enalapril + lisinopril + perindopril + ramipril

This is a combination of four angiotensin-converting enzyme (ACE) inhibitors—enalapril, lisinopril, perindopril, and ramipril. Each of these drugs individually acts by inhibiting the angiotensin-converting enzyme, which reduces the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor. This leads to vasodilation, reduced blood pressure, decreased aldosterone secretion, and overall cardiovascular protection. ACE inhibitors are widely used for treating hypertension and heart failure and for renal protection in certain populations such as those with diabetes[1][2][3][5]. There is no clinical or regulatory precedent for combining multiple ACE inhibitors into a single therapy; such combinations are not recommended due to increased risk of adverse effects without added benefit[5]. Combining multiple ACE inhibitors can significantly increase the risk of hypotension, hyperkalemia, renal dysfunction, and other serious side effects[5].