A fixed-dose triple-drug combination therapy for hypertension, containing an ACE inhibitor (Ramipril), an ARB (Losartan), and a thiazide diuretic (Hydrochlorothiazide). This combination provides synergistic blood pressure lowering through complementary mechanisms, targeting the Renin-Angiotensin-Aldosterone System (RAAS) at two points and reducing plasma volume. It is indicated for patients whose blood pressure is not adequately controlled on dual therapy. Its use requires careful monitoring due to the risk of hypotension, hyperkalemia, and acute kidney injury.
Adult: One tablet once daily, preferably in the morning. Dose must be individualized. This is a maximum-strength FDC; not for initiation. Therapy should be initiated under close medical supervision, often starting with individual components.
Note: Take orally, with or without food, but consistency is key (food affects Ramipril absorption). Take in the morning to avoid nocturia. Swallow whole with a glass of water. Do not skip doses. If a dose is missed, take it as soon as remembered unless it's almost time for the next dose. Do not double the dose.
This combination exerts a multi-pronged attack on hypertension. Ramipril inhibits Angiotensin Converting Enzyme (ACE), reducing the conversion of Angiotensin I to the potent vasoconstrictor Angiotensin II and decreasing aldosterone secretion. Losartan competitively blocks the Angiotensin II type 1 (AT1) receptors, preventing the vasoconstrictor and aldosterone-secreting effects of any Angiotensin II that is formed via alternative pathways (e.g., chymase). Hydrochlorothiazide inhibits sodium-chloride symport in the distal convoluted tubule, promoting natriuresis and diuresis, reducing plasma volume and peripheral vascular resistance.
Pregnancy: CONTRANDICATED in 2nd and 3rd trimesters (Pregnancy Category D). Drugs that act on the RAAS can cause fetal injury and death, including hypotension, neonatal skull hypoplasia, anuria, reversible or irreversible renal failure, and death. Discontinue as soon as pregnancy is detected. In 1st trimester, use only if clearly needed.
Driving: May cause dizziness, lightheadedness, or fatigue, especially during initiation. Patients should be cautioned about operating machinery or driving until they know how the medication affects them.
| Potassium Supplements / Salt Substitutes / K-sparing Diuretics (Spironolactone, Amiloride) | Increased risk of severe hyperkalemia. | Major |
| Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) e.g., Ibuprofen, Diclofenac | Reduced antihypertensive effect, risk of acute renal failure, increased hyperkalemia. | Major |
| Lithium | Increased serum lithium levels and toxicity (HCTZ reduces renal clearance). | Major |
| Other Antihypertensives, Vasodilators, Nitrates | Additive hypotensive effect. | Moderate |
| Antidiabetic Drugs (Insulin, Sulfonylureas) | HCTZ may decrease glucose tolerance, requiring dose adjustment. | Moderate |
| Allopurinol | Increased risk of hypersensitivity reactions, especially with HCTZ. | Moderate |
| Cholestyramine, Colestipol | Reduced absorption of HCTZ. | Moderate |
| Corticosteroids, ACTH | Intensified electrolyte depletion (hypokalemia). | Moderate |
| Alcohol, Barbiturates, Narcotics | Potentiation of orthostatic hypotension. | Moderate |
| Digoxin | Hypokalemia or hyperkalemia can predispose to digoxin toxicity. | Moderate |
| Aliskiren | Concomitant use with dual RAAS blockade is contraindicated in diabetes/renal impairment due to hyperkalemia/renal risk. | Major |
Same composition (Ramipril (2.5mg) + Losartan (50mg) + Hydrochlorothiazide (12.5mg)), different brands: