Successful intervention to mitigate an acetylcholinesterase inhibitor-induced rhinorrhea prescribing cascade: a case report

Abstract

SUMMARY What is known and objective A prescribing cascade if often treated by discontinuing both medications. We describe an intervention to mitigate a prescribing cascade while continuing a clinically necessary medication without negatively impacting the patient. Case Summary A 77 year-old women experienced probable acetylcholinesterase inhibitor-induced rhinorrhea and subsequently self-medicated with diphenhydramine which lead to worsening cognitive function. We reduced the dose of the acetylcholinesterase inhibitor and discontinued the diphenhydramine. The symptoms of rhinorrhea was subsequently reduced without negatively impacting cognition. What is new and conclusion This was the first prescribing cascade intervention that did not require discontinuation of both medications, which may be emulated in future cases of a prescribing cascade.

What Is Known About Preventing, Detecting, and Reversing Prescribing Cascades: A Scoping Review

“…Case studies were also an important resource to help prescribers learn to detect prescribing cascades. Case studies described prescribing cascades associated with a variety of drug therapies, including angiotensin‐converting enzyme inhibitor–induced rhinorrhea and dexamethasone‐induced psychosis. Case studies also illustrated the expanded prescribing cascade concept, which is when the prescribing cascade is extended beyond initiation of a new prescribed drug to consider other potentially unnecessary interventions, such as new use of over‐the‐counter self‐medication or medical devices.…”

Patient and provider perspectives on the development and resolution of prescribing cascades: a qualitative study

“…To raise awareness about risks of prescribing cascades, case reports, examples and approaches to prevent, detect and reverse them have been published [8][9][10][11][12][13][14][15][16][17][18]. A 2018 scoping review describes education and illustrative case examples aimed at prevention and detection, approaches to using health administrative data and social media to help detect prescribing cascades and the use of medication reviews and deprescribing to reverse them [12].…”

Evaluation of the Potential Acetylcholinesterase Inhibitor‐Induced Rhinorrhea Prescribing Cascade

“…6 We aimed to assess this PC using a sample of patient visits from the United States.We used the 2014 and 2015 National Ambulatory Medical Care Survey (NAMCS) data that comprises medications from providers' notes including prescription and over-thecounter (OTC) products. 1 Use of these medications are often limited by adverse events (AEs) including nausea, vomiting, diarrhea, incontinence, hypersalivation, sweating, lacrimation, rhinorrhea, and bronchorrhea.…”

“…6 We aimed to assess this PC using a sample of patient visits from the United States. 1 Use of these medications are often limited by adverse events (AEs) including nausea, vomiting, diarrhea, incontinence, hypersalivation, sweating, lacrimation, rhinorrhea, and bronchorrhea.…”

“…6 This particular cascade is also troublesome because symptoms may be selftreated using OTC products, in which OTC products may not be consistently identified during a clinic visit. Patients on AChEI were 4 times more likely to co-use an RM compared with no AChEI use, suggesting 17% of patient visits involving an AChEI may be experiencing the PC.…”