Pharmaceutical Society of Australia: tests, treatments and procedures consumers and clinicians should question

The prescribing cascade occurs when a new medicine is prescribed to 'treat' a side effect from another drug. The cascade often occurs in the mistaken belief that the side effect is a sign or symptom of a new condition requiring treatment. Other times, it can be a belief that it is more important to continue therapy with the original drug and prescribe another medicine to manage the side effects. Pharmacists and prescribers need to be aware that a new sign or symptom may potentially be a side effect of a current medicine.

Supporting evidence

  • Page A, Clifford R, Potter K, et al. A concept analysis of deprescribing medications in older people. Journal of Pharmacy Practice and Research. 2018; 48(2): 132-148.
  • Rochon P, Gurwitz J. Optimising drug treatment for elderly people: The prescribing cascade, British Med. J. 315 (1997) 1096–1099.
  • Hilmer S, Gnjidic D. The Effects of Polypharmacy in Older Adults, Clin.Pharmacol. Ther. 85 (2009) 86–88.
  • Gill S, Mamdani M, Naglie G, et al. A prescribing cascade involving cholinesterase inhibitors and anticholinergic drugs. Arch. Intern. Med. 165 (2005) 808-813.
  • Vegter S, De Jong-Van Den Berg L. Misdiagnosis and mistreatment of a common side effect - Angiotensin-converting enzyme inhibitor-induced cough, British J. Clin. Pharmacol. 69 (2010) 200–203.
  • Mohammed MA, Moles RJ, Chen TF. Medication-related burden and patients’ lived experience with medicine: a systematic review and metasynthesis of qualitative studies. BMJ Open. 2016 Feb 1;6(2):e010035

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Homeopathic products are widely available to consumers from a variety of platforms including the internet, supermarkets, and health stores. Many consumers are not aware that there is no reliable evidence to support the use of homeopathic products to treat or prevent ailments. There may be a public perception that these products have health benefits. Consumers may put their health at risk if they choose homeopathic products and reject or delay treatments for which there is good evidence for safety and effectiveness. Many products are being sold with little or no information. All health professionals, particularly pharmacists and doctors, have a critical role to educate consumers so they can make informed decisions about how best to manage their health using evidence based medicine.

Supporting evidence

  • Ernst E. A systematic review of systematic reviews of homeopathy. Br J Clin Pharmacol. 2002;54(6):577-582
  • Ernst E. Homeopathy: what does the ‘best’ evidence tell us? Med J Aust.2010;192(8): 458-60
  • National Health and Medical Research Council. 2015. NHMRC Statement on homeopathy and NHMRC Information paper – Evidence on the effectiveness of homeopathy for treating health conditions. At: https://www.nhmrc.gov.au/guidelines-publications/cam02
  • Posadski P, Alotaibi A, Ernst E. Adverse effects of homeopathy: a systematic review of published case reports and case series. International Journal of Clinical Practice. 2012 Dec 1;66(12):1178-88
  • Stonemann P, Sturgis P, Allum N, et al. Incommensurable Worldviews? Is public use of complementary and alternative medicines incompatible with support for science and conventional medicine? PL0s one. 2013;8(1): e53174 

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Inappropriate use of antibiotics could result in infection progression, leading to increased patient morbidity and mortality, as well as contributing to antibiotic resistance. In some chronic conditions, such as COPD, repeated antibiotics form part of a management plan. However, in other cases patients commonly request dispensing of repeat antibiotic prescriptions without consultation with their treating doctor, and sometimes well after the original prescription was written. If a repeat prescription for an antibiotic is requested to be dispensed, consider the clinical appropriateness of the request.

Supporting evidence

  • Australian Commission on Safety and Quality in Health Care (ACSQHC) Antimicrobial Stewardship in Australian Health Care. Sydney: ACSQHC 2018
  • Zayegh I, Charrois TL, Hughes J et al. Antibiotic repeat prescriptions: are patients not refilling them properly? J Pharm Policy Pract. 2014;7(1):17
  • Fredericks I, Hollingworth S, Pudmenzky A, et al. ‘Repeat’ prescriptions and antibiotic resistance: findings from Australian community pharmacy. Int J Pharm Pract. 2017;25(1):50-58
  • Essack S, Bell J, Shephard A. Community pharmacists- Leaders for antibiotic stewardship in respiratory tract infection. Journal of Clinical Pharmacy and Therapeutics. 2018 Apr 1;43(2):302-7

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The use of medications for older people can improve symptom control and reduce disease progression. However, the use of five or more medications is independently associated with poor clinical outcomes including increased hospital admissions, falls and premature mortality. Deprescribing (which is the process of discontinuing or reducing medications) is an intervention to improve the quality use of medicines. Deprescribing is an intervention to manage polypharmacy that requires balancing the potential benefit and harm of each medication then systematically withdrawing medications that are no longer needed or clinically indicated or are inappropriate for that individual at that time. There is a growing body of evidence to support deprescribing in older people.

Supporting evidence

  • Martin P, Tamblyn R, Benedetti A, et al. Effect of a pharmacist-led education intervention on inappropriate medication prescriptions in older adults: the D-PRESCRIBE randomised clinical trial. JAMA 2018; 320(18):1889-1898
  • Page A, Potter K, Clifford R, et al. Deprescribing in older people. Maturitas. 2016;91:115-134. doi: 10.1016/j.maturitas.2016.06.006
  • Potter K, Flicker L, Page A, et al. Deprescribing in frail older people: a randomised controlled trial. PLoS one. 2016;11(3):e0149984. doi: 10.1371/journal.pone.0149984
  • Page AT, Clifford RM, Potter K, et al. The feasibility and the effect of deprescribing in older adults on mortality and health: A systematic review. Br J Clin Pharmacol. 2016;82(3):583-623. doi: 10.1111/bcp.12975
  • Page AT, Clifford R, Potter K, et al. A concept analysis of deprescribing medications in older people. Journal of Pharmacy Practice and Research. 2018;48(2):132-148 doi:10.1002/jppr.1361
  • Potter K, Page A, Clifford R, et al. Deprescribing: A guide for medication reviews. Journal of Pharmacy Practice and Research. 2016;46(4): 358–367 doi:10.1002/jppr.1298
  • Scott IA, Anderson K, Freeman CR, et al. First do no harm: a real need to deprescribe in older patients. Med J Aust 2014;201(7):390-2.
  • Reeve E, Thompson W, Farrell B. Deprescribing: A narrative review of the evidence and practical recommendations for recognizing opportunities and taking action. European Journal of Internal Medicine. 2017 Mar 1;39 (supplement): 3-11

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The use of benzodiazepines, other sedative hypnotics or antipsychotics in older adults for insomnia, agitation or delirium is associated with a range of adverse effects including falls and impaired cognition. Non-pharmacological interventions can be an effective substitute and use of these medicines should be for the shortest duration possible. Reductions in the use of these medicines can be achieved following pharmacist review, interdisciplinary input, staff education and feedback from audits.

Supporting evidence

  • Díaz-Gutiérrez MJ, Martínez-Cengotitabengoa M, Sáez de Adana E, et al. Relationship between the use of benzodiazepines and falls in older adults: A systematic review. Maturitas. 2017;101:17-22.
  • Yu NW, Chen PJ, Tsai HJ, et al. Association of benzodiazepine and Z-drug use with the risk of hospitalisation for fall-related injuries among older people: a nationwide nested case-control study in Taiwan. BMC Geriatr. 2017;17:140.
  • Declercq T, Petrovic M, Azermai M, et al. Withdrawal versus continuation of chronic antipsychotic drugs for behavioural and psychological symptoms in older people with dementia. Cochrane Database Syst Rev 2013;(3):CD007726.
  • Ma H, Huang Y, Cong Z, et al. The efficacy and safety of atypical antipsychotics for the treatment of dementia: a meta-analysis of randomized placebo-controlled trials. J Alzheimers Dis 2014;42(3):915-37.
  • Richter T, Meyer G, Mohler R, et al. Psychosocial interventions for reducing antipsychotic medication in care home residents. Cochrane Database Syst Rev 2012;(12):CD008634.
  • Westbury JL, Gee P, Ling T, et al. RedUSe: reducing antipsychotic and benzodiazepine prescribing in residential aged care facilities. Med J Aust 2018; 208(9):398-403. doi: 10.5694/mja17.00857
  • Alessi C, Vitello M. Insomnia (primary) in older people: non-drug treatments. BMJ Clin Evid. 2015;2302
  • Sawan M, Jeon Y, Chen T. Psychotropic medicines use in residents and culture: influencing clinical excellence (PRACTICE) tool. A development and content validation study. Research in Social and Administrative Pharmacy. 2018 https://doi.org/10.1016/j.sapharm.2018.08.015

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Complementary medicines may also be called 'traditional' or 'alternative' medicines and include items such as vitamins, minerals, herbal products, aromatherapy and homoeopathic products. Many of the products available in pharmacies, supermarkets or health food outlets have limited evidence of efficacy. There is some evidence of efficacy for some complementary medicines, however this may be formulation and dose dependent, and health practitioners are encouraged to seek this information before recommending such products.

Supporting evidence

  • Pharmaceutical Society of Australia (2012). Australian pharmaceutical formulary and handbook: the everyday guide to pharmacy practice (22nd ed). Pharmaceutical Society of Australia, Deakin West, ACT
  • Pharmacy Board Guidelines on Practice Specific Issues: 5. Complementary and alternative medicines. https://www.pharmacyboard.gov.au/codes-guidelines.aspx 
  • Cochrane collaboration – Systematic reviews. https://www.cochrane.org/ Some examples are:
    • Abdelhamid  AS, Brown  TJ, Brainard  JS, et al. Omega‐3 fatty acids for the primary and secondary prevention of cardiovascular disease. Cochrane Database of Systematic Reviews 2018, Issue 7. Art. No.: CD003177. DOI: 10.1002/14651858.CD003177.pub3.
    • Flowers  N, Hartley  L, Todkill  D, et al. Co‐enzyme Q10 supplementation for the primary prevention of cardiovascular disease. Cochrane Database of Systematic Reviews 2014, Issue 12. Art. No.: CD010405. DOI: 10.1002/14651858.CD010405.pub2.
    • Geng  J, Dong  J, Ni  H, et al. Ginseng for cognition. Cochrane Database of Systematic Reviews 2010, Issue 12. Art. No.: CD007769. DOI: 10.1002/14651858.CD007769.pub2.
  • Braun LA, Tiralongo E, Wilkinson JM, et al. Perceptions, use and attitudes of pharmacy customers on complementary medicines and pharmacy practice. BMC Complement Altern med. 2010 Jul 20;10(1):1-7
  • Popattia AS, Winch S, Caze AL. Ethical responsibilities of pharmacists when selling complementary medicines: a systematic review. International Journal of Pharmacy Practice. 2018 Apr 1;26(2):93-103
  • Ung COL, Harnett J, Hu H. Community pharmacist’s responsibilities with regards to traditional medicine/complementary medicine products: A systematic literature review. Research in Social and Administrative Pharmacy. 2017 Jul 1;13(4):686-716 

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Last reviewed 12 December 2018