Medication review brief · for the pharmacist
Ivan Bouchard
75 · male · Urinary incontinence, Hypertension, Insomnia, Osteoarthritis pain, Neuropathic pain, Atrial fibrillation, High cholesterol
Prepared by Domino · Oct 1, 2026
Summary
3 likely prescribing cascade links. If Duloxetine were reviewed, up to 2 downstream medicines might no longer be needed (13 → 10). Dangerous combination: bleeding stack. Anticholinergic burden is 8.
Question 1
Could trouble sleeping be from Duloxetine?
- Duloxetine (Sep 28, 2022) → trouble sleeping → Diphenhydramine (Oct 29, 2022) · likely 0.59 · graph-inferred
- Diphenhydramine (Oct 29, 2022) → confusion or memory problems → Galantamine (Aug 10, 2025) · possible 0.26 · graph-inferred
- Duloxetine (Sep 28, 2022) → trouble sleeping → Zolpidem (Mar 17, 2023) · possible 0.37 · consensus
If reviewed: Diphenhydramine, Zolpidem; medicines 13 → 10; anticholinergic burden 8 → 5; fall-risk drugs 8 → 5.
Do not stop abruptly
- Duloxetine: Taper if changed: stopping suddenly can cause discontinuation symptoms.
- Zolpidem: Taper if changed: stopping suddenly can cause rebound insomnia.
Question 2
Could the confusion be from the strongly anticholinergic bladder medication? Treating it with a dementia drug can create a loop.
- Oxybutynin (Jul 8, 2025) → confusion or memory problems → Galantamine (Aug 10, 2025) · likely 0.99 · consensus
If reviewed: Galantamine; medicines 13 → 11; anticholinergic burden 8 → 5; fall-risk drugs 8 → 6.
Question 3
Could the raised blood pressure be from the NSAID? NSAIDs raise blood pressure and blunt most antihypertensives.
- Celecoxib (Feb 17, 2024) → high blood pressure → Lisinopril (Jul 7, 2024) · likely 0.63 · consensus
If reviewed: Lisinopril; medicines 13 → 11; anticholinergic burden 8 → 8; fall-risk drugs 8 → 7.
Question 4
Could the constipation be from verapamil?
- Diltiazem (Jun 7, 2025) → constipation → Polyethylene glycol (Jun 25, 2025) · possible 0.40 · label
If reviewed: Polyethylene glycol; medicines 13 → 11; anticholinergic burden 8 → 8; fall-risk drugs 8 → 7.
Combinations
- Bleeding stack (Warfarin + Celecoxib + Duloxetine): An anticoagulant or antiplatelet combined with an NSAID or SSRI/SNRI raises bleeding risk.
Medicines
| Medicine | Started | Charted for | Domino |
|---|---|---|---|
| Duloxetine as prescribed Dr. A. Patel (family doctor) | Sep 28, 2022 | Neuropathic pain | Root of a cascade Beers-listed |
| Diphenhydramine as prescribed Dr. T. Nguyen (walk-in clinic) | Oct 29, 2022 | — | Possibly treating a side effect ACB +3 Beers-listed |
| Zolpidem as prescribed Dr. A. Patel (family doctor) | Mar 17, 2023 | Insomnia | Possibly treating a side effect Beers-listed |
| Celecoxib as prescribed Dr. A. Patel (family doctor) | Feb 17, 2024 | Osteoarthritis pain | Root of a cascade Beers-listed |
| Lisinopril as prescribed Dr. A. Patel (family doctor) | Jul 7, 2024 | Hypertension | Possibly treating a side effect |
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.
- Gurwitz JH, et al. Initiation of antihypertensive treatment during nonsteroidal anti-inflammatory drug therapy. JAMA. 1994;272(10):781-786.
- Product monographs and prescribing information (adverse reaction sections), curated by hand for this prototype. Frequencies are approximate bands, not exact rates.
- 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.