Enalapril × Ibuprofen

Ibuprofen (NSAID) suppresses prostaglandin synthesis maintaining glomerular perfusion at lower blood pressure. On enalapril, which dilates efferent arterioles, the combination raises acute kidney injury risk (the 'triple whammy' with a diuretic is more dangerous still).

Reduced urine output, rising creatinine and potassium. Blood pressure rise and oedema. Symptoms appear earlier in older patients and chronic kidney disease.

Avoid chronic ibuprofen on enalapril. If a short course is needed, use the minimum effective dose for 5–7 days with pantoprazole cover. For chronic analgesia: paracetamol, celecoxib, or topical NSAIDs.