A Fatal Case of Triple Whammy in an Elderly Patient

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.

Deprescribing in Older Poly-Treated Patients Affected with Dementia

“…NSAIDs are extremely harmful when associated with diuretics, ACE inhibitors, or blockers of the angiotensin receptor 2. The consequence of this dangerous combination of drugs is called the “triple whammy” and leads to acute renal failure and a potential risk of death [ 13 , 23 , 24 ].…”

beware-of-triple-whammy

“…In a literal sense, "triple whammy" bears the meaning of three simultaneous, deleterious blows with a compounded effect [2]. Since the establishment of the term, similar reports of "triple whammy" had appeared worldwide involving a reduced creatinine clearance in patients taking the three medicines together [3,4,5,6], with fatality rates allegedly being as high as 10%, as reported by the Australian Adverse Drug Reactions Advisory Committee (ADRAC) [6]. Several risk factors for renal failure in "triple whammy" cases were identified, including old age, chronic kidney disease, dehydration, digoxin toxicity, acute illness and the recent addition of an NSAID to the existing ACEIs/ARB and diuretics regimen [7].…”