftokem\nU pacient\u016F l\u00E9\u010Den\u00FDch inhibitory ACE a podstupuj\u00EDc\u00EDch dial\u00FDzu membr\u00E1nami s\u00A0vysok\u00FDm pr\u016Ftokem nebo LDL-afer\u00E9zu se dextran-sulf\u00E1tem byly hl\u00E1\u0161eny \u017Eivot ohro\u017Euj\u00EDc\u00ED, p\u0159etrv\u00E1vaj\u00EDc\u00ED anafylaktick\u00E9 reakce z p\u0159ecitliv\u011Blosti. U t\u011Bchto pacient\u016F je t\u0159eba se inhibitor\u016Fm ACE vyhnout. Je-li v\u0161ak inhibice ACE v kombinaci s\u00A0LDL-afer\u00E9zou nezbytn\u00E1, lze anafylaktick\u00FDm reakc\u00EDm preventivn\u011B br\u00E1nit vysazen\u00EDm l\u00E9\u010Dby inhibitory ACE 24 hodin p\u0159ed l\u00E9\u010Dbou afer\u00E9zou.\nDiuretika \u0161et\u0159\u00EDc\u00ED drasl\u00EDk, soli s\u00A0obsahem drasl\u00EDku\nKombinace perindoprilu s\u00A0diuretiky \u0161et\u0159\u00EDc\u00ED drasl\u00EDk, draseln\u00FDmi solemi se obvykle nedoporu\u010Duje (viz bod 4.5).\nT\u011Bhotenstv\u00ED: \nPod\u00E1v\u00E1n\u00ED ACE inhibitor\u016F by nem\u011Blo b\u00FDt zah\u00E1jeno b\u011Bhem t\u011Bhotenstv\u00ED. S\u00A0v\u00FDjimkou pacientek, pro kter\u00E9 je dlouhodob\u00E1 l\u00E9\u010Dba ACE inhibitory nezbytn\u00E1, by v\u0161echny ostatn\u00ED pacientky m\u011Bly b\u00FDt v\u00A0p\u0159\u00EDpad\u011B pl\u00E1novan\u00E9ho t\u011Bhotenstv\u00ED p\u0159evedeny na jinou antihypertenzn\u00ED l\u00E9\u010Dbu s\u00A0l\u00E9pe ov\u011B\u0159enou bezpe\u010Dnost\u00ED pro t\u011Bhotenstv\u00ED a plod. Pokud do\u0161lo k\u00A0ot\u011Bhotn\u011Bn\u00ED, je t\u0159eba ihned ukon\u010Dit pod\u00E1v\u00E1n\u00ED ACE inhibitor\u016F a v\u00A0p\u0159\u00EDpad\u011B nutnosti dal\u0161\u00ED l\u00E9\u010Dby zah\u00E1jit jinou l\u00E9\u010Dbu (viz bod 4.3 a 4.6).\nSouvisej\u00EDc\u00ED s\u00A0indapamidem\nU pacient\u016F s\u00A0dysfunkc\u00ED jater mohou thiazidov\u00E1 a thiazid\u016Fm podobn\u00E1 diuretika vyvolat jatern\u00ED encefalopatii. Pokud k\u00A0tomu dojde, je t\u0159eba diuretikum okam\u017Eit\u011B vysadit.\nSultoprid:\nKombinace indapamidu a sultopridu se obvykle nedoporu\u010Duje (viz bod 4.5).\nUpozorn\u011Bn\u00ED\nSouvisej\u00EDc\u00ED s p\u0159\u00EDpravkem Gleperil Combi\nRen\u00E1ln\u00ED insuficience\nV\u00A0p\u0159\u00EDpad\u011B z\u00E1va\u017En\u00E9 ren\u00E1ln\u00EDho insuficience (clearance kreatininu < 30 ml/min) je l\u00E9\u010Dba p\u0159\u00EDpravkem kontraindikov\u00E1na.\nU n\u011Bkter\u00FDch hypertonik\u016F bez zjevn\u00FDch st\u00E1vaj\u00EDc\u00EDch ren\u00E1ln\u00EDch l\u00E9z\u00ED, u nich\u017E ren\u00E1ln\u00ED krevn\u00ED testy sv\u011Bd\u010D\u00ED o funk\u010Dn\u00ED ren\u00E1ln\u00ED insuficienci, by m\u011Bla b\u00FDt l\u00E9\u010Dba ukon\u010Dena a p\u0159\u00EDpadn\u011B znovu zapo\u010Data bu\u010F v\u00A0ni\u017E\u0161\u00ED d\u00E1vce, nebo pod\u00E1n\u00EDm pouze jedn\u00E9 ze slo\u017Eek p\u0159\u00EDpravku. \nU t\u011Bchto pacient\u016F b\u011B\u017En\u00E9 l\u00E9ka\u0159sk\u00E9 prohl\u00EDdky zahrnuj\u00ED \u010Dast\u00E9 sledov\u00E1n\u00ED hladin drasl\u00EDku a kreatininu, po dvou t\u00FDdnech l\u00E9\u010Dby a pot\u00E9 ka\u017Ed\u00E9 dva m\u011Bs\u00EDce b\u011Bhem obdob\u00ED stabiln\u00ED terapie. Ren\u00E1ln\u00ED selh\u00E1n\u00ED bylo zaznamen\u00E1no hlavn\u011B u pacient\u016F se z\u00E1va\u017En\u00FDm srde\u010Dn\u00EDm selh\u00E1n\u00EDm nebo soub\u011B\u017En\u00FDm ren\u00E1ln\u00EDm selh\u00E1n\u00EDm zahrnuj\u00EDc\u00EDm sten\u00F3zu ren\u00E1ln\u00ED art\u00E9rie.\nP\u0159\u00EDpravek se obvykle nedoporu\u010Duje v\u00A0p\u0159\u00EDpad\u011B bilater\u00E1ln\u00ED sten\u00F3zy ren\u00E1ln\u00ED art\u00E9rie nebo jedn\u00E9 funk\u010Dn\u00ED ledviny. \nHypotenze, nerovnov\u00E1ha vody a elektrolyt\u016F\nExistuje riziko n\u00E1hl\u00E9 hypotenze v\u00A0p\u0159\u00EDtomnosti st\u00E1vaj\u00EDc\u00ED deplece sod\u00EDku (zvl\u00E1\u0161t\u011B u pacient\u016F se sten\u00F3zou ren\u00E1ln\u00ED art\u00E9rie). Proto je nutn\u00E9 systematick\u00E9 sledov\u00E1n\u00ED klinick\u00FDch p\u0159\u00EDznak\u016F deplece vody a elektrolyt\u016F, kter\u00E9 se mohou objevit s\u00A0interkurentn\u00ED epizodou pr\u016Fjmu nebo zvracen\u00ED. U t\u011Bchto pacient\u016F by m\u011Blo b\u00FDt prov\u00E1d\u011Bno pravideln\u00E9 sledov\u00E1n\u00ED hladiny elektrolyt\u016F v\u00A0plazm\u011B. \nZ\u00E1va\u017En\u00E1 hypotenze m\u016F\u017Ee vy\u017Eadovat pod\u00E1n\u00ED intraven\u00F3zn\u00ED infuze fyziologick\u00E9ho roztoku.\nP\u0159echodn\u00E1 hypotenze nen\u00ED kontraindikac\u00ED pro pokra\u010Dov\u00E1n\u00ED l\u00E9\u010Dby. Po obnoven\u00ED uspokojiv\u00E9ho objemu krve a krevn\u00EDho tlaku m\u016F\u017Ee b\u00FDt l\u00E9\u010Dba zah\u00E1jena bu\u010F ve sn\u00ED\u017Een\u00E9 d\u00E1vce, nebo pod\u00E1v\u00E1n\u00EDm jen jedn\u00E9 ze slo\u017Eek p\u0159\u00EDpravku. \nHladiny drasl\u00EDku\nKombinace perindoprilu a indapamidu nevylu\u010Duje mo\u017Enost vzniku hypokal\u00E9mie, zvl\u00E1\u0161t\u011B u diabetik\u016F nebo u pacient\u016F s\u00A0ren\u00E1ln\u00EDm selh\u00E1n\u00EDm. Stejn\u011B jako u jin\u00FDch antihypertenziv v\u00A0kombinaci s\u00A0diuretikem by m\u011Blo b\u00FDt prov\u00E1d\u011Bno pravideln\u00E9 sledov\u00E1n\u00ED plazmatick\u00FDch hladin drasl\u00EDku.\nPomocn\u00E9 l\u00E1tky:\nTento p\u0159\u00EDpravek obsahuje monohydr\u00E1t lak\u00F3zy a nem\u011Bl by b\u00FDt pod\u00E1v\u00E1n pacient\u016Fm se vz\u00E1cnou d\u011Bdi\u010Dnou poruchou intolerance galakt\u00F3zy, heredit\u00E1rn\u00ED deficienc\u00ED lakt\u00E1zy nebo malabsorpc\u00ED gluk\u00F3zy a galakt\u00F3zy.\nSouvisej\u00EDc\u00ED s\u00A0perindoprilem:\nKa\u0161el:\nP\u0159i u\u017E\u00EDv\u00E1n\u00ED inhibitor\u016F angiotensin-konvertuj\u00EDc\u00EDho enzymu byl zaznamen\u00E1n such\u00FD ka\u0161el. Ka\u0161el je charakteristick\u00FD svoj\u00ED perzistenc\u00ED a vymizen\u00EDm p\u0159i vysazen\u00ED l\u00E9\u010Dby. Pokud se objev\u00ED tento symptom, je nutno po\u010D\u00EDtat s mo\u017Enou iatrogenn\u00ED etiologi\u00ED. V p\u0159\u00EDpad\u011B, kdy se pod\u00E1v\u00E1n\u00ED inhibitoru angiotensin-konvertuj\u00EDc\u00EDho enzymu jev\u00ED jako nezbytn\u00E9, m\u016F\u017Ee b\u00FDt zv\u00E1\u017Eeno pokra\u010Dov\u00E1n\u00ED l\u00E9\u010Dby.\nD\u011Bti a dosp\u00EDvaj\u00EDc\u00ED:\n\u00DA\u010Dinnost a sn\u00E1\u0161enlivost perindoprilu u d\u011Bt\u00ED a dosp\u00EDvaj\u00EDc\u00EDch, v\u00A0monoterapii nebo v\u00A0kombinaci, nebyla stanovena.\nRiziko arteri\u00E1ln\u00ED hypotenze a/nebo ren\u00E1ln\u00ED insuficience (v p\u0159\u00EDpad\u011B srde\u010Dn\u00ED insuficience, deplece vody a elektrolyt\u016F):\nK v\u00FDznamn\u00E9 stimulaci renin - angiotensin - aldosteronov\u00E9ho syst\u00E9mu doch\u00E1z\u00ED zvl\u00E1\u0161t\u011B b\u011Bhem v\u00FDrazn\u00E9 deplece vody a elektrolyt\u016F (striktn\u00ED bezsod\u00EDkov\u00FD re\u017Eim nebo dlouhodob\u00E1 diuretick\u00E1 l\u00E9\u010Dba), u pacient\u016F s inici\u00E1ln\u00EDm n\u00EDzk\u00FDm krevn\u00EDm tlakem, v p\u0159\u00EDpad\u011B sten\u00F3zy ren\u00E1ln\u00ED art\u00E9rie, m\u011Bstnav\u00E9ho srde\u010Dn\u00EDho selh\u00E1n\u00ED nebo cirh\u00F3zy s\u00A0ed\u00E9my a ascitem.\nBlok\u00E1da tohoto syst\u00E9mu inhibitorem angiotensin-konvertuj\u00EDc\u00EDho enzymu m\u016F\u017Ee tud\u00ED\u017E zp\u016Fsobit, zvl\u00E1\u0161t\u011B p\u0159i prvn\u00EDm pod\u00E1n\u00ED nebo b\u011Bhem prvn\u00EDch dvou t\u00FDdn\u016F l\u00E9\u010Dby, n\u00E1hl\u00FD pokles krevn\u00EDho tlaku a/nebo zv\u00FD\u0161en\u00ED plazmatick\u00FDch hladin kreatininu nasv\u011Bd\u010Duj\u00EDc\u00EDch funk\u010Dn\u00ED ren\u00E1ln\u00ED insuficienci. Ob\u010Das m\u016F\u017Ee doj\u00EDt k\u00A0akutn\u00EDmu n\u00E1stupu, a\u010Dkoli jsou takov\u00E9 p\u0159\u00EDpady vz\u00E1cn\u00E9, a k\u00A0prom\u011Bnliv\u00E9 dob\u011B n\u00E1stupu.\nV\u00A0takov\u00FDch p\u0159\u00EDpadech by m\u011Bla b\u00FDt l\u00E9\u010Dba n\u00E1sledn\u011B zah\u00E1jena v\u00A0ni\u017E\u0161\u00ED d\u00E1vce a d\u00E1vka progresivn\u011B zvy\u0161ov\u00E1na.\nStar\u0161\u00ED pacienti:\nP\u0159ed zah\u00E1jen\u00EDm l\u00E9\u010Dby by m\u011Bly b\u00FDt vy\u0161et\u0159eny ren\u00E1ln\u00ED funkce a kal\u00E9mie. Po\u010D\u00E1te\u010Dn\u00ED d\u00E1vka je obvykle p\u0159izp\u016Fsobena podle hodnoty krevn\u00EDho tlaku, zvl\u00E1\u0161t\u011B v p\u0159\u00EDpad\u011B deplece vody a elektrolyt\u016F, aby se zabr\u00E1nilo vzniku n\u00E1hl\u00E9 hypotenze.\nPacienti s potvrzenou ateroskler\u00F3zou:\nRiziko hypotenze existuje u v\u0161ech pacient\u016F, ale zvl\u00E1\u0161tn\u00ED opatrnosti je t\u0159eba zejm\u00E9na u pacient\u016F s ischemickou chorobu srde\u010Dn\u00ED nebo cerebr\u00E1ln\u00ED ob\u011Bhovou nedostate\u010Dnost\u00ED; u t\u011Bchto pacient\u016F je t\u0159eba za\u010D\u00EDt l\u00E9\u010Dbu n\u00EDzkou d\u00E1vkou.\nRenovaskul\u00E1rn\u00ED hypertenze:\nL\u00E9\u010Dbou renovaskul\u00E1rn\u00ED hypertenze je revaskularizace. Inhibitory angiotensin-konvertuj\u00EDc\u00EDho enzymu v\u0161ak mohou b\u00FDt p\u0159\u00EDnosn\u00E9 u pacient\u016F s\u00A0renovaskul\u00E1rn\u00ED hypertenz\u00ED, kte\u0159\u00ED \u010Dekaj\u00ED na korektivn\u00ED chirurgick\u00FD z\u00E1krok nebo u nich\u017E chirurgick\u00FD z\u00E1krok nen\u00ED mo\u017En\u00FD.\nPokud je p\u0159\u00EDpravek Gleperil Combi p\u0159edeps\u00E1n pacient\u016Fm s potvrzenou sten\u00F3zou ren\u00E1ln\u00ED art\u00E9rie nebo s\u00A0podez\u0159en\u00EDm na sten\u00F3zu ren\u00E1ln\u00ED art\u00E9rie, m\u011Bla by b\u00FDt l\u00E9\u010Dba zah\u00E1jena na nemocni\u010Dn\u00EDm l\u016F\u017Eku v\u00A0n\u00EDzk\u00E9 d\u00E1vce a m\u011Bly by b\u00FDt sledov\u00E1ny funkce ledvin a hladiny drasl\u00EDku, proto\u017Ee u n\u011Bkter\u00FDch pacient\u016F se rozvinula funk\u010Dn\u00ED ren\u00E1ln\u00ED insuficience, kter\u00E1 se vr\u00E1tila k\u00A0norm\u00E1ln\u00EDmu stavu po ukon\u010Den\u00ED l\u00E9\u010Dby. \nDal\u0161\u00ED rizikov\u00E9 populace:\nU pacient\u016F se z\u00E1va\u017En\u00FDm srde\u010Dn\u00EDm selh\u00E1n\u00EDm (stupe\u0148 IV) nebo u pacient\u016F s\u00A0inzul\u00EDn-dependentn\u00EDm diabetem (spont\u00E1nn\u00ED tendence ke zv\u00FD\u0161en\u00ED hladin drasl\u00EDku) by m\u011Bla b\u00FDt l\u00E9\u010Dba zah\u00E1jena pod l\u00E9ka\u0159sk\u00FDm dohledem se sn\u00ED\u017Eenou po\u010D\u00E1te\u010Dn\u00ED d\u00E1vkou. U hypertonik\u016F s\u00A0koron\u00E1rn\u00ED insuficienc\u00ED se nem\u00E1 p\u0159eru\u0161ovat l\u00E9\u010Dba betablok\u00E1tory: inhibitor ACE by m\u011Bl b\u00FDt p\u0159id\u00E1n k betablok\u00E1toru. \nAn\u00E9mie\nU pacient\u016F s\u00A0transplantac\u00ED ledvin nebo l\u00E9\u010Den\u00FDch hemodial\u00FDzou se m\u016F\u017Ee objevit an\u00E9mie. Sn\u00ED\u017Een\u00ED hladin hemoglobinu je v\u00FDrazn\u011Bj\u0161\u00ED u pacient\u016F s\u00A0vysok\u00FDmi po\u010D\u00E1te\u010Dn\u00EDmi hodnotami. Tento \u00FA\u010Dinek nen\u00ED z\u00E1visl\u00FD na d\u00E1vce, je v\u0161ak zalo\u017Een na mechanismu inhibice ACE.\nToto m\u00EDrn\u00E9 sn\u00ED\u017Een\u00ED hladin hemoglobinu se vyskytuje v\u00A0prvn\u00EDch \u0161esti m\u011Bs\u00EDc\u00EDch l\u00E9\u010Dby inhibitory ACE a z\u016Fst\u00E1v\u00E1 pot\u00E9 nezm\u011Bn\u011Bn\u00E9. Hladiny hemoglobinu se vracej\u00ED po p\u0159eru\u0161en\u00ED l\u00E9\u010Dby k\u00A0norm\u00E1lu. L\u00E9\u010Dba m\u016F\u017Ee obvykle pokra\u010Dovat, doporu\u010Duje se v\u0161ak pravideln\u00E9 monitorov\u00E1n\u00ED hematologick\u00FDch parametr\u016F.\nOperace\nInhibitory angiotensin-konvertuj\u00EDc\u00EDho enzymu mohou vyvolat hypotenzi b\u011Bhem anest\u00E9zie, zvl\u00E1\u0161t\u011B pokud m\u00E1 pod\u00E1van\u00E9 anestetikum hypotenzn\u00ED potenci\u00E1l. \nProto se doporu\u010Duje, aby byla l\u00E9\u010Dba dlouhodob\u011B p\u016Fsob\u00EDc\u00EDmi inhibitory angiotensin-konvertuj\u00EDc\u00EDho enzymu, jako je perindopril, p\u0159eru\u0161ena jeden den p\u0159ed operac\u00ED, je-li to mo\u017En\u00E9. \nAort\u00E1ln\u00ED sten\u00F3za/hypertrofick\u00E1 kardiomyopatie:\nInhibitory ACE by m\u011Bly b\u00FDt s\u00A0opatrnost\u00ED pou\u017E\u00EDv\u00E1ny u pacient\u016F s\u00A0obstrukc\u00ED v\u00FDtokov\u00E9 \u010D\u00E1sti lev\u00E9 komory.\nJatern\u00ED selh\u00E1n\u00ED:\nVz\u00E1cn\u011B byly inhibitory ACE spojov\u00E1ny se syndromem, kter\u00FD za\u010D\u00EDn\u00E1 cholestatickou \u017Eloutenkou a postupuje v\u00A0n\u00E1hlou jatern\u00ED nekr\u00F3zu a (n\u011Bkdy) v \u00FAmrt\u00ED. Mechanismus tohoto syndromu nebyl pochopen. Pacienti u\u017E\u00EDvaj\u00EDc\u00ED inhibitory ACE, u kter\u00FDch se projev\u00ED \u017Eloutenka nebo z\u0159eteln\u00E1 elevace jatern\u00EDch enzym\u016F, by m\u011Bli p\u0159estat u\u017E\u00EDvat inhibitor ACE a m\u011Bli by b\u00FDt p\u0159im\u011B\u0159en\u011B l\u00E9\u010Debn\u011B sledov\u00E1ni (viz bod 4.8).\nHyperkal\u00E9mie:\nU n\u011Bkter\u00FDch pacient\u016F l\u00E9\u010Den\u00FDch ACE inhibitory, v\u010Detn\u011B perindoprilu, bylo pozorov\u00E1no zv\u00FD\u0161en\u00ED hladiny drasl\u00EDku v\u00A0krevn\u00EDm s\u00E9ru. Mezi pacienty s\u00A0rizikem rozvoje hyperkal\u00E9mie pat\u0159\u00ED ti, kte\u0159\u00ED maj\u00ED ren\u00E1ln\u00ED insuficienci, nekontrolovan\u00FD diabetes mellitus, nebo ti, kte\u0159\u00ED sou\u010Dasn\u011B u\u017E\u00EDvaj\u00ED diuretika \u0161et\u0159\u00EDc\u00ED drasl\u00EDk, dopl\u0148ky stravy s\u00A0obsahem drasl\u00EDku nebo n\u00E1hra\u017Eky soli obsahuj\u00EDc\u00ED drasl\u00EDk; nebo pacienti, kte\u0159\u00ED u\u017E\u00EDvaj\u00ED jin\u00E9 l\u00E9ky spojen\u00E9 se zvy\u0161ov\u00E1n\u00EDm hladiny drasl\u00EDku v\u00A0s\u00E9ru (nap\u0159. heparin). Pokud se sou\u010Dasn\u00E9 u\u017E\u00EDv\u00E1n\u00ED v\u00FD\u0161e uveden\u00FDch l\u00E1tek pova\u017Euje za vhodn\u00E9, doporu\u010Duje se pravideln\u00E9 sledov\u00E1n\u00ED hladiny drasl\u00EDku v\u00A0s\u00E9ru. P\u0159\u00EDpravek se obvykle nedoporu\u010Duje v\u00A0p\u0159\u00EDpad\u011B zv\u00FD\u0161en\u00E9 hladiny drasl\u00EDku v\u00A0plasm\u011B.\nSouvisej\u00EDc\u00ED s\u00A0indapamidem:\nRovnov\u00E1ha vody a elektrolyt\u016F:\nHladiny sod\u00EDku:\nPlazmatickou hladinu sod\u00EDku je nutn\u00E9 stanovit je\u0161t\u011B p\u0159ed zah\u00E1jen\u00EDm l\u00E9\u010Dby a pak ji v pravideln\u00FDch intervalech kontrolovat. Ka\u017Ed\u00E1 diuretick\u00E1 l\u00E9\u010Dba m\u016F\u017Ee v\u00E9st k hyponatr\u00E9mii, n\u011Bkdy s v\u00E1\u017En\u00FDmi n\u00E1sledky. Pokles hladiny sod\u00EDku m\u016F\u017Ee b\u00FDt zpo\u010D\u00E1tku asymptomatick\u00FD, a proto je nutn\u00E9 pravideln\u00E9 sledov\u00E1n\u00ED. Toto sledov\u00E1n\u00ED mus\u00ED b\u00FDt \u010Dast\u011Bj\u0161\u00ED u star\u0161\u00EDch pacient\u016F a u pacient\u016F s cirh\u00F3zou (viz body 4.8 a 4.9).\nHladiny drasl\u00EDku:\nDeplece drasl\u00EDku s\u00A0hypokal\u00E9mi\u00ED je hlavn\u00EDm rizikem thiazidov\u00FDch diuretik a thiazidu podobn\u00FDch diuretik. Riziku rozvoje n\u00EDzk\u00FDch hladin drasl\u00EDku (<\u00A03,4\u00A0mmol/l) je nutno zabr\u00E1nit u vysoce rizikov\u00FDch populac\u00ED, jako jsou star\u0161\u00ED a/nebo podvy\u017Eiven\u00ED jedinci, a\u0165 u\u017E\u00EDvaj\u00ED \u010Di neu\u017E\u00EDvaj\u00ED najednou v\u00EDce l\u00E9k\u016F, pacienti s\u00A0cirh\u00F3zou, s\u00A0ed\u00E9mem a ascitem, koron\u00E1rn\u00ED pacienti a pacienti se srde\u010Dn\u00EDm selh\u00E1n\u00EDm. \nV\u00A0t\u011Bchto p\u0159\u00EDpadech hypokal\u00E9mie zvy\u0161uje kardiotoxicitu srde\u010Dn\u00EDch glykosid\u016F a riziko poruch srde\u010Dn\u00EDho rytmu.\nPacienti s\u00A0dlouh\u00FDm QT intervalem jsou t\u00E9\u017E rizikov\u00ED, a\u0165 je jeho p\u016Fvod vrozen\u00FD nebo iatrogenn\u00ED. Hypokal\u00E9mie, stejn\u011B jako bradykardie, p\u016Fsob\u00ED jako faktor, kter\u00FD napom\u00E1h\u00E1 rozvoji z\u00E1va\u017En\u00FDch poruch rytmu, zvl\u00E1\u0161t\u011B torsades de pointes, kter\u00E9 mohou b\u00FDt fat\u00E1ln\u00ED.\nU v\u0161ech p\u0159\u00EDpad\u016F je nutn\u00E9 \u010Dast\u00E9 sledov\u00E1n\u00ED hladin drasl\u00EDku. Prvn\u00ED m\u011B\u0159en\u00ED plazmatick\u00E9 hladiny drasl\u00EDku by m\u011Blo b\u00FDt provedeno b\u011Bhem prvn\u00EDho t\u00FDdne po zah\u00E1jen\u00ED l\u00E9\u010Dby.\nPokud jsou zji\u0161t\u011Bny n\u00EDzk\u00E9 hladiny drasl\u00EDku, je nutn\u00E1 jejich korekce.\nHladiny v\u00E1pn\u00EDku:\nThiazidov\u00E1 a thiazid\u016Fm podobn\u00E1 diuretika mohou sni\u017Eovat vylu\u010Dov\u00E1n\u00ED v\u00E1pn\u00EDku mo\u010D\u00ED, a zp\u016Fsobit tak m\u00EDrn\u00E9 a p\u0159echodn\u00E9 zv\u00FD\u0161en\u00ED hladin v\u00E1pn\u00EDku v plazm\u011B. V\u00FDznamn\u00E1 hyperkalc\u00E9mie m\u016F\u017Ee m\u00EDt souvislost s nediagnostikovan\u00FDm hyperparathyroidismem. V takov\u00E9m p\u0159\u00EDpad\u011B je nutno l\u00E9\u010Dbu a\u017E do vy\u0161et\u0159en\u00ED funkce p\u0159\u00ED\u0161t\u00EDtn\u00FDch t\u011Bl\u00EDsek p\u0159eru\u0161it.\nGlyk\u00E9mie:\nSledov\u00E1n\u00ED glyk\u00E9mie je nutn\u00E9 u nemocn\u00FDch s diabetem, zejm\u00E9na pokud jsou hladiny drasl\u00EDku n\u00EDzk\u00E9.\nKyselina mo\u010Dov\u00E1:\nPacienti se zv\u00FD\u0161en\u00FDmi hladinami kyseliny mo\u010Dov\u00E9 mohou vykazovat zv\u00FD\u0161enou tendenci k z\u00E1chvat\u016Fm dny.\nRen\u00E1ln\u00ED funkce a diuretika:\nThiazidov\u00E1 a thiazid\u016Fm podobn\u00E1 diuretika jsou pln\u011B \u00FA\u010Dinn\u00E1 pouze p\u0159i norm\u00E1ln\u00ED nebo jen minim\u00E1ln\u011B sn\u00ED\u017Een\u00E9 funkci ledvin (hladina kreatininu v plazm\u011B ni\u017E\u0161\u00ED ne\u017E p\u0159ibli\u017En\u011B 25 mg/l, tj. 220 (mol/l u dosp\u011Bl\u00FDch osob).\nU star\u0161\u00EDch pacient\u016F by m\u011Bla b\u00FDt hodnota plazmatick\u00E9 hladiny kreatininu vzta\u017Eena k v\u011Bku, hmotnosti a pohlav\u00ED pacienta podle Cockroftova vzorce pro v\u00FDpo\u010Det clearence kreatininu: \nclcr = (140 - v\u011Bk) x t\u011Blesn\u00E1 hmotnost / 0,814 x plazmatick\u00E1 hladina kreatininu \nkdy: v\u011Bk je vyj\u00E1d\u0159en v\u00A0letech, \nt\u011Blesn\u00E1 hmotnost v\u00A0kg, \nplazmatick\u00E1 hladina kreatininu v (mol/l.\nTento vzorec odpov\u00EDd\u00E1 star\u0161\u00EDm mu\u017E\u016Fm a m\u011Bl by b\u00FDt upraven pro \u017Eeny vyn\u00E1soben\u00EDm v\u00FDsledku 0,85.\nHypovol\u00E9mie na podklad\u011B ztr\u00E1ty vody a sod\u00EDku navozen\u00E9 diuretikem na po\u010D\u00E1tku l\u00E9\u010Dby sni\u017Euje glomerul\u00E1rn\u00ED filtraci. V\u00FDsledkem m\u016F\u017Ee b\u00FDt zv\u00FD\u0161en\u00ED hladin mo\u010Doviny v krvi a kreatininu v plazm\u011B. Tato p\u0159echodn\u00E1 funk\u010Dn\u00ED ren\u00E1ln\u00ED insuficience nem\u00E1 \u017E\u00E1dn\u00E9 d\u016Fsledky pro pacienty s norm\u00E1ln\u00ED ren\u00E1ln\u00ED funkc\u00ED, m\u016F\u017Ee v\u0161ak d\u00E1le zhor\u0161it ji\u017E preexistuj\u00EDc\u00ED ren\u00E1ln\u00ED insuficienci.\nSportovci:\nSportovci by si m\u011Bli b\u00FDt v\u011Bdomi, \u017Ee p\u0159\u00EDpravek obsahuje l\u00E9\u010Divou l\u00E1tku, kter\u00E1 m\u016F\u017Ee vyvolat pozitivn\u00ED reakci u antidopingov\u00FDch test\u016F.\n"@cs . . . . . . . . . . . . "004.004" . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . "4.4\tZvl\u00E1\u0161tn\u00ED upozorn\u011Bn\u00ED a zvl\u00E1\u0161tn\u00ED opat\u0159en\u00ED pro pou\u017Eit\u00ED"@cs . . .