Medication review brief · for the pharmacist
Marie Patel
91 · female · Hypertension, Anxiety
Prepared by Domino · Oct 1, 2026
Summary
4 likely prescribing cascade links. If Sertraline were reviewed, up to 5 downstream medicines might no longer be needed (6 → 0).
Question 1
Could the trouble sleeping be from the antidepressant? Morning dosing or a different agent may avoid adding a hypnotic.
- Sertraline (Dec 7, 2022) → trouble sleeping → Trazodone (Dec 22, 2022) · likely 0.99 · consensus
- Trazodone (Dec 22, 2022) → light-headed on standing → Midodrine (Jan 20, 2023) · likely 0.59 · graph-inferred
- Midodrine (Jan 20, 2023) → high blood pressure → Felodipine (Feb 9, 2023) · likely 0.59 · graph-inferred
- Midodrine (Jan 20, 2023) → high blood pressure → Lisinopril (Aug 28, 2024) · possible 0.26 · graph-inferred
If reviewed: Trazodone, Midodrine, Felodipine, Lisinopril, Dextromethorphan; medicines 6 → 0; anticholinergic burden 1 → 0; fall-risk drugs 4 → 0.
Do not stop abruptly
- Sertraline: Taper if changed: stopping suddenly can cause discontinuation symptoms.
- Trazodone: Taper if changed: stopping suddenly can cause discontinuation symptoms.
Question 2
Could the dry cough be from the ACE inhibitor? Cough suppressants do not fix it; switching to an ARB usually does.
- Lisinopril (Aug 28, 2024) → persistent dry cough → Dextromethorphan (Oct 13, 2024) · likely 0.99 · study
If reviewed: Dextromethorphan; medicines 6 → 4; anticholinergic burden 1 → 1; fall-risk drugs 4 → 2.
Medicines
| Medicine | Started | Charted for | Domino |
|---|---|---|---|
| Sertraline as prescribed Dr. A. Patel (family doctor) | Dec 7, 2022 | Anxiety | Root of a cascade Beers-listed |
| Trazodone as prescribed Dr. E. Okoro (psychiatry) | Dec 22, 2022 | Insomnia | Possibly treating a side effect ACB +1 |
| Midodrine as prescribed Dr. A. Patel (family doctor) | Jan 20, 2023 | — | Possibly treating a side effect |
| Felodipine as prescribed Dr. A. Patel (family doctor) | Feb 9, 2023 | — | Possibly treating a side effect |
| Lisinopril as prescribed Dr. A. Patel (family doctor) | Aug 28, 2024 | Hypertension | Root of a cascade |
| Dextromethorphan as prescribed Dr. R. Ahmed (walk-in clinic) |
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.
- Vegter S, de Jong-van den Berg LTW. Misdiagnosis and mistreatment of a common side-effect: angiotensin-converting enzyme inhibitor-induced cough. Br J Clin Pharmacol. 2010;69(2):200-203.
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.