Triple whammy — ACEi/ARB + diuretic + NSAID

Interaction at a glance

• Together → ↓ glomerular pressure → AKI
• Avoid NSAID when possible; monitor Cr/K

Mechanism

• Diuretic → ↓ circulating volume
• ACEi/ARB → efferent arteriolar dilation
• NSAID → afferent arteriolar constriction
• Classic: lisinopril + HCTZ + ibuprofen

Clinical consequence

• Together → ↓ glomerular pressure → AKI
• Risk ↑ with CKD, age, dehydration

Monitoring

• Avoid NSAID when possible; monitor Cr/K

Self-check

• What is the main clinical risk of Triple whammy?
  Together → ↓ glomerular pressure → AKI.
• What is the preferred management of Triple whammy?
  Avoid NSAID when possible; monitor Cr/K.
• Should Triple whammy generally be combined?
  No—avoid the combination when feasible.

Drugs in this interaction (64)

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