Decision to fund candesartan with hydrochlorothiazide

Support for funding

General support for the funding of candesartan cilexetil with hydrochlorothiazide noting that it would be a welcome addition to the currently available angiotensin receptor blockers / hydrochlorothiazide listing. Also, that combination products that include a thiazide are clinically useful when hypertension doesn’t respond sufficiently to a single agent.

We are pleased to be listing a new treatment option which will benefit the health of New Zealanders and provide further options.

General support for funding but noting that there would still be no angiotensin-converting-enzyme / hydrochlorothiazide combination available.

The clinical advice we have received [PDF, 409 KB] has noted the strong need for combination therapies to be available and has indicated that either an angiotensin receptor blocker or an angiotensin-converting-enzyme inhibitor would be suitable for meeting this need.

While angiotensin-converting-enzyme / hydrochlorothiazide products are not available on the schedule now, progressing this proposal would not prevent Pharmac from funding these in the future.

Feedback on prescribing frequency

A respondent queried whether candesartan cilexetil with hydrochlorothiazide would be supplied on ‘stat’ dispensing (3 monthly).

It is intended that once listed, candesartan cilexetil with hydrochlorothiazide would be dispensed as a ‘stat’ pharmaceutical as the supplier has sufficient stock in New Zealand to support this.

Feedback on related products

A respondent noted that telmisartan would have been a preferred angiotensin receptor blocker in a combination thiazide product.

We previously included telmisartan + hydrochlorothiazide in the 2021/2022 Annual Invitation to Tender. However, we have been unable to secure long term supply of this product. 

We will continue to explore the need for a third primary angiotensin receptor blocker product, and we note that Pharmac’s Cardiovascular Specialist Advisory Committee has previously suggested that telmisartan would be an appropriate agent.

Respondents questioned why a combination including hydrochlorothiazide was being listed when there was evidence of superior clinical efficacy with other thiazide agents.

We appreciate that hydrochlorothiazide may not be the preferred thiazide agent for hypertension it is the agent most commonly available in combination products. We have been unable to source a non- hydrochlorothiazide combination angiotensin receptor blocker/ angiotensin-converting-enzyme inhibitor-thiazide product. The funding of candesartan cilexetil with hydrochlorothiazide would not prevent the funding of other thiazide products in future if they became available.

A respondent questioned the decision to fund candesartan cilexetil with hydrochlorothiazide, indicating that thiazides can cause significant issues including interaction with non-steroidal anti-inflammatory drugs, and stated that a combination product including hydrochlorothiazide is likely to be less effective than using supratherapeutic doses of candesartan as a sole agent.

Our clinical advisors have told us that candesartan cilexetil with hydrochlorothiazide would be an appropriate replacement for the majority of people who were using quinapril with hydrochlorothiazide prior to the recall of this treatment.

We note that as with all medicines, care needs to be taken in prescribing and providing information to individuals taking the medicines about possible adverse effects and possible interactions with other medications.

We understand that there is evidence to show significant benefit to adding hydrochlorothiazide to candesartan cilexetil.

The decision to use any medicine off label, or at unapproved doses is the sole responsibility of the prescriber acting within their scope of practice.