Medication review brief · for the pharmacist
Frank Russo
82 · male · Type 2 diabetes, Neuropathic pain, Bipolar disorder
Prepared by Domino · Oct 1, 2026
Summary
1 likely prescribing cascade link. If Gabapentin were reviewed, up to 2 downstream medicines might no longer be needed (8 → 5).
Question 1
Could the swelling be from gabapentin or pregabalin?
- Gabapentin (Jul 19, 2024) → ankle and leg swelling → Furosemide (Sep 3, 2024) · likely 0.99 · study
- Furosemide (Sep 3, 2024) → low potassium → Potassium chloride (Oct 1, 2024) · intentional 0.88 · label
If reviewed: Furosemide, Potassium chloride (planned companion); medicines 8 → 5; anticholinergic burden 1 → 0; fall-risk drugs 4 → 2.
Do not stop abruptly
- Gabapentin: Taper if changed: stopping suddenly can cause withdrawal and, rarely, seizures.
Question 2
Could shaking hands be from Lithium?
- Lithium (Jul 11, 2018) → shaking hands → Propranolol (Mar 31, 2024) · possible 0.34 · graph-inferred
If reviewed: Levothyroxine (planned companion), Propranolol; medicines 8 → 5; anticholinergic burden 1 → 1; fall-risk drugs 4 → 2.
Do not stop abruptly
- Lithium: Changes need specialist input: stopping lithium suddenly raises the risk of relapse.
- Propranolol: Taper if changed: stopping suddenly can cause a rebound fast heart rate or angina.
Medicines
| Medicine | Started | Charted for | Domino |
|---|---|---|---|
| Lithium 300 mg twice daily Dr. E. Okoro (psychiatry) | Jul 11, 2018 | Bipolar disorder | Root of a cascade |
| Metformin 1000 mg twice daily Dr. A. Patel (family doctor) | Jul 15, 2021 | Type 2 diabetes | |
| Levothyroxine 75 mcg daily Dr. E. Okoro (psychiatry) | Mar 7, 2023 | Hypothyroidism | |
| Propranolol 10 mg twice daily Dr. E. Okoro (psychiatry) | Mar 31, 2024 | Tremor | Possibly treating a side effect |
| Gabapentin 300 mg three times daily Dr. A. Patel (family doctor) | Jul 19, 2024 | Neuropathic pain | Root of a cascade |
| Furosemide 20 mg daily Dr. T. Nguyen (walk-in clinic) | Sep 3, 2024 | Peripheral edema |
Care team decisions already on record
- metformin → cyanocobalamin: intentional (J. Morin, PharmD, Jul 29, 2026): Planned B12 replacement; metformin is working well. Recheck B12 yearly.
- lithium → levothyroxine: intentional (Dr. E. Okoro, Jul 29, 2026): Lithium-induced hypothyroidism, recognised in 2023. Lithium continues on psychiatry advice.
Evidence
- Read SH, et al. Evidence of a gabapentinoid and diuretic prescribing cascade among older adults with lower back pain. J Am Geriatr Soc. 2021;69(10):2842-2850.
- Product monographs and prescribing information (adverse reaction sections), curated by hand for this prototype. Frequencies are approximate bands, not exact rates.
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.