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As with other ACE inhibitorslisinopril should be given with caution to patients with mitral valve stenosis and obstruction in the outflow of the left ventricle such as aortic stenosis or hypertrophic cardiomyopathy.

Thiazidesincluding hydrochlorothiazidecan cause fluid or electrolyte imbalancehypokalaemiahyponatraemiaand hypochloremic alkalosisWarning signs of fluid or electrolyte imbalance are dryness of mouththirstweaknesslethargydrowsinessmuscle pain or crampsmuscular fatiguehypotensionoliguriatachycardiaand gastrointestinal disturbances such as nausea or vomitingDilutional hyponatraemia may occur in oedematous patients in hot weatherChloride deficit is generally mild and does not require treatmentThiazides have been shown to increase the urinary excretions of magnesiumwhich may result in hypomagnesaemia.

Clinical trial data has shown that dual blockade of the renin-angiotensin-aldosterone systemRAASthrough the combined use of ACE-inhibitorsangiotensin II receptor blockers or aliskiren is associated with a higher frequency of adverse events such as hypotensionhyperkalaemia and decreased renal functionincluding acute renal failurecompared to the use of a single RAAS-acting agentsee sections 4.34.4 and 5.1

In some patients with bilateral renal artery stenosis or stenosis of the artery to a solitary kidneywho have been treated with ACE inhibitorsincreases in blood urea and serum creatinineusually reversible upon discontinuation of therapyhave been seenThis is especially likely in patients with renal insufficiencyIf renovascular hypertension is also present there is an increased risk of severe hypotension and renal insufficiencyIn these patientstreatment should be started under close medical supervision with low doses and careful dose titrationSince treatment with diuretics may be a contributory factor to the aboverenal function should be monitored during the first few weeks of lisinopril/hydrochlorothiazide therapy.

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