My extensive work in geriatrics has led to a great understand of the prescribing cascade. The prescribing cascade is simply defined as using medications to treat side effects of other medications. There are literally hundreds to thousands of these examples. Now in some cases, treating side effects is a necessary evil. We don’t like to make a habit of it, but if a medication is deemed too important to continue then we will purposefully treat side effects (opioids and constipation medication is a classic example). Here’s a few common examples of the prescribing cascade that I’ve see in my practice as a clinical pharmacist..
- A patient starts on Tylenol PM and subsequently develops constipation and dry eyes requiring the use of regular laxatives and artificial tears. Remember that Tylenol PM contains diphenhydramine (a highly anticholinergic medication).
- A patient has a significant increase in pain and begins to take over the counter NSAIDs to help alleviate the new pain. After using the NSAID for a few days to weeks, the patient begins experiencing troublesome GI upset and heartburn type symptoms leading to an Rx of an H2 blocker of PPI.
- A patient has worsening hypertension that requires the Rx of Amlodipine. Following the amlodipine Rx, the patient begins developing troublesome edema that requires the addition of furosemide.
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Eric Christianson, PharmD, BCPS, CGP