Medication review brief · for the pharmacist
Beatrice Hale
84 · female · Hypertension, Osteoarthritis pain, High cholesterol
Prepared by Domino · Oct 1, 2026
Summary
3 likely prescribing cascade links. If Amlodipine were reviewed, up to 4 downstream medicines might no longer be needed (9 → 4). Dangerous combinations: potassium stack, triple whammy. Anticholinergic burden is 4.
Question 1
Could the ankle swelling be from the calcium channel blocker? CCB edema does not respond well to diuretics; a dose change or a different antihypertensive may help instead.
- Amlodipine (Apr 30, 2024) → ankle and leg swelling → Furosemide (Jun 17, 2024) · likely 0.99 · consensus
- Furosemide (Jun 17, 2024) → low potassium → Potassium chloride (Jul 15, 2024) · intentional 0.88 · label
- Furosemide (Jun 17, 2024) → leaking urine, urgency → Oxybutynin (Sep 19, 2024) · likely 0.63 · consensus
- Oxybutynin (Sep 19, 2024) → confusion or memory problems → Donepezil (Feb 25, 2025) · likely 0.99 · consensus
If reviewed: Furosemide, Potassium chloride (planned companion), Oxybutynin, Donepezil; medicines 9 → 4; anticholinergic burden 4 → 0; fall-risk drugs 5 → 1.
Combinations
- Potassium stack (Lisinopril + Potassium chloride): ACE inhibitors and ARBs retain potassium; adding a potassium-sparing diuretic or supplement can push it too high.
- Triple whammy (Lisinopril + Furosemide + Naproxen): An ACE inhibitor or ARB, a diuretic and an NSAID together sharply raise the risk of acute kidney injury.
Medicines
| Medicine | Started | Charted for | Domino |
|---|---|---|---|
| Atorvastatin 20 mg daily Dr. A. Patel (family doctor) | Oct 23, 2021 | High cholesterol | |
| Naproxen 500 mg twice daily Dr. A. Patel (family doctor) | Jan 31, 2024 | Osteoarthritis pain | Beers-listed |
| Omeprazole 20 mg daily Dr. A. Patel (family doctor) | Jan 31, 2024 | GI bleeding risk | Beers-listed |
| Amlodipine 10 mg daily Dr. A. Patel (family doctor) | Apr 30, 2024 | Hypertension | Root of a cascade |
| Furosemide 40 mg daily Dr. T. Nguyen (walk-in clinic) | Jun 17, 2024 | Peripheral edema | Possibly treating a side effect ACB +1 Beers-listed |
| Potassium chloride 20 mEq daily |
Evidence
- McCarthy LM, et al. ThinkCascades: A Tool for Identifying Clinically Important Prescribing Cascades Affecting Older People. Drugs Aging. 2022;39(10):829-840.
- Savage RD, et al. Evaluation of a Common Prescribing Cascade of Calcium Channel Blockers and Diuretics in Older Adults With Hypertension. JAMA Intern Med. 2020;180(5):643-651.
- Doherty AS, Lund LC, Moriarty F, et al. Prescribing Cascades Among Older Community-Dwelling Adults: Application of Prescription Sequence Symmetry Analysis to a National Database in Ireland. Ann Fam Med. 2025;23(4):315-324.
- Product monographs and prescribing information (adverse reaction sections), curated by hand for this prototype. Frequencies are approximate bands, not exact rates.
- Lapi F, et al. Concurrent use of diuretics, angiotensin converting enzyme inhibitors, and angiotensin receptor blockers with non-steroidal anti-inflammatory drugs and risk of acute kidney injury: nested case-control study. BMJ. 2013;346:e8525.
Decision support only. Domino flags patterns in a synthetic record for a clinician to review; it does not diagnose, and it never recommends stopping or changing a medicine. Synthetic data; no real patient.