Prescribing-safety pitfalls
What it means
'Triple whammy' AKI: ACEi/ARB + diuretic + NSAID — avoid, especially in the elderly/volume-depleted. STOPP/START criteria flag inappropriate/omitted drugs in older people. Watch QT-prolonging combinations, serotonergic combinations (serotonin syndrome), and anticholinergic burden in cognitive impairment.
Worked example
An elderly woman on ramipril + bendroflumethiazide develops AKI after starting ibuprofen — the triple-whammy combination.
In the exam
An elderly patient on an ACE inhibitor and a diuretic develops acute kidney injury soon after starting a non-steroidal for joint pain.
What settles it
The triple whammy is ACEi/ARB + diuretic + NSAID; each alone is lower-risk, the combination precipitates AKI.
Classically confused with
Adverse drug reactions (Rawlins–Thompson)
Source: NICE; STOPP/START