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Asking the right questions to prevent prescribing cascades

May 29, 2017

By Lindsay Jolivet

Keeping a close eye on medications, particularly for older adults, is crucial for preventing adverse events, says a new commentary published in The Lancet by Dr. Paula Rochon, vice-president of research at Women’s College Hospital and Retired Teachers of Ontario (RTO) Chair in Geriatric Medicine, and her collaborator Dr. Jerry Gurwitz.

Dr. Paula Rochon
Dr. Paula Rochon

The term prescribing cascade refers to situations when a patient has an adverse reaction to a drug, and their doctor misinterprets the reaction as a new medical condition, responding by prescribing yet another medication.

Drs. Rochon and Gurwitz first described this issue in The Lancet in 1995. Since then, movements for smarter prescribing have taken notice. For example, Choosing Wisely Australia tells clinicians and consumers to watch out for prescribing cascades.

Follow-up studies have identified specific medications that tend to be part of a prescribing cascade. For example, doctors sometimes prescribe non-steroidal anti-inflammatory drugs (NSAIDs) to treat inflammation, pain and fever. But NSAIDs can lead to high blood pressure, which doctors may treat with another prescription medication. Both of these drug types are linked with adverse events in older adults. Prescriptions aren’t the only potential concern: over the counter medications and devices such as pacemakers can also be involved in prescribing cascades.

Despite international interest in the prescribing cascade concept, Drs. Rochon and Gurwitz write that interrupting prescribing cascades is still an underappreciated strategy for optimizing medication safety.

They point to some simple strategies to keep the issue in mind, from electronic alerts warning doctors that they might be creating a prescribing cascade, to simple questions clinicians should ask themselves before writing a prescription:

  1. Are you prescribing a new drug to treat an adverse event from a drug the patient is already taking?
  2. Does the patient really need the original prescription or dose that caused the adverse event?
  3. What are the harms and benefits of continuing the drug therapy that led to the prescribing cascade?

“In the two decades since we first described prescribing cascades, they have made an important impact on medication safety in Canada and abroad. We hope that revisiting the issue will prompt even more clinicians and patients to think carefully about their prescriptions,” Dr. Rochon says.

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