Ramipril and candesartan together?

[Mr Pharm S]

Patient was on ramipril and now GP has added candesartan.

Contacted GP to explain my concerns and he said its a different class of drug and still wants to prescribe it.

Explained angiotensin II antagonists usually reserved for intoleranace to ace inhibitors as theyre both doing very similar job.

He shot me down and told me just to dispense it.

Patient calling back tomorrow.

Made a note in patients records of the info I told GP and that he told me to dispense it anyway.

Am I wrong, can they be prescribed together, I cant find any info anywhere to say they cant but surely theyre doing a very similar thing.

Surely its like using ranitidine (H2) and Lansoprazole (PPI) together.

Any thoughts, please correct me if Im wrong.

[mm45]

Re: Ramipril and candesartan together?

There was a trial(Valheft) that showed ACEi and ARBs can be used benefically in some patients with heart failure if they are not on beta blockers ( although I did all three used once in a specialist area). The combination of ACEi and ARBs reduced symptoms but did not have a significant effect of death, I believe.

[Petey]

Re: Ramipril and candesartan together?

You would be surprised how often I see this in day to day practice.

[paul2008]

Re: Ramipril and candesartan together?

Patient was on ramipril and now GP has added candesartan.

Contacted GP to explain my concerns and he said its a different class of drug and still wants to prescribe it.

Explained angiotensin II antagonists usually reserved for intoleranace to ace inhibitors as theyre both doing very similar job.

He shot me down and told me just to dispense it.

Patient calling back tomorrow.

Made a note in patients records of the info I told GP and that he told me to dispense it anyway.

Am I wrong, can they be prescribed together, I cant find any info anywhere to say they cant but surely theyre doing a very similar thing.

Surely its like using ranitidine (H2) and Lansoprazole (PPI) together.

Any thoughts, please correct me if Im wrong.

IIRC the theory is that ACEi block ACE to prevent the production of Angiotension II but Angiotension II is made in other tissues via another pathway so adding a ARB is required for total blockade of the Angiotension receptors. There is some evidence that they are more effective togethrer but apparently adding a betablocker to the two is very dangereous resulting in increased mortality possibly due to completely turining off the Renin angiotension system.

Ideally this should be under specialist care.

[ChopperT]

Re: Ramipril and candesartan together?

Hi,
It's fine to use an ACEI and A2RB together as long as there is monitoring of renal function. It tends to be reserved for patients in whom bp cannot be controlled with other meds satisfactorily. Whilst a few years ago the coprescibing would have been frowned upon it is now generally accepted. I was also sceptical until I started receiving such recommendations from renal consultants. So far have had no problems from coprescribing and have in about 30% of cases seen a reasonable bp drop as a result. Hope this reassures you.
ChopperT (general practitioner)

[SolomonQ]

Re: Ramipril and candesartan together?

maybe the Gp would have agreed if it was explained that an increase in the ramipril dose (if not at max), would have very similar effect, but also result in a lower pill burden for the patient AND save money for the GP as Amias is quite expensive. However, the patient might have been indicated for both but the GP didn't find it important to explain why to a pharmacist.

As a final thought, I would ask if the GP has done renal and electrolyes tests on the patient before increasing the dose, if not then I would refuse to supply unless I was given sufficient explanation as to why I should do so.

[Jen the 3rd]

Re: Ramipril and candesartan together?

No necessarily, as sometimes increasing the dose of one thing will lead to increased side effects with little additional benefit. Combination therapy can sometimes be better pharmacodynamically.

See
http://www.ncbi.nlm.nih.gov/pubmed/1...ubmed_RVDocSum

As for insisting on U's and E's? Yes, in a hospital setting, but not practical in community unless you are a pharmacist specifically employed to carry out clinical review.

And it depends on what was going on- if a pharmacist explains elementary clinical facts like above GP's might feel a touch patronised. If, however, the pharmacist asks if there has been a change in guidelines or bothers to do the research first (it took me 5 seconds to find the above paper), the GP might be a little more appreciative of the interaction. Dealing with GP's is very different from dealing with junior docs in hospital, a lot of them have been qualified for a very long time and they get more clinical feedback then we get at present not having access to medical notes in community pharmacy.

[paul2008]

Re: Ramipril and candesartan together?

maybe the Gp would have agreed if it was explained that an increase in the ramipril dose (if not at max), would have very similar effect, but also result in a lower pill burden for the patient AND save money for the GP as Amias is quite expensive. However, the patient might have been indicated for both but the GP didn't find it important to explain why to a pharmacist.


As a final thought, I would ask if the GP has done renal and electrolyes tests on the patient before increasing the dose, if not then I would refuse to supply unless I was given sufficient explanation as to why I should do so.

Increasing the dose of ramipril would not have the same effect as I explained above the drugs act in different parts of the renin angiotension system, have a look at the pharmacology and the evidence. The other study that showed this benefit was CHARM although there is some controversy some specialists are using the combination and it would be very difficult for you to say that there is no evidence, better evidence is desirable but why is the drug expert asking the diseasse expert to teach him about drugs? Isn't that what CPD is all about?

In heart failure candesartan is liscenced as an add on to an ACEi or in patients intolerant to ACEi see the spc, which I can't make a link too. I would be very hesitant to give advice contradicting the SPC of a product.

Adding a ARB is only of benefit in certain circumstances but in those it has been shown to reduce hospitalisation and thus save the NHS money so by refusing to dispense this combination in an appropriate situation you could potentially increase the risk of unnecssary and expensive hospitalisation. Of course you would have to figure out if it was appropriate or not and ensure that monitoring was being done.

ACEi have side effects at higher doses than the effect and even if the effect was the same you could achieve the desired effect without the cough etc by adding a lower dose ARB.

Don't mean to sound argumentative, I'm just angry that I can't remermber the evidence and feel the need to waste friday night looking for it. I wish I had UK Mpharm I would not need to use my rusty medicines information skills.

[ChopperT]

Re: Ramipril and candesartan together?

I don't have any concern about the coprescribing as long as there is adequate monitoring. It is a shame that so many doctors and pharmacists don't get along even though we generally share the same 3 goals

1-do what is best for the patient
2-try not to get sued
3-earn some money along the way.

We all make mistakes and I'm always glad to hear from my local pharmacist on the few occasions they call me as it's usually because I've cocked up a dose and they have spotted it. In my interpretation, one of the problems here is that the pharmacist has spotted what they believe to be an error, the gp has then been unable to adequately reassure the pharmacist and possibly been rude in the process. The only way to overcome this sort of problem is 1. to work in an area where the GPs are of a high standard (difficult to guarantee always) and 2.get to know the people you work with so that there is mutual respect and trust. I would try to reassure the pharmacist that I know what I'm doing and hopefully my local pharmacists know me sufficiently well to accept my reassurance. If they still refused I would be polite but thoroughly cheesed off.

I hope you'll forgive "the enemy" writing in you're forum!
ChopperT

[Jen the 3rd]

Re: Ramipril and candesartan together?

Its good to see a GP in our forum though I fear you'll get addicted just like we are!

[SolomonQ]

Re: Ramipril and candesartan together?

Chopper T wrote:

I hope you'll forgive "the enemy" writing in you're forum!

GPs arent our (pharmacist's) enemies, it's the store managers that we hate.

Chooper T, could you clarify what the general perception amongst GPs as to what a Pharmacist does is, please?

[Jen the 3rd]

Re: Ramipril and candesartan together?

Some of my best friends are GP's........

[Tony Schofield]

Re: Ramipril and candesartan together?

ACE inhibitors and ARBs are prescribed together more and more frequently. I even took the combination myself for a period of time earlier this year. Telephoning a doctor and threatening not to dispense is not sensible if you want to preserve your clinical integrity.

It is easy enough with web based resources to look up strangeish combinations of drugs.

[Jeff]

Re: Ramipril and candesartan together?

We all make mistakes and I'm always glad to hear from my local pharmacist on the few occasions they call me as it's usually because I've cocked up a dose and they have spotted it.

I usually phone docs with concerns about patients rather than concerns about prescribing - unless it's stock shortages.
OK I phone with a list of names and they phone me back after surgery.

1. to work in an area where the GPs are of a high standard (difficult to guarantee always) and 2.get to know the people you work with so that there is mutual respect and trust.

1. Leaves those patients at risk still at risk
2. Ends up with the docs phoning me.

[/quote]I hope you'll forgive "the enemy" writing in you're forum!
ChopperT[/QUOTE]
I can't object to your writing - I post on GP-UK ;-)
However pharmacists are pedantic so I can reserve the right to point out that it's not "you're forum" but "your forum"

Jeff

[ChopperT]

Re: Ramipril and candesartan together?

YOU'RE absolutely right. I shouldn't post whilst trying to put my kids to sleep at the same time!