Medication review brief · for the pharmacist
Evelyn Wong
70 · female · Hypertension, Osteoarthritis pain, Neuropathic pain, Coronary artery disease, High cholesterol
Prepared by Domino · Oct 1, 2026
Summary
3 likely prescribing cascade links. If Amitriptyline were reviewed, up to 4 downstream medicines might no longer be needed (8 → 3). Dangerous combination: bleeding stack. Anticholinergic burden is 5.
Question 1
Could light-headed on standing be from Amitriptyline?
- Amitriptyline (Jan 24, 2024) → light-headed on standing → Midodrine (Mar 6, 2024) · likely 0.74 · graph-inferred
- Midodrine (Mar 6, 2024) → high blood pressure → Chlorthalidone (Jun 7, 2025) · possible 0.26 · graph-inferred
- Chlorthalidone (Jun 7, 2025) → gout or high uric acid → Colchicine (Mar 27, 2026) · likely 0.99 · study
If reviewed: Midodrine, Chlorthalidone, Colchicine, Loperamide; medicines 8 → 3; anticholinergic burden 5 → 0; fall-risk drugs 2 → 0.
Do not stop abruptly
- Amitriptyline: Taper if changed: stopping suddenly can cause discontinuation symptoms.
Question 2
Could the gout be from the diuretic raising uric acid? A different antihypertensive may be an option.
- Chlorthalidone (Jun 7, 2025) → gout or high uric acid → Colchicine (Mar 27, 2026) · likely 0.99 · study
- Colchicine (Mar 27, 2026) → diarrhoea → Loperamide (Mar 30, 2026) · likely 0.90 · label
If reviewed: Colchicine, Loperamide; medicines 8 → 5; anticholinergic burden 5 → 3; fall-risk drugs 2 → 1.
Combinations
- Bleeding stack (Clopidogrel + Ibuprofen): An anticoagulant or antiplatelet combined with an NSAID or SSRI/SNRI raises bleeding risk.
Medicines
| Medicine | Started | Charted for | Domino |
|---|---|---|---|
| Amitriptyline as prescribed Dr. H. Singh (family doctor) | Jan 24, 2024 | Neuropathic pain | Root of a cascade ACB +3 Beers-listed |
| Midodrine as prescribed Dr. R. Ahmed (walk-in clinic) | Mar 6, 2024 | Orthostatic hypotension | Possibly treating a side effect |
| Clopidogrel as prescribed Dr. H. Singh (family doctor) | Jan 11, 2025 | Coronary artery disease | |
| Chlorthalidone as prescribed Dr. H. Singh (family doctor) | Jun 7, 2025 | Hypertension | Root of a cascade Beers-listed |
| Ibuprofen as prescribed Dr. C. Laurent (rheumatology) | Jun 12, 2025 | Osteoarthritis pain | Beers-listed |
| Atorvastatin |
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.
- 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.