The Impact of Concurrent Use of Diuretics, RAAS Inhibitors with Non-steroidal Anti-inflammatory Drugs “Triple Whammy” on Renal Function

Muhammad Shahid Iqbal


Objective: This study aimed to evaluate the concomitant use of diuretics, angiotensin-converting-enzyme inhibitors/
angiotensin receptor blocker (ACEIs/ARBs) and non-steroidal anti-inflammatory drugs, frequently termed as
“Triple Whammy,” prescribed among out-patients. It also aimed to determine the impact of this combination
on patients’ renal function. Methodology: A retrospective and observational study was conducted in a hospital
located in the state of Selangor, Malaysia. Patients who were receiving two or more of triple whammy agents were
reviewed and analyzed. The associations between the prescriptions and patients’ demographics and comorbidities
were tested using the Chi-square test. On the other hand, a paired sample t-test was used to determine the impact
of prescriptions on renal function with a consideration of statistical significance when P < 0.05. Results: Out
of 412 prescriptions (60.2% male) were included in this study, 407 prescriptions were containing two of the
mentioned medication with only 5 prescriptions for triple whammy. The majority of prescriptions had (64.1%)
ACEIs/ARBs and diuretics, and it was mainly prescribed to hypertensive patients (98.5%) aged less than 65 years
old (38.3%). Furthermore, males were more likely to receive this combination of ACEIs/ARB and diuretics than
females (P < 0.001) due to the fact that the male gender is considered as a risk factor for cardiovascular conditions
that require ACEIs/ARBs + diuretics. In addition, there was a statistically significant decrease in CrCl after these
risky combinations were initiated. Conclusion: The prescribing trend of triple whammy during the period of data
collection was low compared to prescriptions of two risky combinations. This is indeed a good predictor of safe
prescribing of drugs among physicians, as concomitant use of these three medications may impair renal functions.

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