Medication review brief · for the pharmacist
Raymond Ortiz
96 · male · Hypertension, Parkinson's disease, Osteoarthritis pain, High cholesterol, Enlarged prostate (BPH)
Prepared by Domino · Oct 1, 2026
Summary
2 likely prescribing cascade links. If Naproxen were reviewed, up to 2 downstream medicines might no longer be needed (7 → 4).
Question 1
Could the raised blood pressure be from the NSAID? NSAIDs raise blood pressure and blunt most antihypertensives.
- Naproxen (Feb 13, 2026) → high blood pressure → Hydrochlorothiazide (May 7, 2026) · likely 0.99 · consensus
If reviewed: Hydrochlorothiazide, Pantoprazole (planned companion); medicines 7 → 4; anticholinergic burden 0 → 0; fall-risk drugs 3 → 2.
Do not stop abruptly
- Pantoprazole: Consider a step-down: stopping suddenly can cause rebound acid symptoms.
Question 2
Could light-headed on standing be from Tamsulosin?
- Tamsulosin (Aug 25, 2025) → light-headed on standing → Midodrine (Sep 18, 2025) · likely 0.59 · graph-inferred
- Midodrine (Sep 18, 2025) → high blood pressure → Hydrochlorothiazide (May 7, 2026) · possible 0.26 · graph-inferred
If reviewed: Midodrine; medicines 7 → 5; anticholinergic burden 0 → 0; fall-risk drugs 3 → 2.
Medicines
| Medicine | Started | Charted for | Domino |
|---|---|---|---|
| Atorvastatin as prescribed Dr. H. Singh (family doctor) | Sep 27, 2024 | High cholesterol | |
| Carbidopa-levodopa as prescribed Dr. S. Kim (neurology) | Dec 8, 2024 | Parkinson's disease | |
| Tamsulosin as prescribed Dr. H. Singh (family doctor) | Aug 25, 2025 | Enlarged prostate (BPH) | Root of a cascade |
| Midodrine as prescribed Dr. R. Ahmed (walk-in clinic) | Sep 18, 2025 | — | Possibly treating a side effect |
| Naproxen as prescribed Dr. H. Singh (family doctor) | Feb 13, 2026 | Osteoarthritis pain | Root of a cascade Beers-listed |
| Hydrochlorothiazide as prescribed Dr. H. Singh (family doctor) |
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.
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.