Medication review brief · for the pharmacist
Harold Sato
95 · male · Type 2 diabetes, Osteoarthritis pain, Atrial fibrillation
Prepared by Domino · Oct 1, 2026
Summary
3 likely prescribing cascade links. If Diclofenac were reviewed, up to 2 downstream medicines might no longer be needed (11 → 8). Dangerous combination: bleeding stack. Anticholinergic burden is 5.
Question 1
Could the raised blood pressure be from the NSAID? NSAIDs raise blood pressure and blunt most antihypertensives.
- Diclofenac (Aug 21, 2025) → high blood pressure → Ramipril (Oct 15, 2025) · likely 0.84 · consensus
- Ramipril (Oct 15, 2025) → persistent dry cough → Benzonatate (Nov 14, 2025) · likely 0.99 · study
If reviewed: Ramipril, Benzonatate; medicines 11 → 8; anticholinergic burden 5 → 5; fall-risk drugs 4 → 3.
Question 2
Could nausea be from Metformin?
- Metformin (Dec 29, 2023) → nausea → Dimenhydrinate (Jan 8, 2024) · likely 0.74 · graph-inferred
If reviewed: Dimenhydrinate, Vitamin B12 (planned companion); medicines 11 → 8; anticholinergic burden 5 → 2; fall-risk drugs 4 → 3.
Combinations
- Bleeding stack (Apixaban + Diclofenac): An anticoagulant or antiplatelet combined with an NSAID or SSRI/SNRI raises bleeding risk.
Medicines
| Medicine | Started | Charted for | Domino |
|---|---|---|---|
| Metformin as prescribed Dr. J. Martin (family doctor) | Dec 29, 2023 | Type 2 diabetes | Root of a cascade |
| Dimenhydrinate as prescribed Dr. R. Ahmed (walk-in clinic) | Jan 8, 2024 | Nausea | Possibly treating a side effect ACB +3 Beers-listed |
| Apixaban as prescribed Dr. J. Martin (family doctor) | May 13, 2025 | Atrial fibrillation | |
| Pantoprazole as prescribed Dr. J. Martin (family doctor) | May 14, 2025 | GI bleeding risk | Beers-listed |
| Digoxin as prescribed Dr. J. Martin (family doctor) | May 17, 2025 | Atrial fibrillation | ACB +1 Beers-listed |
| Metoprolol |
Evidence
- 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.
- 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.
- 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.