Medication review brief · for the pharmacist
Doris Hughes
94 · female · Dry cough, High cholesterol, Depression, Osteoporosis
Prepared by Domino · Oct 1, 2026
Summary
2 likely prescribing cascade links. If Duloxetine were reviewed, up to 1 downstream medicine might no longer be needed (6 → 4).
Question 1
Could the trouble sleeping be from the antidepressant? Morning dosing or a different agent may avoid adding a hypnotic.
- Duloxetine (May 7, 2026) → trouble sleeping → Zopiclone (Jun 3, 2026) · likely 0.99 · consensus
If reviewed: Zopiclone; medicines 6 → 4; anticholinergic burden 0 → 0; fall-risk drugs 3 → 1.
Do not stop abruptly
- Duloxetine: Taper if changed: stopping suddenly can cause discontinuation symptoms.
- Zopiclone: Taper if changed: stopping suddenly can cause rebound insomnia.
Question 2
Could the indigestion be from the bisphosphonate (and how it is taken)?
- Alendronate (Apr 28, 2026) → heartburn or indigestion → Pantoprazole (May 8, 2026) · likely 0.70 · label
If reviewed: Pantoprazole; medicines 6 → 4; anticholinergic burden 0 → 0; fall-risk drugs 3 → 3.
Do not stop abruptly
- Pantoprazole: Consider a step-down: stopping suddenly can cause rebound acid symptoms.
Medicines
| Medicine | Started | Charted for | Domino |
|---|---|---|---|
| Benzonatate as prescribed Dr. A. Patel (family doctor) | Mar 21, 2023 | — | |
| Atorvastatin as prescribed Dr. A. Patel (family doctor) | Jul 25, 2024 | — | |
| Alendronate as prescribed Dr. A. Patel (family doctor) | Apr 28, 2026 | Osteoporosis | Root of a cascade |
| Duloxetine as prescribed Dr. A. Patel (family doctor) | May 7, 2026 | Depression | Root of a cascade Beers-listed |
| Pantoprazole as prescribed Dr. T. Nguyen (walk-in clinic) | May 8, 2026 | — | Possibly treating a side effect Beers-listed |
| Zopiclone as prescribed Dr. A. Patel (family doctor) | Jun 3, 2026 |
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.
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.