A triple-drug, fixed-dose combination (FDC) antihypertensive agent containing an ACE inhibitor (Ramipril), an ARB (Telmisartan), and a thiazide diuretic (Hydrochlorothiazide). This combination provides synergistic blood pressure lowering through complementary mechanisms of action, targeting the Renin-Angiotensin-Aldosterone System (RAAS) and sodium/fluid balance. It is indicated for patients with essential hypertension not adequately controlled on dual therapy. The combination may improve adherence and is a cost-effective strategy in the Indian context.
Adult: One tablet once daily. Dose may be titrated after 2-4 weeks of therapy based on BP response and tolerability. Maximum: One tablet daily of this strength.
Note: Can be taken with or without food. Preferably taken at the same time each day, usually in the morning to avoid nocturia. Swallow whole with a glass of water. Ensure adequate hydration, but avoid excessive fluid intake. Do not skip doses.
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. Telmisartan selectively and competitively blocks the binding of Angiotensin II to the AT1 receptor, inhibiting its vasoconstrictor and aldosterone-secreting effects regardless of the source of Angiotensin II. Hydrochlorothiazide inhibits sodium reabsorption in the distal convoluted tubule of the nephron, promoting natriuresis and diuresis, reducing plasma volume and peripheral vascular resistance. The combination provides additive/synergistic effects on BP reduction.
Pregnancy: CONTRANDICATED in 2nd and 3rd trimesters (Pregnancy Category D). Drugs that act directly 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. First-trimester use should be avoided unless absolutely necessary.
Driving: Dizziness, lightheadedness, or syncope may occur, especially during initiation of therapy. Patients should be cautioned about operating machinery or driving until their response is known.
| Potassium supplements / Salt substitutes (KCl) | Increased risk of severe hyperkalemia. | Major |
| Lithium | HCTZ and RAAS inhibition reduce renal clearance of Lithium, leading to Lithium toxicity. | Major |
| NSAIDs (e.g., Ibuprofen, Diclofenac) | Reduce antihypertensive effect, increase risk of renal impairment and hyperkalemia. | Major |
| Other Antihypertensives / Diuretics | Additive hypotensive effect. | Moderate |
| Aliskiren | Increased risk of hyperkalemia, hypotension, and renal impairment (contraindicated in diabetes/renal impairment). | Major |
| Antidiabetic drugs (Insulin, Sulfonylureas) | HCTZ may decrease glucose tolerance, requiring dose adjustment. | Moderate |
| Digoxin | Hypokalemia/hypomagnesemia from HCTZ can increase Digoxin toxicity (though hyperkalemia from RAAS blockers may counteract). Monitor electrolytes. | Moderate |
| Corticosteroids, ACTH | Intensify electrolyte depletion (hypokalemia). | Moderate |
| Cholestyramine, Colestipol | Reduce absorption of HCTZ. Separate administration by at least 4 hours. | Moderate |
| Allopurinol | Increased risk of hypersensitivity reactions when combined with HCTZ. | Moderate |
Same composition (Ramipril (5mg) + Telmisartan (40mg) + Hydrochlorothiazide (12.5mg)), different brands: