Real-World Complexity of Prescribing Cascades

Abstract

Prescribing cascades occur when an adverse drug reaction (ADR) to one medication is treated with additional medication. Most literature focusses on this simplistic singular concept of one medication followed by another. However, ADRs in clinical practice may appear less straightforward, making prescribing cascades difficult to identify and deprescribe. More insight is needed into the real-world complexity of prescribing cascades, since they may negatively impact both patients and the healthcare system. This article aims to provide exemplary cases of the real-world complexity of prescribing cascades and explores strategies to identify, mitigate and prevent them. The real-world cases discussed highlight the multifaceted nature of prescribing cascades in clinical practice. They show several factors contributing to the challenges in recognizing ADRs and preventing prescribing cascades, including misinterpretation of ADRs, fragmented healthcare systems and accumulation of pharmacological effects and comorbidities within an individual patient. Several strategies are recommended to improve identification, mitigation and prevention of prescribing cascades. Although educating patients and healthcare providers (HCPs) can help bridge the knowledge gap, additional strategies are needed. Implementing supportive tools to deprescribe, enhanced communication among HCPs and patients regarding ADRs and rationale for medication changes, and monitoring patients for ADRs are considered the most promising strategies.