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.
The risk of adverse drug reactions (ADR) and hospital admissions related to ADRs 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 patient harm. Prescribing cascades are a type of problematic polypharmacy that occur when an adverse drug event (ADE) is misinterpreted as a new medical condition, and a second medication is prescribed to address this emerging ADE. If a suitable alternative is available, discontinuation of the medication thought to be the cause of the ADR would be the best course of action. The decision to prescribe a second medication to counteract an ADR 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 (CCBs) 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.
These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.
A deprescribing task force led by chair (Manju T. Beier, Pharm D, BCGP, FASCP) was created by ASCP in November 2018. Members comprised of pharmacists practicing in academia, community and long-term care settings. The chair also invited pharmacists from international countries (Canada and Australia) where deprescribing initiatives have a strong focus and literature base. The collective experience and knowledge represent a focus on medication management, medication selection and reconciliation, and monitoring for drug-drug interactions (DDIs). The emphasis is on older adults no matter where they reside in step with ASCP’s mission.
Definition wise, deprescribing is a stepwise reduction of unnecessary or potentially inappropriate medications in concert with patient and family goals and wishes. We recognize that even with the best of intentions, many older adults are left on unnecessary and potentially dangerous or duplicative medications that might precipitate adverse events and other negative outcomes.
The task force prioritized formulation of the Choosing Wisely (CW) List, since the goals of CW intersect and overlap with deprescribing initiatives. The list was created to address general medication regimen review statements, and more importantly to address the paucity of statements that address DDIs with several incriminating medication therapeutic classes prescribed for older adults. After a review of published CW statements on www.choosingwisely.org and also a review of CW statements published by international countries, it was decided by consensus to have a strong emphasis on DDIs.
After several virtual meetings, the CW workgroup was divided into subgroups to formulate DDIs that have a strong evidence base in the literature and those that focus on CNS therapeutic classes, anticholinergic burden, heightened bleeding risk, and other pivotal pharmacokinetic and pharmacodynamic DDIs. For each statement the group formulated a rationale that was evidence-based accompanied with several recent, pertinent references. The compiled list (after several virtual meetings and email discussion) was further reduced to top ten statements with the strongest evidence base and practice trends on medication management in older adults.
The top five list was selected by consensus for initial submission.
Attached is a recently published guest editorial in ASCP’s journal that highlights the emphasis on DDIs.
Beier MT. Vigilance of Drug-Drug Interactions to Mitigate ADRs: Front and Center for Pharmacists (Guest Editorial). Sr Care Pharm 2020; 35:336-7.
A deprescribing task force led by chair (Manju T. Beier, Pharm D, BCGP, FASCP) was created by ASCP in November 2018. Members comprised of pharmacists practicing in academia, community and long-term care settings. The chair also invited pharmacists from international countries (Canada and Australia) where deprescribing initiatives have a strong focus and literature base. The collective experience and knowledge represent a focus on medication management, medication selection and reconciliation, and monitoring for drug-drug interactions (DDIs). The emphasis for all our statements is on older adults no matter where they reside in step with ASCP’s mission. Our first 5 CW statements were published in May 2021.
As previously addressed, the rationale for the new 2022 list (statements 6–10) includes one medication review statement in older adults with limited life expectancy, and three statements emphasizing the adverse combination of CNS medications that have a strong evidence base in the literature including tramadol’s potential for greater harm than benefit for pain relief, especially in older adults. We had previously highlighted pharmacodynamic DDIs for heightened bleeding risk, and this time our statement addresses the complexity of pharmacokinetic DDIs with Direct Oral Anticoagulants (DOACs).
Rochon PA, Gurwitz JH. Optimizing drug treatment for elderly people: the prescribing cascade. BMJ 1997;315(7115):1096-1099.
Gill SS, Mamdani M, Naglie G, et al. A prescribing cascade involving cholinesterase inhibitors and anticholinergic drugs. Arch Intern Med. 2005;165(7):808-813.
Brath H, Mehta N, Savage RD, Gill SS, Wu W, Bronskill SE, 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, Wong CL, Rochon PA. Using a clinical process map to identify prescribing cascades in your patient. BMJ 2020 Feb 19;368:m261.
Savage RD, Visentin JD, Bronskill SE, Wang X, Gruneir A, Giannakeas V, Guan J, Lam K, Luke MJ, Read SH, Stall NM, Wu W, Zhu L, Rochon PA, McCarthy LM. Evaluation of a Common Prescribing Cascade of
Calcium Channel Blockers and Diuretics in Older Adults With Hypertension. JAMA Intern Med. 2020 May 1;180(5):643-651.