Pharmaceutical Society of Australia

The Pharmaceutical Society of Australia (PSA) is the peak national professional pharmacy organisation and represents Australia’s 30,000 pharmacists working in all sectors and locations. PSA’s core functions include: providing continuing professional development, education and practice support; developing and advocating standards and guidelines; and representing pharmacists’ role as frontline health professionals.


Do not initiate medications to treat symptoms, adverse events, or side effects (unless in an emergency) without determining if an existing therapy or lack of adherence is the cause, and whether a dosage reduction, discontinuation of a medication, or another treatment is warranted.

Date reviewed: 12 December 2018

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
How this list was made How this list was made

A working party of members of the Pharmaceutical Society of Australia (PSA) was established. Members of the State and Territory Branch Committees were invited to contribute suggested recommendations. Over 40 recommendations were submitted. The working party grouped the recommendations into themes, eliminated ones that were out of scope, reduced the list to twelve and refined the wording. All PSA members were sent an online survey to rank the proposed recommendations, indicate how likely they would be to implement the recommendations in practice, and suggest additional items for consideration.

Based on the survey responses, six recommendations were shortlisted and supporting evidence gathered. The final list was signed off by the PSA Board in November 2018.

Note: PSA uses Vancouver reference style. Where there are more than three authors, only the first three are listed followed by et al.

Download PSA Recommendations