Prescribing cascades in community-dwelling adults: A systematic review

Abstract

The misattribution of an adverse drug reaction (ADR) as a symptom or illness can lead to the prescribing of additional medication, referred to as a prescribing cascade. The aim of this systematic review is to identify published prescribing cascades in community-dwelling adults. A systematic review was reported in line with the PRISMA guidelines and pre-registered with PROSPERO. Electronic databases (Medline [Ovid], EMBASE, PsycINFO, CINAHL, Cochrane Library) and grey literature sources were searched. Inclusion criteria: community-dwelling adults; risk-prescription medication; outcomes-initiation of new medicine to "treat" or reduce ADR risk; study type-cohort, cross-sectional, case-control, and case-series studies. Title/abstract screening, full-text screening, data extraction, and methodological quality assessment were conducted independently in duplicate. A narrative synthesis was conducted. A total of 101 studies (reported in 103 publications) were included. Study sample sizes ranged from 126 to 11 593 989 participants and 15 studies examined older adults specifically (≥60 years). Seventy-eight of 101 studies reported a potential prescribing cascade including calcium channel blockers to loop diuretic (n = 5), amiodarone to levothyroxine (n = 5), inhaled corticosteroid to topical antifungal (n = 4), antipsychotic to anti-Parkinson drug (n = 4), and acetylcholinesterase inhibitor to urinary incontinence drugs (n = 4). Identified prescribing cascades occurred within three months to one year following initial medication. Methodological quality varied across included studies. Prescribing cascades occur for a broad range of medications. ADRs should be included in the differential diagnosis for patients presenting with new symptoms, particularly older adults and those who started a new medication in the preceding 12 months.

Keywords: appropriate prescribing; community-dwelling adults; prescribing cascades; systematic review.

FIGURE 1

PRISMA flow diagram of included studies.

FIGURE 2

Prescribing cascades examined in non‐exploratory studies (n = 94) stratified by ATC classification. These alluvial plots represent initial (column 1) and subsequent (column 2) medication pairs examined and the primary quantitative association identified (column 3). The height of the strata in columns 1 and 2 is proportional to the number of instances that the relevant medication has been examined across included studies. The height of the strata in column 3 is proportional to the number of identified quantitative associations that belong to each association type. The width of the linkage between column 1 and column 2 is proportional to the number of instances that the unique medication pair has been examined across included studies. The width of the linkage between column 2 and column 3 is proportional to the number of tested medication pairs that result in a prescribing cascade (positive association), do not result in a prescribing cascade (none), indicate a lower likelihood of a prescribing cascade (negative association), or where no association could be examined due to study reporting (N/A: non‐applicable); (A) ATC1 level; (B) Cardiovascular medications (ATC3 level); (C) Nervous system medications (ATC3 level).

FIGURE 3

Quality appraisal summary of included studies (n = 98): (A) cohort studies; (B) case–control studies; (C) cross‐sectional studies.