Appendix B: Commonly used Drugs in Heart Failure Care1, 2, 3

Generic Name
Cost Therapeutic
(trade name) PharmaCare Common Adverse
Adult Dosages per 30 Considerations & Drug Interactions
(strengths and Coverage Effects
days* Contraindications
dosage form)
Angiotensin Converting Enzyme Inhibitors (ACE-I)
ramipril Initial: $8-12 Regular Hypotension, Titrate dosage slowly Diuretics: hypotension.
Altace, G 1.252.5 mg BID Coverage hyperkalemia, by 50100% every
(IR capsule: dry cough, renal 24 weeks. Potassium-sparing diuretics,
1.25, 2.5, 5, 10 mg) Target: insufficiency, potassium supplements,
5 mg twice BID angioedema, Monitor serum angiotensin receptors blockers:
skin rashes, taste creatinine and potassium hyperkalemia.
Max dose: disturbance, 714 days after initiation
10 mg BID proteinuria, of therapy or dose NSAIDs: reduced hypotensive
enalapril Initial: $35 Regular neutropenia, headache, changes. effect, fluid retention, renal
Vasotec, G 1.252.5 mg BID Coverage dizziness. failure.
(IR tablet: Contraindication:
2.5, 5, 10, 20 mg) Target: 10 mg BID Avoid in pregnancy. Lithium: increased lithium
levels and toxicity.
Max dose:
20 mg BID
captopril Initial: $1278 Regular
G 6.2512.5 mg TID Coverage
(IR tablet:
6.25, 12.5, 25, 50, Target: 50 mg TID
100 mg)
Max dose:
150 mg TID
lisinopril Initial: $869 Regular
Prinivil, Zestril, G 2.55 mg once daily Coverage
(IR tablet:
5, 10, 20 mg) Target: 2040 mg
once daily

Max dose:
80 mg once daily
perindopril Initial: $17 Regular
Coversyl 2 mg once daily coverage
(IR tablet:
2, 4, 8 mg) Target:
8 mg once daily

Max dose:
8 mg once daily
trandolapril Initial: 0.51 mg $931 Regular
Mavik once daily coverage
(IR capsule:
0.5, 1, 2, 4 mg) Target:
4 mg once daily

Max dose:
4 mg once daily

BCGuidelines.ca: Chronic Heart Failure Diagnosis and Management: Appendix B (2015) 1

 Generic Name
Cost Therapeutic
(trade name) PharmaCare Common Adverse
Adult Dosages per 30 Considerations & Drug Interactions
(strengths and Coverage Effects
days* Contraindications
dosage form)
Angiotensin Receptor Blockers (ARB)
candesartan Initial: $910 Special Hypotension, Angioedema less Diuretics: hypotension.
Atacand, G 4 mg once daily Authority hyperkalemia, frequent than with ACE-I.
(IR tablet: (IR tablet: renal insufficiency, Potassium-sparing diuretics and
4, 8, 16, 32 mg) Target: 8, 16, 32 mg) angioedema (rare, Monitor serum creatinine ACE-I: hyperkalemia.
32 mg once daily less frequent than and potassium 714 days
No Coverage with ACE-I), headache, after initiation of therapy Potassium: hyperkalemia.
(IR tablet: dizziness. or dose changes.
4 mg) NSAIDs: reduced hypotensive
Contraindication: Avoid effect, fluid retention, renal
losartan Initial: $5$20 Special
in pregnancy. failure.
Cozaar, G 12.5 mg once daily Authority
(IR tablet:
Lithium: increased lithium
25, 50, 100 mg) Target:
levels and toxicity.
150 mg once daily
valsartan Initial: 40 mg BID $1819 Special
Diovan, G Authority
(IR tablet: Target: 160 mg BID
40, 80, 160,
320 mg)
Beta-Blockers
carvedilol Initial: $2244 Special Orthostatic Increase by 50100% Digoxin, amiodarone, diltiazem,
G 3.125 mg BID Authority hypotension, every 2 to 4 weeks. and verapamil: brandycardia.
(IR tablet: worsening heart
3.125, 6.25, Target: failure, worsening HF symptoms may get Nondihydropyridine calcium
12.5, 25 mg) 25 mg BID if <75 kg fluid retention, worse before they get channel blockers (e.g. verapamil
50 mg BID if >75 kg bronchospasm, better. and diltiazem): additive
dyspnea, bradycardia, cardiodepressant effect.
Max dose: malaise, fatigue, More likely to cause
50 mg BID asthenia, erectile orthostatic hypotension CYP2D6 inhibitors (e.g., SSRIs,
dysfunction, masking than bisoprolol. bupropion, ritonavir, sertraline,
bisoprolol Initial: $19 Regular
of symptoms of St. Johns Wort, citalopram,
G 1.25 mg once daily Coverage
hypoglycemia. amiodarone): may increase
(IR tablet:
carvedilol levels
5, 10 mg) Target:
HF symptoms may get worse
10 mg once daily
before they get better.
Max dose:
20 mg once daily
Mineralocorticoid Receptor Antagonists (MRAs; also known as aldosterone receptor antagonists)
spironolactone Initial: $25 Regular Hyperkalemia, Monitor serum creatinine ACE-I, ARB, and potassium
Aldactone, G 12.5 mg once daily Coverage dehydration, nausea, and potassium 3 and supplements: hyperkalemia.
(IR tablet: gynecomastia (usually 7 days after initiation
25, 100 mg) Target: reversible upon or titrating the dose. NSAIDS: reduced diuretic effect,
2550 mg/day discontinuation). Repeat every 13 months worsening renal function,
(>25 mg/day rarely once stable. hyperkalemia.
indicated)
Contraindications:
Pregnancy.

2 BCGuidelines.ca: Chronic Heart Failure Diagnosis and Management: Appendix B (2015)

 Generic Name
Cost Therapeutic
(trade name) PharmaCare Common Adverse
Adult Dosages per 30 Considerations & Drug Interactions
(strengths and Coverage Effects
days* Contraindications
dosage form)
eplerenone Initial: $4386 No Coverage Hyperkalemia, Monitor serum creatinine ACE-I, ARB, and potassium
Inspra 25 mg once daily or dehydration, dizziness, and potassium 3 and supplements: hyperkalemia.
(IR tablet: once every 2 days diarrhea, nausea. 7 days after initiation
25, 50 mg) or titrating the dose. NSAIDs: reduced diuretic effect,
Target: Repeat every 13 months worsening renal function,
50 mg once daily once stable. hyperkalemia.

Contraindications: Strong inhibitors of

Use with strong CYP3A4 (e.g., ketoconazole,
inhibitors of CYP3A4 itraconazole, ritonavir,
(e.g., ketoconazole, nelfinavir, clarithromycin,
itraconazole, ritonavir, telithromycin, nefazodone):
nelfinavir, clarithromycin, significant increases in
telithromycin, eplerenone levels.
nefazodone): significant
increases in eplerenone Strong inducers of CYP3A4
levels. (e.g., carbamazepine,
phenytoin, phenobarbital,
Pregnancy. St. Johns Wort, refampicin):
significant decreases in
eplerenone efficacy.
Direct-Acting Vasodilators
hydralazine Initial: $1379 Regular Hypotension, GI Should be used in
G 1025 mg TID Coverage complaints, SLE- combination with
(IR tablet: like syndrome, isosorbide dinitrate or
10, 25, 50 mg) Target: tachyphylaxis, may nitroglycerin.
75 mg TID to QID worsen oxygen
demand.
isosorbide Initial: $419 Regular Headache, hypotension. Should be used in Sildenafil, vardenafil and
dinitrate 1020 mg TID Coverage combination with tadalafil: severe hypotension.
G hydralzine.
(IR tablet: Target:
10, 30 mg) 40 mg TID to QID
Diuretics
furosemide Initial: $1107 Regular Dehydration, Lithium: lithium toxicity.
Lasix, G 2040 mg/day once Coverage hypokalemia,
(IR tablet: daily or BID hypocalcemia, nausea, Digoxin: digoxin toxicity if
20, 40, 80 mg ) hypotension, azotemia, K+ depleted.
Max total daily hypomagnesemia,
dose: 600 mg anorexia, Oral corticosteroids:
hyperglycemia, hypokalemia.
May be hyperuricemia,
administered weakness, fatigue, NSAIDs: reduced diuretic effect,
BID or TID for rash, increased total increased renal toxicity.
decompensated HF. cholesterol.
metolazone Initial: $752 Regular
Ototoxicity with high
Zaroxolyn 2.5 mg once daily Coverage
doses of furosemide.
(IR tablet: 2.5 mg)
Max total daily
dose: 20 mg

BCGuidelines.ca: Chronic Heart Failure Diagnosis and Management: Appendix B (2015) 3

 Generic Name
Cost Therapeutic
(trade name) PharmaCare Common Adverse
Adult Dosages per 30 Considerations & Drug Interactions
(strengths and Coverage Effects
days* Contraindications
dosage form)
Digoxin
digoxin 0.06250.25 mg $8 Regular Anorexia, nausea, May improve symptoms, Amiodarone, clarithyomycin,
Toloxin, G once daily in the Coverage vomiting, visual exercise tolerance, and cyclosporine, erythromycin,
(IR tablet: evening. disturbances, fatigue, quality of life, but has not itraconazole, propafenone,
0.0625, 0.125, dizziness, confusion, been shown to improve quinidine, ritonavir, tetracycline,
0.25) Lower doses may delirium, cardiac survival. and verapamil: increased
be appropriate arrhythmia. digoxin serum levels.
in patients with Use only in patients with
low body mass systolic HF. Antacids, cholestyramine,
or impaired renal colestipol, neomycin,
function. Electrolytes, creatinine, rifampin, St. Johns Wort, and
and digoxin serum sulfasalazine: reduced digoxin
Measure concentrations should serum levels.
trough serum be obtained 5-7 days
concentrations at after dose adjustments. Amiodarone, beta-blockers,
least 8 hours after diltiazem, and verapamil:
administration and increased risk of bradycardia.
adjust the dose to
maintain the serum
concentration
between 0.6 and
1 nmol/L.

Abbreviations: ACE-I = angiotensin-converting enzyme inhibitor; ARB = angiotensin II receptor blockers; BID = twice daily; G = generic; GI = gastrointestinal;
HF = heart failure; IR = immediate-release; kg = kilogram; mg = milligram; NSAID = nonsteroidal anti-inflammatory drugs; QID = four times daily;
SLE = systemic lupus erythematosus; SSRI = selective serotonin reuptake inhibitor; TID = three times daily.
Footnotes: Pricing is approximate as of May 1, 2015 and does not include dispensing fee or additional markups.
Note: Please review product monographs at hc-sc.gc.ca/dhp-mps/prodpharma/databasdon/index-eng.php and regularly review current Health Canada advisories,
warnings and recalls at www.hc-sc.gc.ca/ahc-asc/media/advisories-avis/index_e.html
PharmaCare Coverage Definitions: G: generic(s) are available; Regular Coverage: also known as regular benefit; does not require Special Authority. Regular
benefits may be fully or partially covered.*; Limited Coverage: requires Special Authority for coverage. Limited Coverage benefits approved by Special Authority
may be fully or partially covered.*; RDP: Reference Drug Program. Drugs included in the RDP are comparable agents of the same therapeutic class. Patients receive
full coverage of drugs designated as the Reference Drug(s) of the therapeutic class. Other drugs in the same RDP category are covered up to the price of the
Reference Drug; No coverage: also known as non-benefit; does not fit the above categories.
* Note: Information on which products PharmaCare covers can be obtained using the B.C. PharmaCare Formulary Search (www.health.gov.bc.ca/pharmacare/
benefitslookup/). In all cases, coverage is subject to drug price limits set by PharmaCare and to the patients PharmaCare plan rules and deductibles. See: www.
health.gov.bc.ca/pharmacare/plans/index.html and www.health.gov.bc.ca/pharmacare/policy.html for further information.
References:
1. eTherapeutics+.
2. RxFiles. Heart Failure: Treatment Overview. 2014.
3. Up-To-Date. Overview of the therapy of heart failure due to systolic dysfunction.

4 BCGuidelines.ca: Chronic Heart Failure Diagnosis and Management: Appendix B (2015)