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The potassium losing effect of thiazide diuretics is usually attenuated by the potassium conserving effect of lisinoprilThe use of potassium supplementspotassium-sparing agents or potassium-containing salt substitutes and other medicinal products that may increase serum potassium levelsparticularly in patients with impaired renal function or diabetes mellitusmay lead to a significant increase in serum potassiumIf concomitant use of lisinopril/hydrochlorothiazide and any of these agents is requiredthey should be used with caution and with frequent monitoring of serum potassiumsee section 4.4

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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.

Thiazides should be used with caution in patients with impaired hepatic function or progressive liver diseasesince minor alterations of fluid and electrolyte balance may precipitate hepatic comasee section 4.3RarelyACE inhibitors have been associated with a syndrome that starts with cholestatic jaundice or hepatitis and progresses to fulminant necrosis andsometimesdeathThe mechanism of this syndrome is not understoodPatients receiving lisinopril/hydrochlorothiazide who develop jaundice or marked elevations of hepatic enzymes should discontinue lisinopril/hydrochlorothiazide and receive appropriate medical follow-up.

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