Beware of the ‘prescribing cascade’
Now that we are embarking on a new year, many of us take on annual resolutions with a focus on diet and exercise. Overlooked is another important way to improve our health: increasing awareness of our medications.
An estimated two out of three Canadians over the age of 65 are prescribed five or more drug therapies, and one out of four are prescribed 10 or more medications over the course of a year. Sometimes these medications are necessary. But sometimes, they may need adjusting or they may even be unnecessary — medications we no longer need or that may have more possible harms than benefits.
We need to check regularly with our healthcare provider that the medications we are on are necessary and at the right dosage.
‘Polypharmacy’ is known as the use of five or more medications. Polypharmacy is particularly relevant to older adults, especially women, because drug use increases with age, often to manage chronic conditions.
Polypharmacy poses risks such as unwanted and sometimes harmful side-effects, as well as possible interactions with other drug therapies, and problems with adhering to complex medication regimens. Women are more at risk for drug-related injuries than men.
Do individuals need to be on so many medications? The answer might be yes.
But one way polypharmacy happens is because of something called “prescribing cascades.” Prescribing cascades occur when a drug therapy is started and an adverse effect develops. These new symptoms are often misinterpreted as a new medical condition which leads to the inappropriate beginning of a new drug therapy to treat the new symptoms.
Take, for example, an individual experiencing mild knee pain. They may be prescribed a non-steroidal anti-inflammatory drug (NSAID) to manage the pain. Subsequently, they develop stomach upset and an anti-ulcer medication is prescribed to treat this new symptom.
By recognizing that this is a prescribing cascade, the healthcare provider can make choices. They can decide whether the initial drug therapy, the NSAID is required, or whether a non-pharmacologic approach such as physiotherapy could manage the knee pain.
Alternatively, if the initial drug therapy is required, the provider could decrease the dose or select an alternative medication with a lower risk of adverse effects to manage the knee pain. In so doing, the need for the additional medication may be eliminated and a prescribing cascade could be avoided.
In our research into prescribing cascades, we initially described three common prescribing cascades. Now more than 160 prescribing cascades have been identified. Highlighting the impact of prescribing cascades is essential because it demonstrates how potentially inappropriate medications could be avoided.
Our recent study, published in the Journal of the American Geriatrics Society also raises another concern about prescribing cascades: the impact of a common prescribing cascade on healthcare use, including emergency room visits and hospital admissions.
Few things are absolute in medicine. When making prescribing decisions, it is always important for healthcare providers to consider individual circumstances and what matters most to a patient.
In some cases, the use of the medication that starts the prescribing cascade is absolutely necessary, the new symptoms are recognized as adverse effects of the drug, and the decision is made that it is best to continue with the drug therapy and treat the side effects as best possible.
The important point is that prescribing cascades are recognized, and the options are considered as part of the drug prescribing or the medication review process.
Here is what you can do as a patient or caregiver to increase awareness of your medications and the potential prescribing cascades that may contribute to polypharmacy:
- Keep a list of all your medications.
- Write down the date they were started,
- the clinician who started them,
- why they were started.
- Review your medications regularly with your healthcare provider.
This information is important as medications may have been started years ago and the provider reviewing the medications may not have this information. Understanding the sequence of events can help to identify prescribing cascades and to decide if action is needed.
By keeping track of this information and regularly reviewing your medications with your healthcare provider, you may reduce the use of medications that you don’t need and the risk of drug-related adverse effects and polypharmacy.
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