10 Common Examples of The Prescribing Cascade

Real Life Pharmacology - Pharmacology Education for Health Care Professionals

Eric Christianson, PharmD; Pharmacology Expert and Clinical Pharmacist

Education, Health & Fitness, Medicine

5 • 716 Ratings

🗓️ 30 October 2025

⏱️ 14 minutes

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Summary

One of the most important yet often overlooked concepts in pharmacology is the prescribing cascade. It occurs when a new medication is prescribed to treat a side effect caused by another drug, without realizing that the first medication is the root cause. This leads to a chain reaction of additional prescriptions, unnecessary complexity, and often, new adverse effects.

Prescribing cascades can sneak up on even the most careful clinicians. A patient develops a new symptom after starting a medication—perhaps swelling, dizziness, or urinary changes—and instead of identifying the drug as the culprit, another medication is added to manage the symptom. Over time, this cycle contributes to polypharmacy, drug interactions, and reduced quality of life.

These cascades are particularly concerning in older adults, where multiple comorbidities and high medication counts make it easy for adverse effects to be misinterpreted as new conditions. But they can occur at any age and in any clinical setting.

The key to preventing prescribing cascades is maintaining a critical mindset:

Assume any new symptoms could be an adverse effect.

Review the timing of medication changes relative to the onset of symptoms.

Consider deprescribing or adjusting doses before adding new drugs.

Encourage thorough medication reconciliation and communication across providers.

Recognizing and interrupting the prescribing cascade is one of the simplest and most impactful ways we can improve medication safety. In this podcast, I share some of my favorite real-world examples that illustrate just how easily these cascades can happen.

Transcript

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0:00.0	Hey, all, welcome back to the real-life pharmacology podcast.
0:03.4	I'm your host pharmacist, Eric Christensen.
0:05.2	Thank you so much for listening today.
0:07.5	I got a little bit of a special episode for you today.
0:11.1	I'm going to run you through 10 examples of the prescribing cascade.
0:16.5	And many of these examples, and obviously much, much more you'll find in my book, Perils of Polypharmacy.
0:25.3	You can find that on Amazon as well as on Audible if you like to listen to books as well.
0:31.9	So these examples, things that I've definitely seen in practice on a relatively frequent basis.
0:39.9	So good reminders for you.
0:42.9	To really pay attention to new medications, they can often be compensating for adverse effects
0:50.8	from medications that a patient's already on.
0:54.6	All right.
1:01.7	Without further ado, let's get into the prescribing Cascade example. So first one is a commonly used anti-hypertensive medication in amylopine.
1:09.0	And one of the most highly testable and one of the most well-known
1:13.1	adverse effects in practice is peripheral edema. So that swelling can result from amylopine.
1:20.7	And I've often seen clinicians try to add a loop diuretic, not recognizing that it's from the amylotapine, the calcium
1:29.3	channel blocker, and try to manage that edema with the use of ferrosamine.
1:36.4	So in this situation, obviously, to resolve this, we'd look at either reducing the amelotapine dose or switching to an alternative anti-hypertensive medication.
1:50.6	Number two, we'll go with cinemas, so Levitopoe, Carbidopa.
1:56.4	One of the potential adverse effects with medications that stimulate dopamine or they are replacing dopamine is the risk for hallucinations.
2:09.5	So with the use of cinnamon causing hallucinations, you could see an antipsychotic placed on the medication regimen for that
2:20.2	patient to try to help treat or manage those hallucinations. Another great example of the
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