Prescribing cascade- What role can you play as a patient?

On an average, elderly Nepali population at the age of 60 consumes around 3-5 medications on a daily basis. As you grow old and acquire diseases the number of medicines you consume starts increasing.  With the recent rise in non-communicable diseases (NCDs) in Nepal the number of medicines consumed is only increasing. For some patients the number of medicines consumed daily is even above 10. While many medicines being consumed, they are linked with one kind or problem or the other, they all might look relevant.  However, the question remains, are they all really necessary? Can the old and the frail body cope with the side effect of all the medicines? We simply cannot turn ignorant and believe the medicine without side effects, especially when we know that even salt and sugar when over consumed results in different diseases. Almost every drug has side effects and they get magnified when the body starts getting old and frail.


Amidst all this, you encounter a new symptom or a problem.  Here in Nepal we have a tendency of visiting the specialists of our choice. Since we make out of pocket expenses for seeing a doctor, the decision to see a particular doctor is purely ours. During the visit, the specialist after thorough investigation adds another one or two medicine to counteract the new symptoms. There concept of family physician or general practitioner who oversees the overall pharmacotherapy of the drugs prescribed to the patient is missing in Nepal. So, prescription cascade may be more prevalent in our country, especially when prescribers are only aware of the disease they are examining. Deprescribing of medicines which has emerged as a new tool to combat polypharmacy seems far too distant a thing here, since each specialist is responsible only for the medicine he/she has prescribed.


The Lancet in 1995 first published the concept of prescribing cascade. Is the new medicine part of the prescribing cascade? It could very well be. So what is prescribing cascade? The term prescribing cascade refers to labeling the adverse reactions of currently prescribed drug as signs and symptoms of a new condition and thereby prescribing a new drug for treating it. Examples of prescription cascade include -Baclofen prescribed for muscle pain caused by statins, Cough suppressants prescribed for cough precipitated by ACE inhibitor, Colchicine prescribed for hyperuricemia caused by Thiazide diuretics. Simply adding another drug to the patient therefore may result in unnecessary drug interactions and adverse drug reactions.


To prevent this, physician should consider each new sign and symptom as a potential adverse effect of a drug being taken, more so if dose of a drug was recently changed or an altogether new drug was recently prescribed for the patient. Drugs should be added only when they are deemed absolutely necessary. Also as a patient, it is your responsibility to give a clear medication history of all different kinds of medicines you are consuming including the herbal and various other preparations. A detailed medication history along with proper medication reconciliation can only prevent prescription cascade. Pharmacists can play a role when it comes to medication reconciliation and taking appropriate medication history.


यो पनि पढ्नुहोस:

सेल्फ मेडीकेशन- चिकित्सकको सल्लाह बिना औषधिको प्रयोग कति ठिक, कति बेठिक?


It is therefore essential to understand that your new signs and symptoms, may be the result of adverse effects of medicines you are currently consuming. It is your duty to give most detailed list of medicines you are consuming, so that the physician does not end up giving you another drug for treating a symptom which could simply have been tackled by reducing the dose of the drug that you are already taking, or deprescribing an old drug or substituting an old drug itself. You may get better or rather suffer based on how big a role you play. You certainly have a role in your therapy, so play your part.





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