Medication review brief · for the pharmacist
Grace Lindqvist
96 · female · Hypertension, Insomnia, Heart failure, High cholesterol
Prepared by Domino · Oct 1, 2026
Summary
5 likely prescribing cascade links. If Hydrochlorothiazide were reviewed, up to 2 downstream medicines might no longer be needed (13 → 10). Dangerous combination: potassium stack. Anticholinergic burden is 7.
Question 1
Could the gout be from the diuretic raising uric acid? A different antihypertensive may be an option.
- Hydrochlorothiazide (Dec 23, 2024) → gout or high uric acid → Colchicine (Nov 28, 2025) · likely 0.99 · study
- Colchicine (Nov 28, 2025) → diarrhoea → Loperamide (Dec 7, 2025) · likely 0.90 · label
If reviewed: Colchicine, Loperamide; medicines 13 → 10; anticholinergic burden 7 → 5; fall-risk drugs 5 → 4.
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 (Aug 14, 2024) → leaking urine, urgency → Trospium (Oct 16, 2024) · likely 0.84 · consensus
- Furosemide (Aug 14, 2024) → gout or high uric acid → Colchicine (Nov 28, 2025) · possible 0.34 · study
- Colchicine (Nov 28, 2025) → diarrhoea → Loperamide (Dec 7, 2025) · likely 0.90 · label
If reviewed: Potassium chloride (planned companion), Trospium; medicines 13 → 10; anticholinergic burden 7 → 3; fall-risk drugs 5 → 4.
Question 3
Could the dry cough be from the ACE inhibitor? Cough suppressants do not fix it; switching to an ARB usually does.
- Lisinopril (Oct 11, 2024) → persistent dry cough → Dextromethorphan (Feb 19, 2025) · likely 0.99 · study
If reviewed: Dextromethorphan; medicines 13 → 11; anticholinergic burden 7 → 7; fall-risk drugs 5 → 3.
Question 4
Could muscle aches be from Simvastatin?
- Simvastatin (Jan 21, 2023) → muscle aches → Acetaminophen (Feb 7, 2023) · likely 0.74 · graph-inferred
If reviewed: Acetaminophen; medicines 13 → 11; anticholinergic burden 7 → 7; fall-risk drugs 5 → 5.
Combinations
- Potassium stack (Lisinopril + Spironolactone + 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 |
|---|---|---|---|
| Simvastatin as prescribed Dr. H. Singh (family doctor) | Jan 21, 2023 | — | Root of a cascade |
| Acetaminophen as prescribed Dr. T. Nguyen (walk-in clinic) | Feb 7, 2023 | Myalgia | Possibly treating a side effect |
| Melatonin as prescribed Dr. H. Singh (family doctor) | Jan 28, 2024 | Insomnia | |
| Furosemide as prescribed Dr. H. Singh (family doctor) | Aug 14, 2024 | Heart failure | Root of a cascade ACB +1 Beers-listed |
| Potassium chloride as prescribed Dr. H. Singh (family doctor) | Aug 14, 2024 | Hypokalaemia | |
| Metoprolol as prescribed Dr. H. Singh (family doctor) |
Evidence
- Rochon PA, Gurwitz JH. The prescribing cascade revisited. Lancet. 2017;389(10081):1778-1780.
- 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.
- 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.
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.