Modernized Reference Drug Program Angiotensin Converting Enzyme Inhibitors (ACEIs)

Fully Covered (Reference Drugs) Partially Covered (Non-Reference Drugs) •• Ramipril with/without •• Benazepril •• Enalapril maleate or sodium with/without HCTZ •• Perindopril Hydrochlorothiazide (HCTZ) •• Captopril •• Fosinopril •• Quinapril with/without HCTZ •• Cilazapril with/without HCTZ •• Lisinopril with/without HCTZ •• Trandolapril 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 To confirm Special Authority Is patient concerned about prescription costs and about getting Prescribers coverage for patient’s the most PharmaCare coverage possible? To confirm Special Authority current medication, call coverage for the patient’s the PharmaCare HelpDesk and select the YES NO No medication change current medication, call 1-866-905-4912 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)?

NO YES No medication change Prescribers Does the patient meet the criteria (below) for full coverage of a drug Submit a Pharmacists that will be only partially covered as of December 1, 2016? Special Authority Request If the patient meets the Specialty Exemptions from criteria, refer to prescriber Criteria for full coverage of a partially covered (non-reference) drug* submitting Special Authority who can submit a Treatment failure on optimal doses or intolerance to ramipril or Requests: paediatric Special Authority Request Complex patient requiring medication(s) for co-existing chronic condition(s) cardiology and paediatrics for coverage

NO YES

Step 2 – Making the switch

Consider the following precautions: Pharmacists ••Be aware that captopril is dosed multiple times per day, whereas other ACEIs are typically dosed once daily. You may wish to contact the prescriber for ••Patients with severe renal impairment or using transplant medications should be switched with caution complex or frail patients such as: and monitored closely. Be aware of the potential risk of hyperkalemia in susceptible patients and possible ••pregnant, lactating or pediatric patients drug-drug interactions between ACEI and transplant medications. ••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 ••Obtain a baseline BP measurement prior to therapeutic substitution OR ensure that the patient has had a • currently being seen by a cardiac specialist 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.

Recommended dosage of Ramipril 1 Approximate equivalent doses of ACEI for blood pressure lowering 1,2 Indication Dose Drug Approximate Dose Equivalence Maximum Daily Dose Hypertension ••Initial (monotherapy): 2.5 mg daily •• Ramipril 2.5 mg daily 20 mg ••Initial (concomitant diuretic): 1.25 mg daily •• Benazapril 10 mg daily 40 mg ••Usual: 2.5 mg to 10 mg daily (can divide BID) •• Captopril 12.5 mg three times daily 150 mg ••Max: 20 mg daily •• Cilazapril 2.5 mg daily 10 mg Heart Failure •Initial: 1.25 mg to 2.5 mg BID • •• Enalapril maleate 5 mg daily 40 mg ••Target: 5 mg BID •• Fosinopril 10 mg daily 40 mg Renal Impairment ••Initial: 1.25 mg daily •• Lisinopril 10 mg daily 80 mg ••CrCl 10 to 40 mL/min: Max 5 mg daily ••CrCl < 10 mL/min: Max 2.5 mg daily •• Quinapril 10 mg daily 40 mg •• Perindopril 2 mg daily 8 mg Hepatic Impairment ••Max dose 2.5 mg daily •• Trandolapril 1 mg daily 4 mg

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: Prescribers Pharmacists 1. CPS [Internet]. Ottawa (ON): Canadian Pharmacists Association; c2016 [updated 2011 Oct; cited 2016 Apr 25]. ACE Inhibitors [CPhA monograph] Available from Check patient progress at next Communicate therapeutic substitution information to the www.e-therapeutics.ca. Also available in paper copy from the publisher. scheduled appointment. appropriate prescriber according to the requirements of PPP-58. 2. Therapeutic Interchange Program and Prescription Interpretations at Vancouver Community of Care. Comparison of Angiotensin Converting Enzyme (ACE) Inhibitors. Check patient progress at next pharmacy visit. Available at www.vhpharmsci.com/vhformulary/Tools/ACEI%20Comparison.pdf