Choosing Wisely:

Don’t initiate medications to treat new and emerging symptoms without first ascertaining that the new symptom is not an adverse drug event of an already prescribed medication.

Rationale and Comments: The risk of adverse drug reactions and hospital admissions related to adverse drug reactions increases with age, polypharmacy, and comorbidities. It is prudent for clinicians to be aware of the prescribing cascade to reduce the prescription of potentially unnecessary medications that may cause harm to the patient. Prescribing cascades are a type of problematic polypharmacy that occur when an adverse drug event is misinterpreted as a new medical condition, and a second medication is prescribed to address this emerging adverse drug event. If a suitable alternative is available, discontinuation of the medication thought to be the cause of the adverse drug reaction would be the best course of action. The decision to prescribe a second medication to counteract an adverse drug reaction from a first medication should only occur after careful consideration, and where the benefits of continuing therapy with the first medication outweigh the risks of additional adverse reactions from the second medication. Older adults are at an increased risk of experiencing prescribing cascades due to the higher incidence of polypharmacy and multi-comorbidity. For example, calcium channel blockers are commonly prescribed for hypertension and have the potential to cause peripheral edema. A prescribing cascade occurs when the edema is misinterpreted as a new medical condition and a diuretic is subsequently prescribed to treat the edema. Ideally, the choice of a different antihypertensive may be the best action at this time, in this example. Addressing the prescribing cascade involves focusing on the medication review process and deprescribing initiatives. There are a range of resources to prevent, detect, and reverse prescribing cascades to improve the appropriate use of medications.
Sponsoring Organizations:
  • American Society of Consultant Pharmacists
  • Sources:
  • Expert consensus
  • Disciplines:
  • Geriatric Medicine
  • References: • Rochon PA, Gurwitz JH. Optimizing drug treatment for elderly people: the prescribing cascade. BMJ. 1997;315(7115):1096-1099.
    • Gill SS, Mamdani M, et al. A prescribing cascade involving cholinesterase inhibitors and anticholinergic drugs. Arch Intern Med. 2005;165(7):808-813.
    • Brath H, Mehta N, et al. What is known about preventing, detecting, and reversing prescribing cascades: a scoping review. J Am Geriatr Soc. 2018;66(11):2079-2085.
    • DeRhodes KH. The dangers of ignoring the Beers Criteria-the prescribing cascade. JAMA Intern Med. 2019;179(7):863-864.
    • O’Mahony D. STOPP/START criteria for potentially inappropriate medications/potential prescribing omissions in older people: origin and progress. Expert Rev Clin Pharmacol. 2020;13(1):15-22.
    • Piggott KL, Mehta N, et al. Using a clinical process map to identify prescribing cascades in your patient. BMJ. 2020;368:m261.
    • Savage RD, Visentin JD, et al. Evaluation of a common prescribing cascade of calcium channel blockers and diuretics in older adults with hypertension. JAMA Intern Med. 2020;180(5):643-651.

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