Medication review brief · for the pharmacist
Raymond Gagnon
73 · male · Hypertension, Parkinson's disease, Osteoarthritis pain, Heart failure, Coronary artery disease, High cholesterol, Anxiety
Prepared by Domino · Oct 1, 2026
Summary
4 likely prescribing cascade links. If Lisinopril were reviewed, up to 1 downstream medicine might no longer be needed (15 → 13). Dangerous combinations: potassium stack, triple whammy, bleeding stack. Anticholinergic burden is 5.
Question 1
Could the dry cough be from the ACE inhibitor? Cough suppressants do not fix it; switching to an ARB usually does.
- Lisinopril (May 20, 2023) → persistent dry cough → Benzonatate (Sep 17, 2023) · likely 0.99 · study
If reviewed: Benzonatate; medicines 15 → 13; anticholinergic burden 5 → 5; fall-risk drugs 9 → 7.
Question 2
Could muscle aches be from Atorvastatin?
- Atorvastatin (Oct 14, 2022) → muscle aches → Ibuprofen (Jan 17, 2023) · likely 0.59 · graph-inferred
- Ibuprofen (Jan 17, 2023) → high blood pressure → Chlorthalidone (Apr 6, 2023) · likely 0.99 · consensus
- Chlorthalidone (Apr 6, 2023) → low potassium → Potassium chloride (Apr 13, 2023) · intentional 0.88 · label
- Ibuprofen (Jan 17, 2023) → high blood pressure → Amlodipine (Mar 2, 2023) · likely 0.99 · consensus
- Amlodipine (Mar 2, 2023) → dizziness or spinning → Meclizine (Mar 28, 2023) · possible 0.34 · graph-inferred
- Amlodipine (Mar 2, 2023) → ankle and leg swelling → Spironolactone (Mar 25, 2023) · possible 0.30 · graph-inferred
- Amlodipine (Mar 2, 2023) → ankle and leg swelling → Furosemide (Apr 10, 2023) · possible 0.25 · consensus
- Ibuprofen (Jan 17, 2023) → high blood pressure → Spironolactone (Mar 25, 2023) · possible 0.30 · graph-inferred
If reviewed: no downstream change; medicines 15 → 14; anticholinergic burden 5 → 5; fall-risk drugs 9 → 9.
Combinations
- Potassium stack (Lisinopril + Spironolactone + Potassium chloride): ACE inhibitors and ARBs retain potassium; adding a potassium-sparing diuretic or supplement can push it too high.
- Triple whammy (Lisinopril + Furosemide + Chlorthalidone + Spironolactone + Ibuprofen + Diclofenac): An ACE inhibitor or ARB, a diuretic and an NSAID together sharply raise the risk of acute kidney injury.
- Bleeding stack (Aspirin (low dose) + Ibuprofen + Diclofenac + Sertraline): An anticoagulant or antiplatelet combined with an NSAID or SSRI/SNRI raises bleeding risk.
Medicines
| Medicine | Started | Charted for | Domino |
|---|---|---|---|
| Atorvastatin as prescribed Dr. A. Patel (family doctor) | Oct 14, 2022 | High cholesterol | Root of a cascade |
| Ibuprofen as prescribed Dr. A. Patel (family doctor) | Jan 17, 2023 | — | Possibly treating a side effect Beers-listed |
| Amlodipine as prescribed Dr. A. Patel (family doctor) | Mar 2, 2023 | Hypertension | Possibly treating a side effect |
| Spironolactone as prescribed Dr. A. Patel (family doctor) | Mar 25, 2023 | — | Possibly treating a side effect |
| Meclizine as prescribed Dr. R. Ahmed (walk-in clinic) | Mar 28, 2023 | — | Possibly treating a side effect ACB +3 Beers-listed |
| Chlorthalidone as prescribed |
Evidence
- 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.
- 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.
- Product monographs and prescribing information (adverse reaction sections), curated by hand for this prototype. Frequencies are approximate bands, not exact rates.
- 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.
- 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.
- 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.