Prescription Cascades
Author: Dian Han (Pharm. D. Candidate) Reviewer: Dr. Grace Lee (MD)
A prescription cascade is the process by which the side effect of a medication is misdiagnosed as a symptom of a new medical condition, leading to the addition of a new medication to treat this symptom. This can recursively lead to further drug interactions, side effects, and the addition of even more prescriptions.
Prescription cascades can have a multitude of negative consequences for patient health. Since all medications unavoidably have their own set of side effects, adding medications unnecessarily can make recognition and resolution of the initial side effect difficult, cause unexpected new drug interactions, ultimately resulting in negative health outcomes for patients. Some common side effects include nausea, vomiting, diarrhea, dizziness, insomnia, and dry cough. Prescription cascades also increase healthcare costs via medication spending, physicians’ visits and hospitalizations. Thus, it is important for prescription cascades to be identified, managed, and prevented when possible.
Although the risk factors that lead to prescribing cascades are unknown, the risk factors for experiencing a side effect from a medication are well studied. Being an older adult, a woman, using multiple medications, and taking cardiovascular drugs, anticoagulants, antibiotics and nonsteroidal anti-inflammatory drugs are risk factors for experiencing side effects, which increase the risk that a medication will be initiated to treat that side effect. Most often, side effects of medications arise within the first four months of therapy, and 75% occur in the first month of starting a new medication. If you receive care from multiple physicians (for example, both a specialist and your family doctor), one may be unaware of a prescription the other prescribed, which can lead to further inappropriate medication prescribing.
To prevent prescription cascades from occurring, communication is the most important tool that we have. It is good practice to bring all of your medications or a comprehensive medication list with you to each of your doctors appointments, including any non-prescription vitamins, supplements, or herbal products you are taking. If you have recently started taking a new medication, communicate this to your healthcare circle at each appointment. Ask your pharmacist if you qualify for a free MedsCheck medication review. Fill all of your prescriptions at the same pharmacy, so that your pharmacist has your complete medication profile, and can monitor for any drug interactions or unnecessary medication therapies. Lastly, as recommended by the Institute of Safe Medication Practices, ask your healthcare provider questions that can help to identify prescription cascades:
Am I experiencing a symptom that could be a medication’s side effect?
Is this new medication being used to treat a side effect from another medication I am taking?
Is a safer medication available, or could I be taking a lower dose?
Do I really need to be taking this medication at all?
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