Assessing the Scope and Appropriateness of Prescribing Cascades

McCarthy, Lisa; Visentin, Jessica D.; Rochon, Paula A.

doi:10.1111/jgs.15800

Cited by 64 publications

(88 citation statements)

References 5 publications

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“…First, older individuals have an increased risk of medication-related harm due to an age-related change in pharmacokinetics and -dynamics, a lower physiological reserve and drug-drug or drug-disease interactions [ 13 – 15 ]. Additionally, they are more susceptible to PIMs due to a lack of evidence regarding the benefits and harms of medications in multimorbid older adults and the frequently observed “prescribing cascade” where new medication is prescribed to treat a side effect of another medication [ 16 ]. Lastly, the application of single disease evidence-based guidelines to an individual with multimorbidity results in complex polypharmacy as they do not take into account potential drug- and disease-drug interactions [ 17 , 18 ].…”

Section: Introductionmentioning

confidence: 99%

Potentially inappropriate medication and attitudes of older adults towards deprescribing

et al. 2020

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Introduction Multimorbidity and polypharmacy are current challenges when caring for the older population. Both have led to an increase of potentially inappropriate medication (PIM), illustrating the need to assess patients’ attitudes towards deprescribing. We aimed to assess the prevalence of PIM use and whether this was associated with patient factors and willingness to deprescribe. Method We analysed data from the LESS Study, a cross-sectional study on self-reported medication and on barriers and enablers towards the willingness to deprescribe (rPATD questionnaire). The survey was conducted among multimorbid (≥3 chronic conditions) participants ≥70 years with polypharmacy (≥5 long-term medications). A subset of the Beers 2019 criteria was applied for the assessment of medication appropriateness. Results Data from 300 patients were analysed. The mean age was 79.1 years (SD 5.7). 53% had at least one PIM (men: 47.8%%, women: 60.4%%; p = 0.007). A higher number of medications was associated with PIM use (p = 0.002). We found high willingness to deprescribe in both participants with and without PIM. Willingness to deprescribe was not associated with PIM use (p = 0.25), nor number of PIMs (p = 0.81). Conclusion The willingness of older adults with polypharmacy towards deprescribing was not associated with PIM use in this study. These results suggest that patients may not be aware if they are taking PIMs. This implies the need for raising patients’ awareness about PIMs through education, especially in females, in order to implement deprescribing in daily practice.

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Section: Introductionmentioning

confidence: 99%

Potentially inappropriate medication and attitudes of older adults towards deprescribing

et al. 2020

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“…14 Use of a loop diuretic for this purpose constitutes a prescribing cascade, in which a drug-induced adverse event prompts additional medication treatment rather than discontinuing or reducing the original prescription. 15 This prescribing cascade can be classified as problematic prescribing 16 because it not only results in the use of additional medications (eg, potassium supplements) and thus exacerbates polypharmacy 17 but can also lead to preventable adverse events (eg, acute kidney injury, severe dehydration, increased urinary frequency or incontinence, hypotension, fall-related injuries, and electrolyte abnormalities that may result in arrhythmias). [18][19][20][21][22][23][24][25][26][27] With a dearth of evidence available regarding the prescribing cascade, including a case report 28 and a study 29 that used cross-sectional data, as well as the risk of poor health outcomes and increased health care utilization associated with the prescribing cascade, 30 there is a need for more extensive research.…”

Section: Introductionmentioning

confidence: 99%

Magnitude of and Characteristics Associated With the Treatment of Calcium Channel Blocker–Induced Lower-Extremity Edema With Loop Diuretics

et al. 2019

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IMPORTANCE Calcium channel blockers, specifically dihydropyridine calcium channel blockers (DH CCBs, eg, amlodipine), may cause lower-extremity edema. Anecdotal reports suggest this may result in a prescribing cascade, where DH CCB-induced edema is treated with loop diuretics. OBJECTIVE To assess the magnitude and characteristics of the DH CCB prescribing cascade. DESIGN, SETTING, AND PARTICIPANTS This cohort study used a prescription sequence symmetry analysis to assess loop diuretic initiation before and after the initiation of DH CCBs among patients aged 20 years or older without heart failure. Data from a private insurance claims database from 2005 to 2017 was analyzed. Use of loop diuretics associated with initiation of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and other commonly used medications was used as negative controls. Data were analyzed from March 2019 through October 2019. EXPOSURES Initiation of DH CCB or negative control medications. MAIN OUTCOMES AND MEASURES The temporality of loop diuretic initiation relative to DH CCB or negative control initiation. Secular trend-adjusted sequence ratios (aSRs) with 95% CIs were calculated using data from 360 days before and after initiation of DH CCBs. RESULTS Among 1 206 093 DH CCB initiators, 55 818 patients (4.6%) (33 100 [59.3%] aged <65 years; 32 916 [59.0%] women) had a new loop diuretic prescription 360 days before or after DH CCB initiation, resulting in an aSR of 1.87 (95% CI, 1.84-1.90). An estimated 1.44% of DH CCB initiators experienced the prescribing cascade. The aSR was disproportionately higher among DH CCB initiators who were prescribed high doses (aSR, 2.20; 95% CI, 2.13-2.27), initiated amlodipine (aSR, 1.89; 95% CI, 1.86-1.93), were men (aSR, 1.96; 95% CI, 1.91-2.01), and used fewer antihypertensive classes (aSR, 2.55; 95% CI, 2.47-2.64). The evaluation of ACE inhibitors or ARBs as negative controls suggested hypertension progression may have tempered the incidence of the prescribing cascade (aSR for ACE inhibitors and ARBs, 1.27; 95% CI, 1.24-1.29). CONCLUSIONS AND RELEVANCE This study found an excessive use of loop diuretics following initiation of DH CCBs that cannot be completely explained by secular trends or hypertension progression. The prescribing cascade was more pronounced among those initially prescribed a high dose of DH CCBs.

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“…This case serves as an important reminder of a clinical pharmacist's role in identifying and mitigating prescribing cascade. An ACE inhibitor-induced cough may occur within hours of the first dose of medication or its onset can be delayed for weeks, even months, after initiation of therapy [1][2][3][4][5][6][7]. While the cough usually resolves within one to four weeks after discontinuation of therapy, it may persist for up to three months in some individuals.…”

Section: Discussionmentioning

confidence: 99%

“…In addition to antihypertensive effects, ACE inhibitors have the benefit of reducing complications caused by some diseases, such as coronary artery disease, heart failure, diabetes, and diabetic nephropathy [1]. Although ACE inhibitors are generally tolerable, almost 20 percent of patients discontinue treatment due to adverse drug effects, particularly the induction of a dry cough [1,2]. It is estimated that up to 35 percent of patients treated with an ACE inhibitor experience drug-induced cough [3,4].…”

Section: Introductionmentioning

confidence: 99%

Angiotensin Converting Enzyme (ACE) Inhibitor-Induced Cough Resulting in Prescribing Cascade

Wright¹,

Bardolia²,

Bankes³

et al. 2020

Clin Case Rep

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Objective: Prescribing cascade usually results from the misdiagnosis of a drug-related adverse event or condition. Although the prevalence of prescribing cascade remains unknown, it likely increases the risks associated with polypharmacy (e.g., adverse drug events). Furthermore, consequences of prescribing cascade are more likely to be detrimental for the elderly population due to the presence of multiple chronic diseases and the complexity of the derived medication regimen. This case aims to shed light on a particular prescribing cascade due to Angiotensin-Converting Enzyme (ACE) inhibitor-induced cough. Case: A 101-year-old male with a past medical hypertension, osteoarthritis, gastroesophageal reflux disease, atrial fibrillation, hyperlipidemia, muscle weakness, and mild intermittent asthma was experiencing worsening of cough. To manage his hypertension, the patient was previously prescribed lisinopril and amlodipine. To control the cough, the patient was then prescribed benzonatate (Tessalon Perles®) and budesonideformoterol (Symbicort®). Lisinopril-induced cough was postulated; after the discontinuation of lisinopril and the initiation of losartan, the cough resolved. However, the use of the benzonatate and budesonide-formoterol was not re-evaluated. Conclusion: This case is an example of prescribing cascade resulting from a misdiagnosis of an ACE inhibitor-induced cough. Misdiagnosis may result in inappropriate prescribing of medications that increase the risks resulting from polypharmacy, such as adverse drug events. Pharmacists are uniquely positioned to intercept and avoid such prescribing cascade.

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Assessing the Scope and Appropriateness of Prescribing Cascades

Cited by 64 publications

References 5 publications

Potentially inappropriate medication and attitudes of older adults towards deprescribing

Potentially inappropriate medication and attitudes of older adults towards deprescribing

Magnitude of and Characteristics Associated With the Treatment of Calcium Channel Blocker–Induced Lower-Extremity Edema With Loop Diuretics

Angiotensin Converting Enzyme (ACE) Inhibitor-Induced Cough Resulting in Prescribing Cascade

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