Download Angiotensin Converting Enzyme Inhibitors (ACEIs)

Modernized Reference Drug Program
Angiotensin Converting Enzyme Inhibitors (ACEIs)
Fully Covered (Reference Drugs)
Partially Covered (Non-Reference Drugs)
•• Ramipril with/without
Hydrochlorothiazide (HCTZ)
•• Benazepril
•• Captopril
•• Cilazapril with/without HCTZ
•• Perindopril
•• Quinapril with/without HCTZ
•• Trandolapril
•• Enalapril maleate or sodium with/without HCTZ
•• Fosinopril
•• Lisinopril with/without HCTZ
Information provided is not intended as a substitute for professional judgement.
Step 1 – Does your patient need to switch medications to retain PharmaCare coverage?
Is patient already taking the fully covered (reference) drug listed above?
NO
YES
No medication change
Pharmacists
Prescribers
Is patient concerned about prescription costs and about getting
the most PharmaCare coverage possible?
YES
NO
To confirm Special Authority
coverage for the patient’s
current medication, call
1-866-905-4912
No medication change
To confirm Special Authority
coverage for patient’s
current medication, call
the PharmaCare HelpDesk
and select the
Self-Service Option
Does patient already have Special Authority coverage of their existing drug (i.e., is eligible
for continued full coverage as explained in Section 4 of the Guide to the Modernized RDP)?
YES
NO
No medication change
Prescribers
Does the patient meet the criteria (below) for full coverage of a drug
that will be only partially covered as of December 1, 2016?
Criteria for full coverage of a partially covered (non-reference) drug*
Treatment failure on optimal doses or intolerance to ramipril or
Complex patient requiring medication(s) for co-existing chronic condition(s)
Submit a
Special Authority Request
Specialty Exemptions from
submitting Special Authority
Requests: paediatric
cardiology and paediatrics
Pharmacists
If the patient meets the
criteria, refer to prescriber
who can submit a
Special Authority Request
for coverage
YES
NO
Step 2 – Making the switch
Consider the following precautions:
•• Be aware that captopril is dosed multiple times per day, whereas other ACEIs are typically dosed once daily.
•• Patients with severe renal impairment or using transplant medications should be switched with caution
and monitored closely. Be aware of the potential risk of hyperkalemia in susceptible patients and possible
drug-drug interactions between ACEI and transplant medications.
•• Obtain a baseline BP measurement prior to therapeutic substitution OR ensure that the patient has had a
recent BP measurement.
•• Patients can switch at the next fill of their prescription. Switch the patient to the fully covered ACEI at a
therapeutically appropriate dose as shown below.
Pharmacists
You may wish to contact the prescriber for
complex or frail patients such as:
•• pregnant, lactating or pediatric patients
•• patients with an acute or unstable cardiac condition, e.g.:
• hospitalization in the past 6 months for cardiac reasons
• cardiac medication has changed in the past 6 months
• currently being seen by a cardiac specialist
Recommended dosage of Ramipril 1
Approximate equivalent doses of ACEI for blood pressure lowering 1,2
Indication
Dose
Drug
Hypertension
•• Initial (monotherapy): 2.5 mg daily
•• Initial (concomitant diuretic): 1.25 mg daily
•• Usual: 2.5 mg to 10 mg daily (can divide BID)
•• Max: 20 mg daily
•• Ramipril
2.5 mg daily
20 mg
•• Benazapril
•• Captopril
•• Cilazapril
•• Enalapril maleate
•• Fosinopril
•• Lisinopril
•• Quinapril
•• Perindopril
•• Trandolapril
10 mg daily
12.5 mg three times daily
2.5 mg daily
5 mg daily
10 mg daily
10 mg daily
10 mg daily
2 mg daily
1 mg daily
40 mg
150 mg
10 mg
40 mg
40 mg
80 mg
40 mg
8 mg
4 mg
Heart Failure
•• Initial: 1.25 mg to 2.5 mg BID
•• Target: 5 mg BID
Renal Impairment
•• Initial: 1.25 mg daily
•• CrCl 10 to 40 mL/min: Max 5 mg daily
•• CrCl < 10 mL/min: Max 2.5 mg daily
Hepatic Impairment
•• Max dose 2.5 mg daily
Approximate Dose Equivalence
Maximum Daily Dose
Monitor blood pressure, potassium, and renal function. Inform the patient of the changes made, of any self-monitoring required, and of plans for follow-up.
* If medical circumstances warrant, Special Authority may be granted
for exceptional coverage on a case-by-case basis.
References:
1. CPS [Internet]. Ottawa (ON): Canadian Pharmacists Association; c2016 [updated
2011 Oct; cited 2016 Apr 25]. ACE Inhibitors [CPhA monograph] Available from
www.e-therapeutics.ca. Also available in paper copy from the publisher.
2. Therapeutic Interchange Program and Prescription Interpretations at Vancouver
Community of Care. Comparison of Angiotensin Converting Enzyme (ACE) Inhibitors.
Available at www.vhpharmsci.com/vhformulary/Tools/ACEI%20Comparison.pdf
Prescribers
Pharmacists
Check patient progress at next
scheduled appointment.
Communicate therapeutic substitution information to the
appropriate prescriber according to the requirements of PPP-58.
Check patient progress at next pharmacy visit.