The Meds Most Likely To Produce A Dangerous “Prescribing Cascade” In Later Life

First, what is a “prescribing cascade”?

It’s what happens when a medication causes a side effect (or even a bunch of side effects), which can then lead to a “side effect train” whereby the patient then has to take something else to treat the side effect, then something else to treat the side effect(s) of that medication, and so on, until they are taking an increasingly large stack of medications.

To use a common statin as an example, a book that we reviewed cites a case in which a woman’s LDL levels were high and she was prescribed simvastatin (Zocor), 20mg/day. Here’s what happened, in sequence:

1. Her own non-statin self-prescription (with her doctor’s signature) worked, and she went back to her life, her work, and took up running.
2. She started getting panic attacks. So, her doctor prescribed her sertraline (Zoloft) (a very common SSRI antidepressant) and when that didn’t fix it, paroxetine (Paxil). This didn’t work either… because the problem was not actually her mental health. The panic attacks got worse…
3. Then, while exercising, she started noticing progressive arm and leg weakness. Her doctor finally took her off the simvastatin, and temporarily switched to ezetimibe (Zetia), a less powerful nonstatin drug that blocks cholesterol absorption, which change eased her arm and leg problem.
4. As the Zetia was a stopgap measure, the doctor put her on atorvastatin (Lipitor). Now she got episodes of severe chest pressure, and a skyrocketing heart rate. She also got tremors and lost her body temperature regulation.
5. So the doctor stopped the atorvastatin and tried rosovastatin (Crestor), on which she now suffered exhaustion (we’re not surprised, by this point) and muscle pains in her arms and chest.
6. So the doctor stopped the rosovastatin and tried lovastatin (Mevacor), and now she had the same symptoms as before, plus light-headedness.
7. So the doctor stopped the lovastatin and tried fluvastatin (Lescol). Same thing happened.
8. So he stopped the fluvastatin and tried pravastatin (Pravachol), without improvement.
9. So finally he took her off all these statins because the high LDL was less deleterious to her life than all these things.
10. She did her own research, and went back to the doctor to ask for cholestyramine (Questran), which is a bile acid sequestrent and nothing to do with statins. She also asked for a long-acting niacin. In high doses, niacin (one of the B-vitamins) raises HDL (good) cholesterol, lowers LDL, and lowers tryglycerides.

You can find that book, here: The Truth About Statins – by Barbara H. Roberts, M.D.

The highest-risk meds to be aware of

Researchers (Dr. Lisa Ellet et al.) investigated the prevalance of this happening in people entering long-term residential aged care (a demographic already at increased risk for overmedication, and also easy to observe), and found that before entering aged care, 16.7% of residents had at least one statistically significant prescribing cascade, increasing to 25.1% after admission.

Of these, many cascades involved medicines already known to carry higher risks in older adults, including antipsychotics, benzodiazepines, and opioids.

In other words, bluntly, the meds most commonly given by doctors and other prescribers to make patients less bothersome to them.

That said, not for nothing did we use statins as an example above, because starting statins was associated with later initiation of several other medications, including antipsychotics and antidepressants, while benzodiazepine use was associated with later antipsychotic prescribing.

The lesson to be learned from this?

❝There’s a real opportunity here to intervene earlier through routine medication reviews, better monitoring of side effects and, where appropriate, deprescribing strategies❞

~ Dr. Gill Caughey, another researcher in this study

You can read this paper in full, here: Prescribing cascades potentially associated with harms before and after transition to long-term care facilities

Want to know more?

You might find these previous articles of ours of interest:

• Are You Taking PIMs? Getting Off The Overmedication Train ← “PIMs” stands for “potentially inappropriate medications”, be they prescribed purely in error, or as part of a prescribing cascade
• Medications That Shouldn’t Be Taken Long-term (With Natural Alternatives)
• The Common Meds That Make You More Likely To Die From A fall
• The Commonly-Prescribed Painkiller That Barely Works (And Is Dangerous)
• The Common Meds That Make You Much More Susceptible To Heatstroke ← especially important in the kind of weather many of us are having these days!

And for a more in-depth exploration than we have room for here, check out this book that we reviewed:

To Medicate or Not? That is the Question! – by Dr. Asha Bohannon

Take care!