In most clinical situations, I’m a stickler for trying to prevent the prescribing cascade. I lay out hundreds of polypharmacy case examples including the prescribing cascade in my highly rated book Perils of Polypharmacy. The prescribing cascade is simply defined as using medications to treat the side effects of other medications.  There are literally hundreds to thousands of these examples.  Here are three notorious examples that I see on a routine basis in practice. In reality, there are definitely some situations where it is appropriate to add another medication to help minimize the adverse effects or risks of another medication. Below, I will lay out my top 3 proper causes of the prescribing cascade.

Furosemide is most frequently used in patients with heart failure. Its use is justified in this situation. Due to its mechanism of action, potassium goes with the fluid that is running out of the body through the urine. It can cause profound hypokalemia and potassium supplementation is often necessary when using this medication (or other loops/thiazide diuretics).

Methotrexate is used for many autoimmune disorders. I most often see it used as a mainstay in rheumatoid arthritis. This medication can impact folic acid homeostasis and contribute to deficiency and adverse effects. Because of this fact, adding folic acid supplementation is recommended in patients taking methotrexate.

There are numerous chemotherapy regimens that will be necessary to help treat a patient’s cancer. Chemotherapy-induced nausea and vomiting will likely necessitate drug therapy. In 2021 we did an updated review of chemotherapy-induced nausea and vomiting and some of the agents you might see utilized for management.

What other proper causes of the prescribing cascade have you seen in your practice? Feel free to comment below!

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