Perindopril monotherapy and PROGRESS in Europe

BMJ 2005; 331 doi: https://doi.org/10.1136/bmj.331.7510.235-b (Published 21 July 2005) Cite this as: BMJ 2005;331:235
  1. Richard Wennberg, associate professor (Richard.Wennberg{at}uhn.on.ca),
  2. Camilla Zimmermann, assistant professor
  1. University of Toronto, University Health Network, Toronto, Canada M5T 2S8
  2. University of Toronto, University Health Network, Toronto, Canada M5T 2S8

    EDITOR—Perindopril has been registered in Poland as monotherapy for the prevention of recurrent stroke. The perindopril protection against recurrent stroke study (PROGRESS) is given as the only supporting evidence for this new indication, which is difficult to reconcile with the trialists' admission in the text of the publication that treatment with perindopril alone showed no discernible reduction in the risk of stroke.1

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    Polish advertisement for perindopril monotherapy

    Promotion of the new indication for perindopril is ongoing in Poland. Full page advertisements have run in Medycyna Praktyczna (issues 7-8/2004), announcing this “NEW INDICATION FOR USE,” the capitalised words situated above a cartoon brain. Below the brain we read: “Secondary prevention of cerebrovascular incidents. THE ONLY ACEI registered for secondary prevention of cerebrovascular incidents in patients regardless of their age.” Prominently displayed is the familiar PROGRESS logo.

    No mention of indapamide is made in the prescribing instructions. No mention is made in the registration information that risk reduction in PROGRESS was seen only if indapamide was given in combination with perindopril.

    In Italy, based on PROGRESS, perindopril (4 mg/day) has been granted a similar extended indication as monotherapy for the prevention of recurrent stroke. The Italian advertising inserts ignore the critical role of indapamide in PROGRESS.2 Yet in their BMJ commentary, the PROGRESS trialists admit that perindopril in monotherapy at 4 mg/day provided no detectable benefits for prevention of recurrent stroke.3

    It is unclear how these registration mistakes may have arisen. Both perindopril and indapamide are manufactured by Servier, a sponsor of the PROGRESS trial (perindopril is currently under patent protection; indapamide is no longer protected by patent). It is possible that the promoters of perindopril in these countries have misunderstood the findings of the PROGRESS trial. Whatever the origins of the mistakes, they are problematic sequelae of the ambiguously reported clinical trial data.4


    • Competing interests None declared.


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