Download Angiotensin Receptor Blockers (ARBs)

Modernized Reference Drug Program
Angiotensin Receptor Blockers (ARBs)
Please note: Special Authority approval is required for access to coverage of any ARB. Additional Special Authority approval is required for access to full coverage of a partially covered ARB.
Fully Covered (Reference Drugs)
Partially Covered (Non-Reference Drugs)
•• Candesartan with/without
hydrochlorothiazide (HCTZ)
•• Telmisartan with/without
HCTZ or Amlodipine
•• Eprosartan with/without HCTZ
•• Losartan with/without HCTZ
•• Valsartan with/without HCTZ
•• Olmesartan with/without HCTZ
•• Irbesartan 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 concerned about prescription costs and about getting
the most PharmaCare coverage possible?
YES
NO
No medication change
Prescribers
Pharmacists
To confirm Special Authority
coverage for the patient’s
current medication, call
1-866-905-4912
To confirm Special Authority
coverage for patient’s
current medication, call
the PharmaCare HelpDesk
and select the
Self-Service Option
Is the patient eligible for continued full coverage as explained
in Section 4 of the Guide to the Modernized RDP?
NO
YES
No medication change
Pharmacists
Does the patient meet the criteria (below) for full coverage of a drug
that will be only partially covered as of December 1, 2016?
Prescribers
Criteria for full coverage of a partially covered (non-reference) ARB*
Intractable cough or angioedema on an Angiotensin Converting Enzyme Inhibitor (ACE-I) and
Failure on optimal doses or intolerance to all the fully covered (reference) drugs.
NO
Submit a
Special Authority Request
If the patient meets the
criteria, refer to prescriber
who can submit a
Special Authority Request
for coverage
YES
Step 2 – Making the switch
Consider the following precaution:
•• Patients with severe renal impairment or using transplant medications should be switched with caution and
monitored closely. Be aware of the potential for drug-drug interactions with transplant medications and the
risk of hyperkalemia in susceptible patients.
•• 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 ARB 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 Doses of ARBs 1
Hypertension
•• Candesartan •• Initial: 8 mg daily
•• Max: 32 mg daily
•• Losartan
•• Initial: 25 mg daily
•• Max: 100 mg daily
•• Telmisartan
•• Initial: 40 mg daily
•• Max: 80 mg daily
•• Valsartan
•• Initial: 80 mg daily
•• Max: 320 mg daily
Approximate daily equivalent doses of ARBs 1-3
Heart Failure
Risk Reduction Risk Reduction of AdjustmentsPost-MI in Select CV Events in Select Renal
Individuals*
Individuals*
•• Initial: 4 mg daily
•• Target: 32 mg daily
•• Moderate
•• Severe impairment:
to severe
lower initial dose
impairment or
(4 mg daily)
dialysis: lower
initial dose
(4 mg daily)
•• 80 mg daily
•• Initial: 40 mg BID •• 20 mg BID,
titrated up to
•• Target: 80-160 mg
160 mg BID as
BID
tolerated
AdjustmentsHepatic
Comparable doses are approximate and are
recommended doses for hypertension. Note:
When switching products consider indication, liver
function, renal function, other medical conditions
such as HF or hypertension and allergies. Monitor
blood pressure, potassium and renal function.
Drug
Approximate Maximum
Equivalent Daily Dose
Dose
•• None
•• 25 mg daily initial
dose
•• Candesartan
8 mg
32 mg
•• Losartan
50 mg
100 mg
•• None
•• 40 mg daily initial
dose
•• Severe impairment:
Use not
recommended
•• Telmisartan
40 mg
80 mg
•• Valsartan
80 mg
320 mg
•• Eprosartan
600 mg
600 mg
•• Mild to moderate
impairment: max
80 mg daily
•• Severe impairment:
not recommended
•• Irbesartan
150 mg
300 mg
•• Olmesartan
20 mg
40 mg
•• None
* Refer to product monograph for details. Ml: Myocardial Infarction CV: cardiovascular
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 2014
Oct; cited 2016 Apr 25]. Angiotensin II Receptor Antagonists [CPhA monograph] Available
from www.e-therapeutics.ca. Also available in paper copy from the publisher.
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.
2 Therapeutic Interchange Program and Prescription Interpretations at Vancouver Community of Care.
Comparison of Angiotensin II Receptor Blockers (ARB). Available at www.vhpharmsci.com/vhformulary/Tools/AngiotensinII-Blocker-comparison.htm
3 Pharmacist’s Letter/Prescriber’s Letter. Angiotensin Receptor Blocker (ARB) antihypertensive dose comparison. Aug 2009 (full update Feb 2012); 25: 250801.