“Kind of blurry”: Deciphering clues to prevent, investigate and manage prescribing cascades

Abstract

Background Prescribing cascades, where a medication is used to treat the side effect of another medication, contribute to polypharmacy and related morbidity. Little is known about clinicians’ and patients’ experiences with prescribing cascades. In this study, we explored why and how prescribing cascades occur across a variety of care settings and how they are managed. Methods and findings This descriptive qualitative study employed semi-structured interviews with older adults who may have experienced a prescribing cascade(s), their caregivers, and healthcare providers. Interviewees were recruited through physician referral from a Geriatric Day Hospital, two long-term care homes in Ottawa, Ontario, and through self-referral across Ontario, Canada. An inductive approach was used to code data and determine themes. Thirty-one interviews were conducted for ten unique patient cases. Some interviewees were involved in more than one case, resulting in 22 unique interviewees. Three themes were identified. First, recognition of prescribing cascades is linked to awareness of medication side effects. Second, investigation and management of prescribing cascades is simultaneous and iterative (rather than linear and sequential). Third, prevention of prescribing cascades requires intentional strategies to help people anticipate and recognize medication side effects. Difficulty with recruitment from both long-term care homes and through self-referral was the central limitation. This exemplifies challenges associated with studying a poorly recognized and underexplored phenomenon. Conclusions In order to better recognize, investigate and manage prescribing cascades, clinicians and patients need to know more about medication side effects; they need to ask ‘can this be caused by a drug?’ when signs and symptoms arise or worsen; and they need access to information about medication experiences to have benefit-risk discussions and make decisions about deprescribing. Approaches for raising public awareness of prescribing cascades should be trialed to raise the profile of this issue and facilitate continued exploration of the phenomenon.

Association of a calcium channel blocker and diuretic prescribing cascade with adverse events: A population‐based cohort study

“…Finding an association between the initial drug therapy, a new medical condition, and the prescribing of a new drug therapy can be facilitated by knowing three pieces of information: when a drug was started, why it was started, and who started it. 19 This information allows the sequence of prescribing indicating a prescribing cascade to become clear and potentially avoids additional investigations that may be initiated to rule out potentially more serious diagnoses. 28 Further, it is important to F I G U R E 2 Cumulative incidence of serious adverse events in the 90-day follow-up period.…”

“…11 We know from individual case reports and qualitative interviews that prescribing cascades are associated with the development of adverse events including confusion, 17 incontinence, 12 and head injury, 18 and have important impacts on the quality of life. 19,20 Yet, we know little about the downstream impact that prescribing cascades can precipitate at a population-level, requiring emergency room visits and hospitalizations. 10 In this study, we use a population-based cohort of older women and men who did, and did not, experience a CCB-diuretic prescribing cascade 10 to compare the rate of subsequent serious adverse events (SAE), as measured by emergency room visits or hospitalizations.…”

“…Large population‐based cohort studies demonstrate that prescribing cascades occur 10–12 and link new users of sodium glucose co‐transporter 2 inhibitors to dispensing of an anti‐mycotic drug among those with diabetes, 13 calcium channel blockers (CCB) to the initiation of diuretic therapy among those with hypertension 10,14–16 and gabapentinoid dispensing to the initiation of diuretic therapy among those with new lower back pain 11 . We know from individual case reports and qualitative interviews that prescribing cascades are associated with the development of adverse events including confusion, 17 incontinence, 12 and head injury, 18 and have important impacts on the quality of life 19,20 . Yet, we know little about the downstream impact that prescribing cascades can precipitate at a population‐level, requiring emergency room visits and hospitalizations 10 …”

Mapping potentially inappropriate medications in older adults using the Anatomical Therapeutic Chemical (ATC) classification system

“…First, we wanted to explore its utilization in identifying potentially problematic medications involved in prescribing cascades, which occur when drug‐induced adverse events of a new medication trigger the prescribing of an additional new medication. Prescribing cascades are considered important contributors to polypharmacy and targets for deprescribing 34‐36 . Here, we utilized a previously published review that has identified all available prescribing cascades using a distinct methodology, the sequence symmetry analysis (SSA) 37 .…”

Communicating adverse drug events: serotonin toxicity

“…To highlight some of these phenomena and to help others identify and manage them, we have published a number of case reports (see Table 1) and the results of related interviews with our patients and GDH clinicians. 1,3,4 The rise of serotonergic agents and related toxicity…”