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Quantifying problematic prescribing cascades

  • At: PPR 2022 (2022)
  • Type: Poster
  • Poster code: PT-07
  • By: MOHAMMAD, Atiya (OLVG & UMCG)
  • Co-author(s): Atiya Mohammad, Promovendus, Department of Clinical Pharmacy, OLVG hospital, the Netherlands
    Jacqueline Hugtenburg, Department of Clinical Pharmacy and Pharmacology, University Medical Centre Groningen, the Netherlands
    Joost Vanhommerig, Department of Clinical Pharmacology and Pharmacy, Amsterdam UMC, the Netherlands
    Petra Denig, Department of Research and Epidemiology, OLVG hospital, the Netherlands
    Patricia van den Bemt
    Fatma Karapinar-Carkit

  • Abstract:

    A prescribing cascade (PC) occurs when a first medication (index) causes an adverse drug reaction (ADR) and is recognized as a medical condition, which is subsequently treated with another medication (marker). A PC becomes problematic when the benefits of this combination of medications do not outweigh the risks on the patient’s health. Problematic PCs can result in polypharmacy and unnecessary treatment, which effects the quality of life of patients negatively. Especially elderly, for who an ADR can be misinterpreted as age progression, can experience the results of problematic PCs. To improve the quality of life and prevent unnecessary treatment, healthcare providers should be more aware of problematic PCs.

    To identify and quantify the occurrence of problematic PCs.

    A mixed-methods study was performed including a literature review and an assessment by 16 experts (pharmacists and physicians in primary and secondary care) to assess whether PCs were problematic. Next, a Prescription Sequence Symmetry Analysis (PSSA) was performed to quantify these problematic PCs. Dispensing data were obtained from Ncontrol from 2015 until 2020. The PSSA analyses the adjusted sequence ratio (aSR) of patients receiving the marker medication after the index medication versus patients receiving the marker medication before the index medication. An aSR ≥1 indicates an increased probability that a PC might be occurring.

    Experts assessed 90 PCs from literature of which 68 were regarded problematic. These PCs mostly concerned antidepressants, antipsychotics and lipid modifying agents as index medication. Depression, erectile dysfunction and urinary incontinence were the most frequently occurring ADRs. A significant aSR was found for 44 (65%) PCs for more than 93,000 out of 423,000 incident users, with a mean age of 68 years. Of the 44 PCs, the aSR was between 1-1.5 for 20 PCs and >1.5 for 24 PCs. The highest aSR was 5.97 [95% CI 5.34-6.61] for lithium (index) inducing parkinsonism, followed by dopaminergic medication (marker), based on 84 incident users. ACE-inhibitors (index) inducing urinary infection, followed by antibiotics, was based on the most (33,563) incident users.

    Out of 68 problematic PCs, 44 had a significant association. This suggests that more awareness is needed amongst healthcare providers for the recognition of problematic PCs. By raising awareness amongst healthcare providers, steps can be taken to reverse or prevent problematic PCs. More should be done to prevent healthcare providers in treating ADRs as medical conditions and thus prevent the unnecessary accumulation of medications and polypharmacy.

Last update 4 October 2019

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