Altitude is the only thing in India that can genuinely hurt you
Everything else on a well-run trip is a matter of comfort and planning. Altitude is medicine, and it deserves to be treated differently.
Leh sits high enough that flying in from the plains puts you several thousand feet up in ninety minutes, with no acclimatisation at all. Most people are fine. A meaningful minority are not, and the ones who are not are frequently the fittest people in the group, because fitness has nothing to do with it.
The rules are unglamorous and they work. The first full day after flying in is a rest day — not a gentle sightseeing day, a rest day. Hydrate more than feels necessary. No alcohol for the first forty-eight hours. Go up slowly after that, and sleep lower than the highest point you reached.
Know the symptoms, and know that the treatment for the serious ones is descent, immediately, not aspirin and optimism.
Talk to your own doctor before you go, particularly about preventative medication, which is a conversation for them and not for us.
Any itinerary that has you flying into Leh and driving to a high pass the same day is wrong. Say no to it.
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