Medication review brief · for the pharmacist
Olga Andersen
80 · female · Urinary incontinence, Dry cough, Hypertension, Type 2 diabetes, Coronary artery disease, High cholesterol, Anxiety, Osteoporosis
Prepared by Domino · Oct 1, 2026
Summary
5 likely prescribing cascade links. If Simvastatin were reviewed, up to 3 downstream medicines might no longer be needed (12 → 8). Dangerous combination: bleeding stack.
Question 1
Could muscle aches be from Simvastatin?
- Simvastatin (Aug 2, 2025) → muscle aches → Ibuprofen (Sep 16, 2025) · likely 0.74 · graph-inferred
- Ibuprofen (Sep 16, 2025) → high blood pressure → Chlorthalidone (Nov 15, 2025) · likely 0.99 · consensus
- Ibuprofen (Sep 16, 2025) → ankle and leg swelling → Torsemide (Nov 8, 2025) · likely 0.59 · graph-inferred
If reviewed: Ibuprofen, Torsemide, Chlorthalidone; medicines 12 → 8; anticholinergic burden 2 → 2; fall-risk drugs 4 → 2.
Question 2
Could the indigestion be from the bisphosphonate (and how it is taken)?
- Alendronate (Dec 10, 2023) → heartburn or indigestion → Omeprazole (Jan 1, 2024) · likely 0.88 · label
If reviewed: Omeprazole; medicines 12 → 10; anticholinergic burden 2 → 2; fall-risk drugs 4 → 4.
Do not stop abruptly
- Omeprazole: Consider a step-down: stopping suddenly can cause rebound acid symptoms.
Question 3
Could the diarrhoea be from metformin? An extended-release form or dose change may help.
- Metformin (Nov 7, 2023) → diarrhoea → Loperamide (Nov 25, 2023) · likely 0.88 · label
If reviewed: Loperamide; medicines 12 → 10; anticholinergic burden 2 → 1; fall-risk drugs 4 → 4.
Combinations
- Bleeding stack (Aspirin (low dose) + Ibuprofen): An anticoagulant or antiplatelet combined with an NSAID or SSRI/SNRI raises bleeding risk.
Medicines
| Medicine | Started | Charted for | Domino |
|---|---|---|---|
| Benzonatate as prescribed Dr. J. Martin (family doctor) | Sep 22, 2022 | Dry cough | |
| Metformin as prescribed Dr. J. Martin (family doctor) | Nov 7, 2023 | Type 2 diabetes | Root of a cascade |
| Loperamide as prescribed Dr. J. Martin (family doctor) | Nov 25, 2023 | Diarrhoea | Possibly treating a side effect ACB +1 |
| Alendronate as prescribed Dr. J. Martin (family doctor) | Dec 10, 2023 | Osteoporosis | Root of a cascade |
| Omeprazole as prescribed Dr. T. Nguyen (walk-in clinic) | Jan 1, 2024 | Reflux / indigestion | Possibly treating a side effect Beers-listed |
| Mirabegron as prescribed Dr. M. Fischer (urology) |
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.
- 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.