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The triple whammy of (ACE/ARB) + (diuretic) + (NSAID) is a dangerous trio

This common combination of medication is considered a dangerous trio and is also known as the triple whammy.1 There are 4 key points:

  1. Avoid this combination if possible.
  2. Be aware of the risk factors for renal failure e.g. older patients with CHF or liver disease or volume depletion from vomiting/diarrhoea or low fluid intake on hot days.
  3. Take care with older i.e. 75 years patients - check renal function yearly at least.
  4. Advise patients not to self-medicate with NSAIDs when prescribing angiotensin converting enzyme receptor/ angiotensin II receptor antagonist (ACE/ARB) and diuretics.2

When volume depletion occurs consider stopping any (prescribed or OTC) NSAIDs and monitor renal function and serum potassium levels.1  

There is also the double whammy i.e. NSAID with either diuretics or ACE/ARB, with the numbers needed to harm for one year 300 versus 158 for triple whammy.3

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