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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.