Prescribing cascades in adults. A systematic review
Introduction
The phenomenon of the drug cascade, otherwise known as the prescribing cascade, occurs when a doctor prescribes drugs to a patient for newly developed disease symptoms, that are, in effect, side effects of the previous drug. As a result of such an action, the patient is unnecessarily given additional drugs, which are also not insignificant to the patient’s body and may cause further side effects. These, in turn, may again be misinterpreted by the doctor, who may once again prescribe unnecessary drugs….
The drug cascade is a potentially dangerous activity that can endanger the health of patients.
The most vulnerable group is the elderly, due to non-specific side effects such as delirium, falls, fatigue or constipation, which are common to many diseases.
The article presents a systematic analysis of prescribing cascades, among adults living in the community. The study aimed to identify cases in which patients are prescribed further medications to treat the side effects of medications already in use, which is known as a prescribing cascade.
The study protocol was previously published and pre-registered in PROSPERO (an international database of registered systematic reviews in the field of public health). The study was reported according to PRISMA guidelines.
Results
– A total of 101 studies were included in the review (reported in 103 publications), and the study sample size ranged from 126 to 11,593,989 participants.
– Among all studies reviewed for adverse effects, the most common were depression (n=13), peripheral edema (n=11), urinary incontinence (n=9) and parkinsonism (n=9).
– The most common drug combinations in the cascade included:
1. amiodarone – for levothyroxine used for hypothyroidism (n=5)
2. calcium channel blockers (CCBs) – on loop diuretics, used to treat peripheral edema (n=5)
3. inhaled corticosteroids – on topical antifungals for the treatment of candidiasis (n=4)
4. antiparkinsonian drugs – used for symptoms of Parkinson’s disease after antipsychotic treatment (n=4)
5. acetylcholinesterase inhibitors – for incontinence medications (n=4)
6. cough medicines – given after treatment with angiotensin-converting enzyme inhibitors (ACEIs)
7. metoclopramide – following treatment for Parkinson’s disease (n=3)
8. nonsteroidal anti-inflammatory drugs NSAIDs – used after treatment of ulcers
Researchers reviewed the medical literature in search of studies on prescribing cascades in community-dwelling adult populations. The analysis revealed that drug cascades are common and involve a wide variety of drug classes, including analgesics, anti-inflammatory drugs, antihypertensives and psychotropic drugs.
The most common cause of prescribing cascades was adverse drug reactions, such as nausea, diarrhea, headaches and dizziness. Patients usually received further medications to treat these symptoms, leading to a drug cascade.
Comment
The article’s authors point out that prescribing cascades can lead to increased health care costs and the risk of serious side effects. Therefore, it is important for physicians to carefully monitor patients and try to avoid the prescribing cascade whenever possible.
Of considerable note is the iKASCADE project, which is bringing together specialists to create a list of the most common drug cascades that are clinically significant, i.e. those where the risk of a prescribing cascade is higher than the benefit of additional treatment.
The problem of the occurrence of a prescribing cascade is becoming increasingly common and the preparation of a list of the most common cascades will help doctors and health professionals to choose treatments in the best interests of the patient.
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