Medication review brief · for the pharmacist
Carmen Kowalski
94 · female · Hypertension, Reflux / indigestion, Heart failure, High cholesterol
Prepared by Domino · Oct 1, 2026
Summary
3 likely prescribing cascade links. If Metoprolol were reviewed, up to 3 downstream medicines might no longer be needed (12 → 8). Dangerous combination: potassium stack. Anticholinergic burden is 9.
Question 1
Could dizziness or spinning be from Metoprolol?
- Metoprolol (Feb 25, 2025) → dizziness or spinning → Meclizine (Mar 17, 2025) · possible 0.42 · graph-inferred
- Meclizine (Mar 17, 2025) → confusion or memory problems → Donepezil (May 5, 2025) · likely 0.74 · graph-inferred
- Donepezil (May 5, 2025) → nausea → Ondansetron (May 15, 2025) · likely 0.74 · graph-inferred
If reviewed: Meclizine, Donepezil, Ondansetron; medicines 12 → 8; anticholinergic burden 9 → 5; fall-risk drugs 7 → 3.
Do not stop abruptly
- Metoprolol: Taper if changed: stopping suddenly can cause a rebound fast heart rate or angina.
Question 2
Could the urgency or leaking be from the diuretic? Changing the timing of the dose can help before adding a bladder medication.
- Furosemide (Feb 22, 2025) → leaking urine, urgency → Trospium (Feb 27, 2025) · likely 0.99 · consensus
If reviewed: Trospium, Potassium chloride (planned companion); medicines 12 → 9; anticholinergic burden 9 → 5; fall-risk drugs 7 → 6.
Question 3
Could confusion or memory problems be from Meclizine?
- Meclizine (Mar 17, 2025) → confusion or memory problems → Donepezil (May 5, 2025) · likely 0.74 · graph-inferred
- Donepezil (May 5, 2025) → nausea → Ondansetron (May 15, 2025) · likely 0.74 · graph-inferred
If reviewed: Donepezil, Ondansetron; medicines 12 → 9; anticholinergic burden 9 → 6; fall-risk drugs 7 → 4.
Question 4
Could diarrhoea be from Pantoprazole?
- Pantoprazole (Jul 22, 2023) → diarrhoea → Loperamide (Oct 4, 2023) · possible 0.34 · graph-inferred
If reviewed: Loperamide; medicines 12 → 10; anticholinergic burden 9 → 8; fall-risk drugs 7 → 7.
Do not stop abruptly
- Pantoprazole: Consider a step-down: stopping suddenly can cause rebound acid symptoms.
Combinations
- Potassium stack (Lisinopril + Potassium chloride): ACE inhibitors and ARBs retain potassium; adding a potassium-sparing diuretic or supplement can push it too high.
Medicines
| Medicine | Started | Charted for | Domino |
|---|---|---|---|
| Atorvastatin as prescribed Dr. H. Singh (family doctor) | Sep 21, 2022 | High cholesterol | |
| Pantoprazole as prescribed Dr. H. Singh (family doctor) | Jul 22, 2023 | Reflux / indigestion | Root of a cascade Beers-listed |
| Loperamide as prescribed Dr. H. Singh (family doctor) | Oct 4, 2023 | — | Possibly treating a side effect ACB +1 |
| Furosemide as prescribed Dr. H. Singh (family doctor) | Feb 22, 2025 | Heart failure | Root of a cascade ACB +1 Beers-listed |
| Metoprolol as prescribed Dr. H. Singh (family doctor) | Feb 25, 2025 | Heart failure | Root of a cascade ACB +1 |
| Trospium |
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.
- Product monographs and prescribing information (adverse reaction sections), curated by hand for this prototype. Frequencies are approximate bands, not exact rates.
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.