Common medications trigger potentially harmful prescribing cascades in older adults

A new Ontario-wide study reveals that common medications, from statins to iron supplements, are quietly setting off prescribing cascades that leave older adults unknowingly taking drugs to treat side effects of other drugs.

A potentially inappropriate prescribing cascade (PIPC) happens when a medication's side effect gets mistaken for a new health problem, leading to another prescription that may not have been needed in the first place. One common example flagged in the study involves non-steroidal anti-inflammatory drugs (NSAIDs). Commonly prescribed for pain, these drugs are associated with a rise in blood pressure, which can lead to a new prescription for high blood pressure, rather than a second look at the original pain medication. Older adults are especially vulnerable to this pattern because they're more likely to be on multiple medications at once, due to having multiple conditions, making it harder for both patients and clinicians to trace a new symptom back to an existing drug.

"These sequences of events are common but often missed in clinical practice," said Dr. Rochon, who holds the Barry J. Goldlist Chair in Aging and Health at Sinai Health and is also a professor of medicine at the University of Toronto. "Knowing what medications, you are taking, when they were started and for what indication is important in order to identify possible prescribing cascades that may be problematic "

The study brought together an interdisciplinary, international team of collaborators and leaders in drug prescribing and geriatric medicine research from the United States, Belgium, Italy, Israel and Ireland, along with Sinai Health researchers Drs. Vasily Giannakeas, Nathan Stall and Christina Reppas-Rindlisbacher and research staff Wei Wu and Joyce Li.

With the expertise of 12 international panelists specializing in internal medicine, geriatric medicine and clinical pharmacology, the research team previously created a list of 65 PIPCs. Using this list and population-level prescription data from ICES, Ontario's health data institute working with Lavina Matai and Zhiyin Li, the researchers examined each PIPC against three factors: how common the initial drug was in the population, how often it was followed by the second drug, and how strong the link was between the two. That analysis allowed them to pinpoint the 24 potentially inappropriate prescribing cascades most commonly seen in the population and with a potential to cause harm.

Seeing the pattern behind every prescription

For Dr. Rochon, the findings highlight a gap that opens quietly, one prescription at a time. "Our concern is that so often these conversations between the health care prescriber and the patient are being missed, so people don't recognize the sequences of events and that they are connected to one another," she said.

The work also carries a particular weight for mature women, as they tend to live with more chronic conditions than men over their lifetime. Mature women are prescribed more drug therapies, and experience more adverse drug events. By being on multiple medications at once, they are more exposed to the risk that a drug's side effect gets mistaken for a new diagnosis rather than traced back to its source.

Source:

Lunenfeld-Tanenbaum Research Institute

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