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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.