Medication review brief · for the pharmacist
Ingrid Chowdhury
94 · female · Insomnia, Reflux / indigestion, Osteoarthritis pain, Neuropathic pain, High cholesterol
Prepared by Domino · Oct 1, 2026
Summary
6 likely prescribing cascade links. If Naproxen were reviewed, up to 3 downstream medicines might no longer be needed (10 → 6). Dangerous combinations: potassium stack, triple whammy.
Question 1
Could the raised blood pressure be from the NSAID? NSAIDs raise blood pressure and blunt most antihypertensives.
- Naproxen (Aug 16, 2024) → high blood pressure → Nifedipine (Oct 14, 2024) · likely 0.99 · consensus
- Nifedipine (Oct 14, 2024) → ankle and leg swelling → Spironolactone (Nov 18, 2024) · likely 0.59 · graph-inferred
- Nifedipine (Oct 14, 2024) → ankle and leg swelling → Torsemide (Oct 19, 2024) · possible 0.46 · consensus
- Torsemide (Oct 19, 2024) → low potassium → Spironolactone (Nov 18, 2024) · likely 0.59 · graph-inferred
- Naproxen (Aug 16, 2024) → ankle and leg swelling → Torsemide (Oct 19, 2024) · likely 0.59 · graph-inferred
- Naproxen (Aug 16, 2024) → high blood pressure → Spironolactone (Nov 18, 2024) · possible 0.36 · graph-inferred
If reviewed: Nifedipine, Torsemide, Spironolactone; medicines 10 → 6; anticholinergic burden 2 → 1; 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.
- Duloxetine (Dec 3, 2023) → trouble sleeping → Trazodone (Apr 5, 2024) · possible 0.37 · consensus
- Trazodone (Apr 5, 2024) → light-headed on standing → Midodrine (May 31, 2024) · likely 0.59 · graph-inferred
- Midodrine (May 31, 2024) → high blood pressure → Enalapril (Jun 21, 2024) · likely 0.74 · graph-inferred
- Midodrine (May 31, 2024) → high blood pressure → Nifedipine (Oct 14, 2024) · possible 0.26 · graph-inferred
If reviewed: Trazodone, Midodrine, Enalapril; medicines 10 → 6; anticholinergic burden 2 → 1; fall-risk drugs 5 → 3.
Do not stop abruptly
- Duloxetine: Taper if changed: stopping suddenly can cause discontinuation symptoms.
- Trazodone: Taper if changed: stopping suddenly can cause discontinuation symptoms.
Question 3
Could light-headed on standing be from Trazodone?
- Trazodone (Apr 5, 2024) → light-headed on standing → Midodrine (May 31, 2024) · likely 0.59 · graph-inferred
- Midodrine (May 31, 2024) → high blood pressure → Enalapril (Jun 21, 2024) · likely 0.74 · graph-inferred
- Midodrine (May 31, 2024) → high blood pressure → Nifedipine (Oct 14, 2024) · possible 0.26 · graph-inferred
- Nifedipine (Oct 14, 2024) → ankle and leg swelling → Spironolactone (Nov 18, 2024) · likely 0.59 · graph-inferred
- Nifedipine (Oct 14, 2024) → ankle and leg swelling → Torsemide (Oct 19, 2024) · possible 0.46 · consensus
If reviewed: Midodrine, Enalapril; medicines 10 → 7; anticholinergic burden 2 → 1; fall-risk drugs 5 → 4.
Do not stop abruptly
- Trazodone: Taper if changed: stopping suddenly can cause discontinuation symptoms.
Combinations
- Potassium stack (Enalapril + Spironolactone): ACE inhibitors and ARBs retain potassium; adding a potassium-sparing diuretic or supplement can push it too high.
- Triple whammy (Enalapril + Torsemide + Spironolactone + Naproxen): An ACE inhibitor or ARB, a diuretic and an NSAID together sharply raise the risk of acute kidney injury.
Medicines
| Medicine | Started | Charted for | Domino |
|---|---|---|---|
| Famotidine as prescribed Dr. H. Singh (family doctor) | Sep 16, 2023 | Reflux / indigestion | |
| Duloxetine as prescribed Dr. H. Singh (family doctor) | Dec 3, 2023 | Neuropathic pain | Root of a cascade Beers-listed |
| Atorvastatin as prescribed Dr. H. Singh (family doctor) | Mar 26, 2024 | High cholesterol | |
| Trazodone as prescribed Dr. H. Singh (family doctor) | Apr 5, 2024 | Insomnia | Root of a cascade ACB +1 |
| Midodrine as prescribed Dr. T. Nguyen (walk-in clinic) | May 31, 2024 | — | Possibly treating a side effect |
| Enalapril 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.
- 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.
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.