Medication review brief · for the pharmacist
Lucille Andersen
88 · female · Hypertension, Hypothyroidism, Osteoarthritis pain, High cholesterol
Prepared by Domino · Oct 1, 2026
Summary
3 likely prescribing cascade links. If Ramipril were reviewed, up to 1 downstream medicine might no longer be needed (8 → 6). Dangerous combination: triple whammy.
Question 1
Could the dry cough be from the ACE inhibitor? Cough suppressants do not fix it; switching to an ARB usually does.
- Ramipril (Nov 10, 2024) → persistent dry cough → Benzonatate (Jan 22, 2025) · likely 0.99 · study
If reviewed: Benzonatate; medicines 8 → 6; anticholinergic burden 0 → 0; fall-risk drugs 2 → 1.
Question 2
Could gout or high uric acid be from Hydrochlorothiazide?
- Hydrochlorothiazide (Jul 25, 2023) → gout or high uric acid → Naproxen (Apr 6, 2024) · likely 0.59 · graph-inferred
- Naproxen (Apr 6, 2024) → stomach irritation or bleeding risk → Pantoprazole (Oct 8, 2024) · intentional 0.53 · label
If reviewed: no downstream change; medicines 8 → 7; anticholinergic burden 0 → 0; fall-risk drugs 2 → 1.
Question 3
Could muscle aches be from Simvastatin?
- Simvastatin (Dec 21, 2023) → muscle aches → Naproxen (Apr 6, 2024) · likely 0.59 · graph-inferred
- Naproxen (Apr 6, 2024) → stomach irritation or bleeding risk → Pantoprazole (Oct 8, 2024) · intentional 0.53 · label
If reviewed: no downstream change; medicines 8 → 7; anticholinergic burden 0 → 0; fall-risk drugs 2 → 2.
Combinations
- Triple whammy (Ramipril + Hydrochlorothiazide + Ibuprofen + 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 |
|---|---|---|---|
| Hydrochlorothiazide as prescribed Dr. H. Singh (family doctor) | Jul 25, 2023 | Hypertension | Root of a cascade Beers-listed |
| Simvastatin as prescribed Dr. H. Singh (family doctor) | Dec 21, 2023 | High cholesterol | Root of a cascade |
| Naproxen as prescribed Dr. H. Singh (family doctor) | Apr 6, 2024 | — | Possibly treating a side effect Beers-listed |
| Levothyroxine as prescribed Dr. H. Singh (family doctor) | May 24, 2024 | Hypothyroidism | |
| Ibuprofen as prescribed Dr. H. Singh (family doctor) | Oct 5, 2024 | — | Beers-listed |
| Pantoprazole as prescribed Dr. H. Singh (family doctor) |
Evidence
- 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.
- 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.
- 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.