Medication review brief · for the pharmacist
Henry Okafor
91 · male · Osteoarthritis pain, Atrial fibrillation
Prepared by Domino · Oct 1, 2026
Summary
4 likely prescribing cascade links. If Naproxen were reviewed, up to 4 downstream medicines might no longer be needed (8 → 3). Dangerous combination: bleeding stack. Anticholinergic burden is 3.
Question 1
Could the raised blood pressure be from the NSAID? NSAIDs raise blood pressure and blunt most antihypertensives.
- Naproxen (Apr 10, 2024) → high blood pressure → Hydrochlorothiazide (Jun 12, 2024) · likely 0.99 · consensus
- Hydrochlorothiazide (Jun 12, 2024) → gout or high uric acid → Allopurinol (Feb 9, 2025) · likely 0.99 · study
- Hydrochlorothiazide (Jun 12, 2024) → gout or high uric acid → Colchicine (Jan 12, 2025) · likely 0.99 · study
- Colchicine (Jan 12, 2025) → diarrhoea → Loperamide (Jan 21, 2025) · likely 0.99 · label
If reviewed: Hydrochlorothiazide, Colchicine, Loperamide, Allopurinol; medicines 8 → 3; anticholinergic burden 3 → 1; fall-risk drugs 2 → 1.
Combinations
- Bleeding stack (Apixaban + Naproxen): An anticoagulant or antiplatelet combined with an NSAID or SSRI/SNRI raises bleeding risk.
Medicines
| Medicine | Started | Charted for | Domino |
|---|---|---|---|
| Metoprolol 25 mg twice daily Dr. K. Osei (cardiology) | Dec 17, 2022 | Atrial fibrillation | ACB +1 |
| Apixaban 2.5 mg twice daily Dr. K. Osei (cardiology) | Dec 17, 2022 | Atrial fibrillation | |
| Naproxen 500 mg twice daily Dr. C. Laurent (rheumatology) | Apr 10, 2024 | Osteoarthritis pain | Root of a cascade Beers-listed |
| Omeprazole 20 mg daily Dr. C. Laurent (rheumatology) | Apr 10, 2024 | GI bleeding risk | Beers-listed |
| Hydrochlorothiazide 25 mg daily Dr. A. Patel (family doctor) | Jun 12, 2024 | Hypertension | Possibly treating a side effect Beers-listed |
| Colchicine 0.6 mg 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.
- Gurwitz JH, et al. Initiation of antihypertensive treatment during nonsteroidal anti-inflammatory drug therapy. JAMA. 1994;272(10):781-786.
- 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.
- Rochon PA, Gurwitz JH. The prescribing cascade revisited. Lancet. 2017;389(10081):1778-1780.
- Product monographs and prescribing information (adverse reaction sections), curated by hand for this prototype. Frequencies are approximate bands, not exact rates.
- American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023;71(7):2052-2081.
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.