NE is a 62-year-old man with seasonal allergies, hyperlipidemia, and mild osteoarthritis. His blood pressure has historically been well controlled without medication, typically ranging from 122–130/74–82 mmHg. As spring arrives, NE develops worsening allergy symptoms, including sneezing, nasal congestion, itchy eyes, and rhinorrhea. He visits his healthcare provider and is started on Allegra-D for allergy relief.
Allegra-D contains two medications:
- Fexofenadine, a second-generation antihistamine
- Pseudoephedrine, an oral decongestant
Within several weeks, NE notices that his allergy symptoms have improved. However, at his next routine appointment, his blood pressure is 152/92 mmHg. Because of the elevated blood pressure, the provider diagnoses hypertension and starts lisinopril 10 mg daily.
Two months later, NE returns for follow-up. His blood pressure has improved but remains elevated at 148/88 mmHg. The lisinopril dose is increased, but at his next visit, his blood pressure is still above goal.
Amlodipine 5 mg daily is added.
At this point, he is taking:
- Allegra-D for allergies
- Lisinopril for hypertension
- Amlodipine for hypertension
The Prescribing Cascade
In this case, pseudoephedrine in Allegra-D contributed to the elevation in blood pressure. Pseudoephedrine is a sympathomimetic decongestant. It can cause vasoconstriction and stimulate the cardiovascular system, potentially leading to an increase in blood pressure.
Instead of identifying pseudoephedrine as a potential cause of the elevated blood pressure, the elevated readings were treated as a new medical condition. This led to the addition of lisinopril and eventually amlodipine. This is a classic example of a prescribing cascade:
What Could Have Been Done Instead?
Before starting one or two antihypertensive medications, the healthcare team could have reviewed his medication list and recognized that Allegra-D contained pseudoephedrine.
Because his primary allergy symptoms were sneezing, rhinorrhea, and itchy eyes, and because the antihistamine component was providing much of the desired allergy relief, it may have been reasonable to discontinue Allegra-D and switch to fexofenadine alone.
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