Recognise and stop the prescribing cascade.
A prescribing cascade occurs when a new medicine is prescribed to ‘treat’ an adverse reaction to another drug in the mistaken belief that a new medical condition requiring treatment has developed. Prescribing cascades should be avoided because they are associated with adverse outcomes due to the second or additional drugs, which places the patient at risk. One example of a prescribing cascade is when a patient is prescribed a non-steroidal drug for pain, and is then prescribed proton pump inhibitors (PPIs) to reduce the risk of stomach side effects caused by the first prescribed drug. As prescribing cascades are precipitated by adverse drug reactions, they can be prevented by avoidance and early detection of the initial adverse drug reaction. For instance, many adverse drug reactions in the elderly are dose-related. It is advised that starting treatment at low doses and titrating to effect may reduce their risk. Most adverse drug reactions occur within a few months of starting a medicine. Clinicians should consider the potential for an adverse drug reaction to be the cause of any new symptoms, particularly if a drug has been recently started or changed. Patients should be asked about new symptoms, as many patients do not report adverse drug reactions. When such reactions occur, non-drug treatment strategies should be considered as the most appropriate first-line management, rather than starting a second medicine to counteract adverse effects.
- Caughey GE, Roughead EE, Pratt N, et al. Increased risk of hip fracture in the elderly associated with prochlorperazine: is a prescribing cascade contributing? Pharmacoepidemiol Drug Saf 2010;19:977-82.
- Kalisch LM, Caughey GE, Roughead EE, Gilbert AL. The prescribing cascade. Australian Prescriber 2011;34;162-166.
- Martin JH, Coombes I. Mortality from common drug interactions systems, knowledge and clinical reasoning to optimise prescribing. Internal Medicine Journal 2014;44(7):621-4.
A working party of members of the Australasian Society of Clinical and Experimental Pharmacologists and Toxicologists (ASCEPT) was established to propose an initial list of recommendations. ASCEPT’s membership was then invited to participate in an online survey to comment on the appropriateness of the proposed recommendations and suggest additional items for consideration.
Based on the survey responses, six recommendations were shortlisted. Following an evidence review the top 5 list items were selected. The final list was signed off by the ASCEPT President in April 2016.
- 1 Recognise and stop the prescribing cascade.
- 2 Reduce the use of medicines when there is a safer or more effective non-pharmacological management strategy.
- 3 Avoid using a higher or lower dose than is necessary for the patient to optimise the ‘benefit-to-risk’ ratio and achieve the patient’s therapeutic goals.
- 4 Stop medicines when no further benefit will be achieved or the potential harms outweigh the potential benefits for the individual patient.
- 5 Reduce use of multiple concurrent therapeutics (hyper-polypharmacy).