Prescribing Cascade � What, When, How and the Ways to Mitigate

Rational prescribing is essential for adequate patient compliance and proper therapeutic outcome. Often medicines are prescribed randomly to take care of the drug induced adverse reactions without changing the culprit drug or modifying it抯 dose, rather commonly by adding another drug towards amelioration of the presenting complain, ignoring it抯 drug related occurrence. This 慞rescribing Cascade� turns out to be a vicious cycle by promoting polypharmacy thus leading to it抯 adverse consequences. This can happen to any person at any age but elderly population are more vulnerable because of their age related physiological changes and co-morbidities. There are several ways to curb the vicious cycle down like anticholinergic burden assessment, selecting the right drug for the right person, medication reconciliation etc.

The prescribing cascade and medication therapy management between cholinesterase inhibitors and anticholinergic drugs / 中国药学杂志

OBJECTIVE: To discuss about one patient with Alzheimer′s disease and urinary incontinence and to investigate the prescribing cascade between cholinesterase inhibitors and anticholinergic drugs further more. METHODS: Clinical pharmacists participated in a medication therapy management program aiming at one patient with Alzheimer′s disease and urinary incontinence. By doing this they successfully identified and interrupted a prescribing cascade. Then some constructive advices were provided to doctors and patients on the rational administration of drugs. RESULTS: The drug treatment plan was adjusted by clinical pharmacists and doctors after evaluating the benefits and risks about the use of cholinesterase inhibitors and anticholinergic drugs in the elderly patient with chronic disease. And this change directly led to a significant relief of urinary incontinence in the patient. CONCLUSION: The use of cholinesterase inhibitors in Alzheimer′s patients increases the risk of urinary incontinence, and at the same time additional use of anticholinergic drugs in the treatment of urinary incontinence can further damage the cognition.Therefore, clinical pharmacists and doctors should pay great attention to the prescribing cascade of cholinesterase inhibitors and anticholinergic drugs. To identify and interrupt prescribing cascades is important when clinical pharmacists and doctors are prescribing prescriptions for elderly patients with chronic diseases. They must work closely for the optimization of prescriptions and the improvement of medication safety in elderly patients.

Prescribing cascade: A proposed new way to evaluate it

Prescribing cascade is defined as the situation in which a first drug administered to a patient causes adverse event signs and symptoms, that are misinterpreted as a new condition, resulting in a new medication being prescribed. The cascade may have multiple steps and differ in complexity and severity. Despite being well identified, prescribing cascade is an increasingly common problem in medical practice. It constitutes a warning about irrational use of medicines that puts health at risk and increases treatment costs if it is not taken into account. In this article, representative cases taken from Hospital General de Agudos Dr. Cosme Argerich pharmacovigilance database were selected to assess a proper score and an algorithm that define the probable prescribing cascade.

La prescripción en cascada identifica la situación generada tras la administración a un paciente de un medicamento que le provoca un evento adverso, el cual al no ser debidamente reconocido como tal por el profesional desencadena nuevas prescripciones farmacológicas que pueden agravar o generar nuevos eventos adversos. Por ello, de acuerdo a la idiosincrasia de cada paciente, la cascada puede tener múltiples pasos y diferir en complejidad y gravedad. A pesar de estar identificada, la prescripción en cascada es un problema cada vez más común en la práctica médica y una advertencia sobre el uso irracional de los medicamentos que pone en riesgo la salud e incrementa sus costos si no se tiene en cuenta. En este artículo, se seleccionaron casos representativos tomados de la base de datos de farmacovigilancia del Hospital General de Agudos Dr. Cosme Argerich para probar un nuevo score y un algoritmo de decisión, que evalúen la supuesta cascada prescriptiva.