Medication review brief · for the pharmacist
Agnes Lindqvist
70 · female · Gout / hyperuricaemia, Hypertension, Type 2 diabetes, Osteoarthritis pain, Neuropathic pain, High cholesterol, Osteoporosis
Prepared by Domino · Oct 1, 2026
Summary
3 likely prescribing cascade links. If Pregabalin were reviewed, up to 1 downstream medicine might no longer be needed (9 → 7). Dangerous combination: triple whammy. Anticholinergic burden is 3.
Question 1
Could the swelling be from gabapentin or pregabalin?
- Pregabalin (Feb 8, 2025) → ankle and leg swelling → Furosemide (May 9, 2025) · likely 0.99 · study
If reviewed: Furosemide; medicines 9 → 7; anticholinergic burden 3 → 2; fall-risk drugs 3 → 1.
Do not stop abruptly
- Pregabalin: Taper if changed: stopping suddenly can cause withdrawal and, rarely, seizures.
Question 2
Could the diarrhoea be colchicine toxicity? Diarrhoea is an early sign; the dose may need review.
- Colchicine (Jan 16, 2023) → diarrhoea → Loperamide (Jan 20, 2023) · likely 0.90 · label
If reviewed: Loperamide; medicines 9 → 7; anticholinergic burden 3 → 1; fall-risk drugs 3 → 3.
Question 3
Could the raised blood pressure be from the NSAID? NSAIDs raise blood pressure and blunt most antihypertensives.
- Naproxen (May 20, 2025) → high blood pressure → Ramipril (Oct 21, 2025) · likely 0.63 · consensus
If reviewed: Ramipril; medicines 9 → 7; anticholinergic burden 3 → 3; fall-risk drugs 3 → 3.
Combinations
- Triple whammy (Ramipril + Furosemide + Naproxen): An ACE inhibitor or ARB, a diuretic and an NSAID together sharply raise the risk of acute kidney injury.
Medicines
| Medicine | Started | Charted for | Domino |
|---|---|---|---|
| Rosuvastatin as prescribed Dr. A. Patel (family doctor) | Nov 27, 2022 | — | |
| Colchicine as prescribed Dr. A. Patel (family doctor) | Jan 16, 2023 | — | Root of a cascade ACB +1 |
| Calcium + vitamin D as prescribed Dr. A. Patel (family doctor) | Jan 16, 2023 | — | |
| Loperamide as prescribed Dr. A. Patel (family doctor) | Jan 20, 2023 | — | Possibly treating a side effect ACB +1 |
| Pregabalin as prescribed Dr. A. Patel (family doctor) | Feb 8, 2025 | Neuropathic pain | Root of a cascade |
| Furosemide as prescribed Dr. T. Nguyen (walk-in clinic) | May 9, 2025 |
Evidence
- Read SH, et al. Evidence of a gabapentinoid and diuretic prescribing cascade among older adults with lower back pain. J Am Geriatr Soc. 2021;69(10):2842-2850.
- Product monographs and prescribing information (adverse reaction sections), curated by hand for this prototype. Frequencies are approximate bands, not exact rates.
- 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.
- Lapi F, et al. Concurrent use of diuretics, angiotensin converting enzyme inhibitors, and angiotensin receptor blockers with non-steroidal anti-inflammatory drugs and risk of acute kidney injury: nested case-control study. BMJ. 2013;346:e8525.
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.