Prescribing Cascade and Deprescribing

Sibel ÜLKER GÖKSELa

aEge University Faculty of Medicine, Department of Medical Pharmacology, İzmir, Türkiye

ABSTRACT
When a medication is prescribed to overcome an adverse drug reaction induced by another medication, it is called as a ”prescribing cascade”. Prescribing cascades are most commonly detected when polypharmacy is applied to chronically ill elder patients. Intentional/unintentional, appropriate/inappropriate, the prescribing cascades are used for prophylactic or therapeutic purposes as well. Medications for dementia, antihypertensives, sedative and hypnotic drugs, opioids, non-steroidal anti-inflammatory drugs, antiepileptics, antibiotics, and medicines for nausea are drugs commonly involved in prescribing cascades. Symptoms in the elderly that may be attributed to drug adverse effect are depression, confusion, restlessness/agitation/delirium, memory loss/changes in consciousness, dizziness/drowsiness, syncope/postural hypotension, frequent falls, extrapyramidal symptoms, nausea/vomitting, gastrointestinal bleeding, constipation, urinary incontinence, visual problems, QT prolongation, peripheral oedema, tinnitus, electrolyte disturbances. Deprescribing tools are used to prevent cascade routes. Beers criteria, STOPP-START, IMPACT Tool and TIME Criteria are common deprescribing protocols adopted to countries with reference to available drugs on the market.
Keywords: Deprescriptions; drug prescriptions; potentially inappropriate medication list; inappropriate prescribing

Referanslar

  1. MSD Manual Professional Version [Internet]. Merck & Co, Inc., Rahway NJ. USA. ©2023 [cited: Aug 31, 2023]. Drug-Related Problems in Older Adults. Available from: [Link]
  2. Dovjak P. Polypharmacy in elderly people. Wien Med Wochenschr. 2022;172(5-6):109-13. [Crossref]  [PubMed]
  3. Rochon PA, Gurwitz JH. Optimising drug treatment for elderly people: the prescribing cascade. BMJ. 1997;315(7115):1096-9. [Crossref]  [PubMed]  [PMC]
  4. Chen Z, Liu Z, Zeng L, Huang L, Zhang L. Research on prescribing cascades: a scoping review. Front Pharmacol. 2023;14:1147921. [Crossref]  [PubMed]  [PMC]
  5. Rochon PA, Gurwitz JH. Drug therapy. Lancet. 1995;346(8966):32-6. [Crossref]  [PubMed]
  6. Rochon PA, Gurwitz JH. The prescribing cascade revisited. Lancet. 2017;389(10081):1778-80. Erratum in: Lancet. 2017;389(10085):2192. [Crossref]  [PubMed]
  7. Dreischulte T, Shahid F, Muth C, Schmiedl S, Haefeli WE. Prescribing Cascades: How to Detect Them, Prevent Them, and Use Them Appropriately. Dtsch Arztebl Int. 2022;119(44):745-52. [Crossref]  [PubMed]  [PMC]
  8. Doherty AS, Shahid F, Moriarty F, Boland F, Clyne B, Dreischulte T, et al. Prescribing cascades in community-dwelling adults: A systematic review. Pharmacol Res Perspect. 2022;10(5):e01008. [Crossref]  [PubMed]  [PMC]
  9. Nguyen PV, Spinelli C. Prescribing cascade in an elderly woman. Can Pharm J (Ott). 2016;149(3):122-4. [Crossref]  [PubMed]  [PMC]
  10. Gill SS, Mamdani M, Naglie G, Streiner DL, Bronskill SE, Kopp A, et al. A prescribing cascade involving cholinesterase inhibitors and anticholinergic drugs. Arch Intern Med. 2005;165(7):808-13. [Crossref]  [PubMed]
  11. Masurkar PP, Chatterjee S, Sherer JT, Aparasu RR. Antimuscarinic Cascade Across Individual Cholinesterase Inhibitors in Older Adults with Dementia. Drugs Aging. 2021;38(7):593-602. [Crossref]  [PubMed]
  12. Rosenberg J, Rochon PA, Gill SS. Unveiling a prescribing cascade in an older man. J Am Geriatr Soc. 2014;62(3):580-1. [Crossref]  [PubMed]
  13. Gill SS, Anderson GM, Fischer HD, Bell CM, Li P, Normand SL, et al. Syncope and its consequences in patients with dementia receiving cholinesterase inhibitors: a population-based cohort study. Arch Intern Med. 2009;169(9):867-73. [Crossref]  [PubMed]
  14. Savage RD, Visentin JD, Bronskill SE, Wang X, Gruneir A, Giannakeas V, 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):643-51. [Crossref]  [PubMed]  [PMC]
  15. Farrell B, Galley E, Jeffs L, Howell P, McCarthy LM. "Kind of blurry": Deciphering clues to prevent, investigate and manage prescribing cascades. PLoS One. 2022;17(8):e0272418. [Crossref]  [PubMed]  [PMC]
  16. Avorn J, Gurwitz JH, Bohn RL, Mogun H, Monane M, Walker A. Increased incidence of levodopa therapy following metoclopramide use. JAMA. 1995;274(22):1780-2. [Crossref]  [PubMed]
  17. Hoang T, Liu J, Pratt N, Zheng VW, Chang KC, Roughead E, et al. Detecting signals of detrimental prescribing cascades from social media. Artif Intell Med. 2016;71:43-56. [Crossref]  [PubMed]  [PMC]
  18. Hachiken H, Murai A, Wada K, Kuwahara T, Hosomi K, Takada M. Difference between the frequencies of antisecretory drug pre- scriptions in users of buffered vs. enteric-coated low-dose aspirin therapies. Int J Clin Pharmacol Ther. 2013;51(10):807-15. [Crossref]  [PubMed]
  19. Gadzhanova S, Pratt N, Roughead E. Use of SGLT2 inhibitors for diabetes and risk of infection: Analysis using general practice records from the NPS MedicineWise MedicineInsight program. Diabetes Res Clin Pract. 2017;130:180-5. [Crossref]  [PubMed]
  20. Lund LC, Højlund M, Henriksen DP, Hallas J, Kristensen KB. Sodium-glucose cotransporter-2 inhibitors and the risk of gout: A Danish population based cohort study and symmetry analysis. Pharmacoepidemiol Drug Saf. 2021;30(10):1391-1395. [Crossref]  [PubMed]
  21. Brahma DK, Wahlang JB, Marak MD, Ch Sangma M. Adverse drug reactions in the elderly. J Pharmacol Pharmacother. 2013;4(2):91-4. [Crossref]  [PubMed]  [PMC]
  22. Sino CG, Bouvy ML, Jansen PA, Schop IM, Egberts TC, Schuurmans MJ. Signs and symptoms indicative of potential adverse drug reactions in homecare patients. J Am Med Dir Assoc. 2013;14(12):920-5. [Crossref]  [PubMed]
  23. Woodward MC. Deprescribing: achieving better health outcomes for older people through reducing medications. J Pharm Pract Res. 2003;33(4):323-8. [Crossref]
  24. By the 2023 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023;71(7):2052-81. [Crossref]  [PubMed]
  25. O'Mahony D, Cherubini A, Guiteras AR, Denkinger M, Beuscart JB, Onder G, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 3. Eur Geriatr Med. 2023;14(4):625-32. Erratum in: Eur Geriatr Med. 2023. [Crossref]  [PubMed]  [PMC]
  26. 268. IMPACT 2020 2.0 [Internet] PrescQIPP community Interest Company. [cited: 31 Ağustos 2023] Available from: [Link]
  27. Derbyshire NHS [Internet]. Deprescribing: a practical guide. December 2019. [cited: 31 Ağustos 2023] Available from: [Link]
  28. Lewis T. Using the NO TEARS tool for medication review. BMJ. 2004;329(7463):434. [Crossref]  [PubMed]  [PMC]
  29. Todd A, Jansen J, Colvin J, McLachlan AJ. The deprescribing rainbow: a conceptual framework highlighting the importance of patient context when stopping medication in older people. BMC Geriatr. 2018;18(1):295. [Crossref]  [PubMed]  [PMC]
  30. Bruyère Guidelines [Internet] Bruyère Research Institute, Ottawa, Canada© Copyright 2019 Bruyère [cited: 31 Ağustos 2023] Available from: [Link]
  31. MedStopper [Internet] [cited: 31 Ağustos 2023] Available from: [Link]
  32. Garfinkel D, Zur-Gil S, Ben-Israel J. The war against polypharmacy: a new cost-effective geriatric-palliative approach for improving drug therapy in disabled elderly people. Isr Med Assoc J. 2007;9(6):430-4.
  33. Ian A Scott, Leonard C Gray, Jennifer H Martin, Peter I Pillans, Charles A Mitchell. Deciding when to stop: towards evidence-based deprescribing of drugs in older populations. Evid Based Med. 2013;18(4):121-4. [Crossref]  [PubMed]
  34. Türkiye Yaşlıda Uygunsuz İlaç Kullanım Kriterleri [Internet] Akademik Geriatri Derneği Copyright © 2023 [Erişim tarihi: 31 Ağustos 2023] Erişim linki: [Link]
  35. Hickman E, Gillies C, Khunti K, Seidu S. Deprescribing, polypharmacy and prescribing cascades in older people with type 2 diabetes: A Focused Review. J Indian Inst Sci. 2023,103(1):191-204. [Crossref]
  36. Stratton MA, Salinas RC. Clinical pharmacology. In: Ham RJ, Warshaw GA, Flaherty E, eds. Primary Care Geriatrics: A Case-Based Approach. 5th ed. Elsevier; 2007. p.90-9. [Crossref]