A prescribing cascade may be simple and predictable or complex and unrecognized. The latter can be hazardous to the patient.
A prescribing cascade refers to adverse effects from one drug prompting the prescription of a second drug.
This is relatively common and straightforward.
Baseline Drug and Effect
Downstream drug
diuretic and hypokalemia
potassium replacement
constipation and opioids
laxative
steroids and immuno-suppression
antibiotics
This can become a cascade when the second drug creates another adverse effects prompting a third drug, which has adverse effects that prompts and fourth, and so on.
Risk factors:
(1) polypharmacy
(2) polyprovider
(3) higher comorbidity
(4) poor clinical documentation of therapeutic indications
Hazards:
(1) continued administration of a downstream drug after triggering drug discontinued
(2) acceleration of clinical decline
(3) failure to recognize that abnormal findings are an adverse effect of a drug that is continued rather than adjusted or changed
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