Medication review brief · for the pharmacist
Ernest Mensah
89 · male · Hypertension, Osteoarthritis pain, Heart failure, Enlarged prostate (BPH), Anaemia
Prepared by Domino · Oct 1, 2026
Summary
4 likely prescribing cascade links. If Hydrochlorothiazide were reviewed, up to 4 downstream medicines might no longer be needed (15 → 10). Anticholinergic burden is 8.
Question 1
Could the urgency or leaking be from the diuretic? Changing the timing of the dose can help before adding a bladder medication.
- Hydrochlorothiazide (Oct 2, 2023) → leaking urine, urgency → Oxybutynin (Nov 11, 2023) · likely 0.60 · consensus
- Hydrochlorothiazide (Oct 2, 2023) → high blood sugar → Metformin (Jun 2, 2024) · possible 0.42 · graph-inferred
- Metformin (Jun 2, 2024) → low vitamin b12 → Vitamin B12 (Feb 19, 2026) · intentional 0.70 · label
If reviewed: Oxybutynin, Potassium chloride (planned companion), Metformin, Vitamin B12 (planned companion); medicines 15 → 10; anticholinergic burden 8 → 5; fall-risk drugs 8 → 6.
Question 2
Could constipation be from Ferrous sulfate?
- Ferrous sulfate (Nov 7, 2022) → constipation → Docusate (Nov 10, 2022) · likely 0.74 · graph-inferred
If reviewed: Docusate; medicines 15 → 13; anticholinergic burden 8 → 8; fall-risk drugs 8 → 8.
Question 3
Could the dizziness be from the alpha blocker (often on standing)? Vestibular sedatives are strongly anticholinergic and add fall risk.
- Tamsulosin (Jun 24, 2024) → dizziness or spinning → Meclizine (Jul 29, 2024) · likely 0.99 · consensus
- Meclizine (Jul 29, 2024) → trouble emptying the bladder → Terazosin (Aug 2, 2024) · likely 0.50 · label
If reviewed: Meclizine; medicines 15 → 13; anticholinergic burden 8 → 5; fall-risk drugs 8 → 6.
Medicines
| Medicine | Started | Charted for | Domino |
|---|---|---|---|
| Ferrous sulfate as prescribed Dr. A. Patel (family doctor) | Nov 7, 2022 | Anaemia | Root of a cascade |
| Docusate as prescribed Dr. T. Nguyen (walk-in clinic) | Nov 10, 2022 | Constipation | Possibly treating a side effect |
| Hydrochlorothiazide as prescribed Dr. A. Patel (family doctor) | Oct 2, 2023 | Hypertension | Root of a cascade Beers-listed |
| Oxybutynin as prescribed Dr. T. Nguyen (walk-in clinic) | Nov 11, 2023 | Urinary incontinence | Possibly treating a side effect ACB +3 Beers-listed |
| Potassium chloride as prescribed Dr. A. Patel (family doctor) | Nov 28, 2023 | Hypokalaemia | |
| Celecoxib |
Evidence
- McCarthy LM, et al. ThinkCascades: A Tool for Identifying Clinically Important Prescribing Cascades Affecting Older People. Drugs Aging. 2022;39(10):829-840.
- 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.
- 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.