Medication review brief · for the pharmacist
Irene Nguyen
86 · female · Neuropathic pain, Heart failure, High cholesterol
Prepared by Domino · Oct 1, 2026
Summary
3 likely prescribing cascade links. If Torsemide were reviewed, up to 2 downstream medicines might no longer be needed (10 → 7). Anticholinergic burden is 8.
Question 1
Could the urgency or leaking be from the diuretic? Changing the timing of the dose can help before adding a bladder medication.
- Torsemide (Apr 7, 2025) → leaking urine, urgency → Oxybutynin (May 2, 2025) · likely 0.84 · consensus
- Oxybutynin (May 2, 2025) → confusion or memory problems → Rivastigmine (Aug 6, 2025) · likely 0.99 · consensus
If reviewed: Oxybutynin, Rivastigmine; medicines 10 → 7; anticholinergic burden 8 → 5; fall-risk drugs 9 → 6.
Question 2
Could the dry cough be from the ACE inhibitor? Cough suppressants do not fix it; switching to an ARB usually does.
- Lisinopril (Jun 7, 2023) → persistent dry cough → Dextromethorphan (Sep 21, 2023) · likely 0.81 · study
- Dextromethorphan (Sep 21, 2023) → dizziness or spinning → Dimenhydrinate (Sep 28, 2023) · possible 0.42 · graph-inferred
- Dimenhydrinate (Sep 28, 2023) → confusion or memory problems → Rivastigmine (Aug 6, 2025) · possible 0.26 · graph-inferred
- Lisinopril (Jun 7, 2023) → dizziness or spinning → Dimenhydrinate (Sep 28, 2023) · possible 0.26 · graph-inferred
If reviewed: Dextromethorphan, Dimenhydrinate; medicines 10 → 7; anticholinergic burden 8 → 5; fall-risk drugs 9 → 6.
Medicines
| Medicine | Started | Charted for | Domino |
|---|---|---|---|
| Furosemide as prescribed Dr. J. Martin (family doctor) | May 13, 2023 | Heart failure | ACB +1 Beers-listed |
| Lisinopril as prescribed Dr. J. Martin (family doctor) | Jun 7, 2023 | — | Root of a cascade |
| Metoprolol as prescribed Dr. J. Martin (family doctor) | Jul 4, 2023 | Heart failure | ACB +1 |
| Dextromethorphan as prescribed Dr. J. Martin (family doctor) | Sep 21, 2023 | — | Possibly treating a side effect |
| Dimenhydrinate as prescribed Dr. T. Nguyen (walk-in clinic) | Sep 28, 2023 | Dizziness / vertigo | Possibly treating a side effect ACB +3 Beers-listed |
| Rosuvastatin |
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.