Medication review brief · for the pharmacist
Ernest Campbell
86 · male · Hypertension, Osteoarthritis pain, Neuropathic pain, Heart failure, High cholesterol, Enlarged prostate (BPH)
Prepared by Domino · Oct 1, 2026
Summary
3 likely prescribing cascade links. If Tamsulosin were reviewed, up to 2 downstream medicines might no longer be needed (14 → 11). Dangerous combinations: potassium stack, sedation stack. Anticholinergic burden is 6.
Question 1
Could the dizziness be from the alpha blocker (often on standing)? Vestibular sedatives are strongly anticholinergic and add fall risk.
- Tamsulosin (Oct 28, 2022) → dizziness or spinning → Meclizine (Dec 3, 2022) · likely 0.99 · consensus
- Tamsulosin (Oct 28, 2022) → light-headed on standing → Midodrine (Nov 23, 2023) · possible 0.26 · graph-inferred
If reviewed: Meclizine, Midodrine; medicines 14 → 11; anticholinergic burden 6 → 3; fall-risk drugs 9 → 7.
Question 2
Could low potassium be from Furosemide?
- Furosemide (Oct 21, 2023) → low potassium → Spironolactone (Dec 7, 2023) · likely 0.74 · graph-inferred
- Furosemide (Oct 21, 2023) → gout or high uric acid → Febuxostat (Dec 17, 2023) · likely 0.57 · study
- Furosemide (Oct 21, 2023) → light-headed on standing → Midodrine (Nov 23, 2023) · possible 0.42 · graph-inferred
If reviewed: Midodrine, Febuxostat; medicines 14 → 11; anticholinergic burden 6 → 5; fall-risk drugs 9 → 8.
Question 3
Could persistent dry cough be from Lisinopril?
- Lisinopril (Jun 13, 2023) → persistent dry cough → Codeine (Aug 3, 2023) · possible 0.30 · graph-inferred
If reviewed: no downstream change; medicines 14 → 13; anticholinergic burden 6 → 6; fall-risk drugs 9 → 8.
Combinations
- Potassium stack (Lisinopril + Spironolactone): ACE inhibitors and ARBs retain potassium; adding a potassium-sparing diuretic or supplement can push it too high.
- Sedation stack (Codeine + Gabapentin): Beers 2023: avoid opioids with benzodiazepines or gabapentinoids (sedation, respiratory depression).
Medicines
| Medicine | Started | Charted for | Domino |
|---|---|---|---|
| Tamsulosin as prescribed Dr. J. Martin (family doctor) | Oct 28, 2022 | Enlarged prostate (BPH) | Root of a cascade |
| Meclizine as prescribed Dr. R. Ahmed (walk-in clinic) | Dec 3, 2022 | Dizziness / vertigo | Possibly treating a side effect ACB +3 Beers-listed |
| Gabapentin as prescribed Dr. J. Martin (family doctor) | Dec 9, 2022 | Neuropathic pain | |
| Terazosin as prescribed Dr. J. Martin (family doctor) | Jan 13, 2023 | — | Beers-listed |
| Acetaminophen as prescribed Dr. J. Martin (family doctor) | Jan 29, 2023 | Osteoarthritis pain | |
| Lisinopril as prescribed Dr. J. Martin (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.
- 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.