Abstract
Triple whammy is a drug-induced renal failure which in patients treated with ACE-inhibitors or angiotensin II receptor blockers, diuretics and non-steroidal anti-inflammatory drugs. We report a case of a 79-year-old woman affected with hypertension, depression and arthritis that was hospitalized for abdominal pain and discharged with normal renal function and with poly-treatment: furosemide, aspirin, carvedilol, omeprazole and ramipril. Few days later she was visited for depressive symptoms, pain in the right shoulder and cystitis and treatment with oral ketoprofen and ciprofloxacin was prescribed. One week later she experienced loss of appetite, asthenia and swelling of the face. Blood analyses showed acute renal failure, whereas clinical examination showed heart failure and pleural effusion. She was again hospitalized in a geriatric ward for metabolic acidosis. Drug treatments and hemodialysis did not improve clinical conditions and she died thirteen days after her hospitalization. History suggested the onset of drug-related acute renal failure probably due to the combination of furosemide, ketoprofen and ramipril, defined as triple whammy.
Highlights
The combination ofan angiotensin converting enzyme-inhibitor (ACEI) or an angiotensin II receptor blocker (ARB), a diuretic and a non-steroidal antiinflammatory drug (NSAID) may increase the risk of acute kidney injury, calledtriple whammy, because each drug is able to affect kidney function through different mechanisms [12,13].In particular, diuretics can lead to hypovolaemia, ACE-inhibitors/ARBs cause haemodynamic decrease of glomerular filtration rate due to efferent arteriolar vasodilation, and NSAIDs inhibit prostacyclin synthesis [14,15,16]
We described a case of drug-related acute renal failure, defined as triple whammy, in an elderly woman, related to drug drug-interaction induced by inappropriate prescription
During the treatment with diuretics and NSAIDs, despite a reduction in renal blood flow and the presence of renal afferent arteriolar constriction, glomerular filtration is probably maintained as a result of the effect of angiotensin II mediated efferent arteriolar vasoconstriction and sodium retention [23,24,25]
Summary
Adverse drug reactions (ADRs) represent a common problem during drug treatment [1,2] and may induce organ failure, in the elderly [3,4]. A 79-year-old woman with history of hypertension, depression and arthritis was hospitalized for abdominal pain and discharged with normal renal function(serum creatinine=0.82 mg/dL, normal values 0.7-1.2 mg/dL; Chronic Kidney Disease Epidemiology Collaboration: 84.1 mL/min, normal values >60 mL/min) and with the following pharmacological treatment: furosemide (25 mg/day), aspirin (100 mg/ day), carvedilol (12.5 mg/day), omeprazole (20 mg/day) and ramipril (5 mg/day). Few days later she was visited at home for the worsening of depressive symptoms, pain in the right shoulder and cystitis and treatment with oral ketoprofen (160 mg/day) and ciprofloxacin (250 mg bid) was prescribed. Bicarbonate administration and hemodialysis did not improve the clinical conditions and the patient died thirteen days later
Sign-in/Register to view highlights & summary Sign-in/Register to access full text options 
Free) 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a call
