Occurrence of the triple whammy in an outpatient clinic of a tertiary hospital

Hanis Hanum Zulkifly, Haifak Mat Zaid, Yaman Walid Kassab, Long Chiau Ming, Nahlah Elkudssiah Ismail, Shazwani Shaharuddin

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Background: The combination of Non-steroidal Anti-inflammatory Drugs (NSAIDs), Angiotensin-Converting Enzyme Inhibitors (ACEIs) and diuretics, among patients is common. The combination of these drugs can lead to renal disease and kidney failure over a long term use. Objectives: To identify the occurrence of the concomitant prescriptionof NSAIDs, ACEIsand diuretics, usually referred to as triple whammy, received by out-patients at a Malaysian tertiary hospital. It also aimed to identify the occurrence of triple whammy among the population of the elderly. Methods: A retrospective study was performed in a tertiary care hospital, situated in the state of Selangor, Malaysia. The patients’ prescriptions with NSAIDs, ACEIs and diuretics, from the outpatient pharmacy department were reviewed and recorded. The association between the prescriptions with age was investigated using the chi-square test. A value of P<0.05 was considered significant. Results: A total of 424 prescriptions (56.1% male) were included in this study. The findings showed that 422 prescriptions were with one or more of NSAIDs, ACEIs and diuretic, and only 2 prescriptions were with all three drugs. Majority of the prescriptions (40.1%) were with the combination of ACEIs and diuretics. A combination of ACEI and diuretics were mainly (21.7%) prescribed to patients above 65 years of age, albeit, it is statistically not significant. Conclusion: The occurrence of triple whammy at a tertiary hospital during the period of data collection is low. This is indeed a good predictor of safe prescribing of drugs among physicians, as concomitant use of these three medications may impair renal function, especially in the elderly and dehydrated patients.

Original languageEnglish
Pages (from-to)S39-S44
Number of pages6
JournalIndian Journal of Pharmaceutical Education and Research
Issue number2
Publication statusPublished - Apr 2016
Externally publishedYes


  • Angiotensin-converting enzyme inhibitors
  • Diuretics
  • Kidney failure
  • Non-steroidal anti-inflammatory drugs
  • Renal impairment

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