Medication review brief · for the pharmacist
Aiko Bouchard
90 · female · Hypertension, Reflux / indigestion, Osteoarthritis pain
Prepared by Domino · Oct 1, 2026
Summary
1 likely prescribing cascade link. If Diclofenac were reviewed, up to 2 downstream medicines might no longer be needed (6 → 3).
Question 1
Could the raised blood pressure be from the NSAID? NSAIDs raise blood pressure and blunt most antihypertensives.
- Diclofenac (Jun 20, 2023) → high blood pressure → Lisinopril (Oct 9, 2024) · possible 0.37 · consensus
- Lisinopril (Oct 9, 2024) → persistent dry cough → Dextromethorphan (Mar 22, 2025) · likely 0.99 · study
If reviewed: Lisinopril, Dextromethorphan; medicines 6 → 3; anticholinergic burden 1 → 1; fall-risk drugs 2 → 0.
Question 2
Could the dry cough be from the ACE inhibitor? Cough suppressants do not fix it; switching to an ARB usually does.
- Lisinopril (Oct 9, 2024) → persistent dry cough → Dextromethorphan (Mar 22, 2025) · likely 0.99 · study
If reviewed: Dextromethorphan; medicines 6 → 4; anticholinergic burden 1 → 1; fall-risk drugs 2 → 0.
Question 3
Could diarrhoea be from Pantoprazole?
- Pantoprazole (Jun 19, 2024) → diarrhoea → Loperamide (Jul 29, 2024) · possible 0.42 · graph-inferred
If reviewed: Loperamide; medicines 6 → 4; anticholinergic burden 1 → 0; fall-risk drugs 2 → 2.
Do not stop abruptly
- Pantoprazole: Consider a step-down: stopping suddenly can cause rebound acid symptoms.
Medicines
| Medicine | Started | Charted for | Domino |
|---|---|---|---|
| Diclofenac as prescribed Dr. A. Patel (family doctor) | Jun 20, 2023 | — | Root of a cascade Beers-listed |
| Omeprazole as prescribed Dr. A. Patel (family doctor) | Jun 23, 2023 | GI bleeding risk | Beers-listed |
| Pantoprazole as prescribed Dr. A. Patel (family doctor) | Jun 19, 2024 | Reflux / indigestion | Root of a cascade Beers-listed |
| Loperamide as prescribed Dr. T. Nguyen (walk-in clinic) | Jul 29, 2024 | Diarrhoea | Possibly treating a side effect ACB +1 |
| Lisinopril as prescribed Dr. A. Patel (family doctor) | Oct 9, 2024 | Hypertension | Root of a cascade |
| Dextromethorphan |
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.
- 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.