Medication review brief · for the pharmacist
Ruth Novak
72 · female · Dry cough, Hypertension, Osteoarthritis pain, Atrial fibrillation, Coronary artery disease, Depression, Osteoporosis
Prepared by Domino · Oct 1, 2026
Summary
2 likely prescribing cascade links. If Naproxen were reviewed, up to 2 downstream medicines might no longer be needed (14 → 11). Dangerous combinations: potassium stack, triple whammy, bleeding stack.
Question 1
Could the raised blood pressure be from the NSAID? NSAIDs raise blood pressure and blunt most antihypertensives.
- Naproxen (Mar 30, 2024) → high blood pressure → Valsartan (May 26, 2024) · likely 0.84 · consensus
- Naproxen (Mar 30, 2024) → high blood pressure → Chlorthalidone (Oct 2, 2024) · possible 0.37 · consensus
- Chlorthalidone (Oct 2, 2024) → low potassium → Spironolactone (Nov 29, 2024) · possible 0.30 · graph-inferred
If reviewed: Valsartan, Chlorthalidone; medicines 14 → 11; anticholinergic burden 2 → 2; fall-risk drugs 7 → 5.
Question 2
Could the trouble sleeping be from the antidepressant? Morning dosing or a different agent may avoid adding a hypnotic.
- Duloxetine (Dec 22, 2022) → trouble sleeping → Trazodone (Jan 13, 2023) · likely 0.99 · consensus
If reviewed: no downstream change; medicines 14 → 13; anticholinergic burden 2 → 2; fall-risk drugs 7 → 6.
Do not stop abruptly
- Duloxetine: Taper if changed: stopping suddenly can cause discontinuation symptoms.
Combinations
- Potassium stack (Valsartan + Spironolactone): ACE inhibitors and ARBs retain potassium; adding a potassium-sparing diuretic or supplement can push it too high.
- Triple whammy (Valsartan + Chlorthalidone + Spironolactone + Naproxen): An ACE inhibitor or ARB, a diuretic and an NSAID together sharply raise the risk of acute kidney injury.
- Bleeding stack (Apixaban + Aspirin (low dose) + Naproxen + Duloxetine): An anticoagulant or antiplatelet combined with an NSAID or SSRI/SNRI raises bleeding risk.
Medicines
| Medicine | Started | Charted for | Domino |
|---|---|---|---|
| Duloxetine as prescribed Dr. A. Patel (family doctor) | Dec 22, 2022 | Depression | Root of a cascade Beers-listed |
| Aspirin (low dose) as prescribed Dr. A. Patel (family doctor) | Dec 28, 2022 | Coronary artery disease | Beers-listed |
| Pantoprazole as prescribed Dr. A. Patel (family doctor) | Dec 29, 2022 | GI bleeding risk | Beers-listed |
| Trazodone as prescribed Dr. R. Ahmed (walk-in clinic) | Jan 13, 2023 | Insomnia | Possibly treating a side effect ACB +1 |
| Calcium + vitamin D as prescribed Dr. A. Patel (family doctor) | Oct 24, 2023 | Osteoporosis | |
| Apixaban as prescribed |
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.
- 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.
- 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.