Medication review brief · for the pharmacist
Harold Roy
71 · male · Hypertension, Osteoarthritis pain, Heart failure, High cholesterol
Prepared by Domino · Oct 1, 2026
Summary
4 likely prescribing cascade links. If Simvastatin were reviewed, up to 2 downstream medicines might no longer be needed (10 → 7). Dangerous combinations: potassium stack, triple whammy. Anticholinergic burden is 4.
Question 1
Could muscle aches be from Simvastatin?
- Simvastatin (Apr 30, 2024) → muscle aches → Cyclobenzaprine (Aug 29, 2024) · likely 0.74 · graph-inferred
- Cyclobenzaprine (Aug 29, 2024) → confusion or memory problems → Galantamine (Oct 23, 2024) · likely 0.74 · graph-inferred
- Simvastatin (Apr 30, 2024) → muscle aches → Ibuprofen (Oct 27, 2024) · possible 0.30 · graph-inferred
If reviewed: Cyclobenzaprine, Galantamine; medicines 10 → 7; anticholinergic burden 4 → 2; fall-risk drugs 6 → 4.
Question 2
Could the gout be from the diuretic raising uric acid? A different antihypertensive may be an option.
- Hydrochlorothiazide (Dec 30, 2024) → gout or high uric acid → Febuxostat (Oct 15, 2025) · likely 0.99 · study
If reviewed: no downstream change; medicines 10 → 9; anticholinergic burden 4 → 4; fall-risk drugs 6 → 5.
Question 3
Could the gout be from the diuretic raising uric acid? A different antihypertensive may be an option.
- Furosemide (Feb 28, 2025) → gout or high uric acid → Febuxostat (Oct 15, 2025) · likely 0.57 · study
- Furosemide (Feb 28, 2025) → low potassium → Spironolactone (Apr 17, 2025) · possible 0.30 · graph-inferred
If reviewed: no downstream change; medicines 10 → 9; anticholinergic burden 4 → 3; fall-risk drugs 6 → 5.
Combinations
- Potassium stack (Lisinopril + Spironolactone): ACE inhibitors and ARBs retain potassium; adding a potassium-sparing diuretic or supplement can push it too high.
- Triple whammy (Lisinopril + Furosemide + Hydrochlorothiazide + Spironolactone + Ibuprofen): 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 |
|---|---|---|---|
| Simvastatin as prescribed Dr. A. Patel (family doctor) | Apr 30, 2024 | — | Root of a cascade |
| Cyclobenzaprine as prescribed Dr. T. Nguyen (walk-in clinic) | Aug 29, 2024 | Myalgia | Possibly treating a side effect ACB +2 Beers-listed |
| Galantamine as prescribed Dr. T. Nguyen (walk-in clinic) | Oct 23, 2024 | Cognitive impairment | Possibly treating a side effect |
| Ibuprofen as prescribed Dr. A. Patel (family doctor) | Oct 27, 2024 | — | Possibly treating a side effect Beers-listed |
| Hydrochlorothiazide as prescribed Dr. A. Patel (family doctor) | Dec 30, 2024 | Hypertension | Root of a cascade Beers-listed |
Evidence
- 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.
- 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.