1. The ECG shows a sinus rhythm, a normal axis, and a rate of 60 beats per minute. This is normal, as with most hypertensive patients.
2. After its inception in 1993, Pharmac extended a system known as “benchmark pricing” or “class effect”. Medicines judged by Pharmac to produce the same or similar therapeutic effect in the treatment of identical or similar conditions are grouped together and a single reference price reimbursement level is set. Medicines above the reference price require partial or full payment by the patient. In 2002, the rarely used ACE inhibitor drugs quinapril and cilazapril were funded.
3. Currently, cilazapril, quinapril, lisinopril, perindopril, and enalapril are Pharmac-funded ACE inhibitors for adult patients with hypertension. Both losartan and candesartan are funded ARBs.
4. Most countries use ACE inhibitors other than cilazapril. In New Zealand, just over half of the 500,000 prescriptions for ACE inhibitors annually are for cilazapril. However, since most other countries do not use cilazapril, there is only one manufacturer left that still makes it. In addition, the combined cilazapril 5 mg / hydrochlorothiazide 12.5 mg tablet is no longer manufactured.
5. The option is simply to replace cilazapril / hydrochlorothiazide with a diuretic combined with an ACE inhibitor or an ARB. At approximately equivalent strength, the funded tablets are quinapril 20 mg / hydrochlorothiazide 12.5 mg or losartan 50 mg / hydrochlorothiazide 12.5 mg. However, your patient’s blood pressure is a little high for a direct exchange.
a. Yes, but as of May 1, the prescription must state that this medication was taken by the patient before May 1. No new patient will be funded for cilazapril alone.
6. It is perfectly reasonable to simply switch a patient from cilazapril to another funded ACE inhibitor. However, the limited supply of cilazapril and the end of the supply of cilazapril / hydrochlorothiazide could provide an opportunity to switch to equally effective but better tolerated ARBs for hypertension.
a. A 2018 comprehensive review of ACE inhibitors and ARBs used in the management of hypertension, published in the Journal of the American College of Cardiology, concluded that ARA drugs are a better and safer option than ACE inhibitor drugs. The review states: “Given the same efficacy result but fewer adverse events with ARBs, the overall risk-benefit analysis indicates that at present there is little or no reason to use ACE inhibitors for the treatment of hypertension. “
7. You choose to replace the combined cilazapril 5 mg / hydrochlorothiazide 12.5 mg tablet with candesartan 16 mg for two weeks, then 32 mg long-term. You ask your patient to come back at two and six weeks to have their blood pressure reassessed. If his blood pressure remains high, you will add either chlorthalidone 12.5 mg per day or indapamide 2.5 mg each morning. It will be a stronger combination. Therefore, he would then take four tablets each morning.
a. You plan to check creatinine and electrolyte levels during your two-week blood pressure checkup, as well as two weeks after adding the diuretic, and then every three to six months for the first year. You then plan to check them on an annual basis. You know that some patients have a significant drop in serum sodium or significant kidney failure with ACE inhibitors, ARBs, or diuretic drugs.
b. You appreciate that your patient’s amlodipine dose can also be increased in the medium term, as needed for blood pressure control. For optimal blood pressure management, you aim for an average blood pressure of 130/80 mmHg or less.
Chris Ellis is Consultant Cardiologist at Auckland City Hospital and Heart Group and Mercy Hospital, Auckland
Details of this case study have been edited to protect patient privacy