Medication review brief · for the pharmacist
Nora Murphy
80 · female · Osteoarthritis pain, Atrial fibrillation, Depression
Prepared by Domino · Oct 1, 2026
Summary
3 likely prescribing cascade links. If Ibuprofen were reviewed, up to 3 downstream medicines might no longer be needed (10 → 6). Dangerous combination: bleeding stack.
Question 1
Could the raised blood pressure be from the NSAID? NSAIDs raise blood pressure and blunt most antihypertensives.
- Ibuprofen (Feb 24, 2024) → high blood pressure → Nifedipine (Apr 28, 2024) · likely 0.84 · consensus
- Nifedipine (Apr 28, 2024) → ankle and leg swelling → Torsemide (Aug 7, 2024) · likely 0.99 · consensus
- Torsemide (Aug 7, 2024) → low potassium → Potassium chloride (Aug 10, 2024) · intentional 0.70 · label
- Ibuprofen (Feb 24, 2024) → ankle and leg swelling → Torsemide (Aug 7, 2024) · possible 0.45 · graph-inferred
If reviewed: Nifedipine, Torsemide, Potassium chloride (planned companion); medicines 10 → 6; anticholinergic burden 1 → 0; fall-risk drugs 5 → 3.
Question 2
Could the trouble sleeping be from the antidepressant? Morning dosing or a different agent may avoid adding a hypnotic.
- Sertraline (Dec 22, 2024) → trouble sleeping → Zopiclone (Jan 30, 2025) · likely 0.99 · consensus
- Sertraline (Dec 22, 2024) → shaking hands → Propranolol (Jan 21, 2025) · possible 0.42 · graph-inferred
If reviewed: Propranolol, Zopiclone; medicines 10 → 7; anticholinergic burden 1 → 1; fall-risk drugs 5 → 2.
Do not stop abruptly
- Sertraline: Taper if changed: stopping suddenly can cause discontinuation symptoms.
- Propranolol: Taper if changed: stopping suddenly can cause a rebound fast heart rate or angina.
- Zopiclone: Taper if changed: stopping suddenly can cause rebound insomnia.
Combinations
- Bleeding stack (Apixaban + Ibuprofen + Sertraline): An anticoagulant or antiplatelet combined with an NSAID or SSRI/SNRI raises bleeding risk.
Medicines
| Medicine | Started | Charted for | Domino |
|---|---|---|---|
| Apixaban as prescribed Dr. H. Singh (family doctor) | Jun 21, 2023 | Atrial fibrillation | |
| Ibuprofen as prescribed Dr. H. Singh (family doctor) | Feb 24, 2024 | Osteoarthritis pain | Root of a cascade Beers-listed |
| Pantoprazole as prescribed Dr. H. Singh (family doctor) | Feb 27, 2024 | GI bleeding risk | Beers-listed |
| Nifedipine as prescribed Dr. H. Singh (family doctor) | Apr 28, 2024 | — | Possibly treating a side effect ACB +1 |
| Omeprazole as prescribed Dr. H. Singh (family doctor) | May 25, 2024 | — | Beers-listed |
| Torsemide as prescribed Dr. H. Singh (family doctor) |
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.
- 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.
- 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.