t 75, Mrs. Reynolds started noticing some chang- es—at bedtime, she was having trouble falling asleep. For several months, she felt like she was spending hours tossing and turning in bed, eyes wide awake. Otherwise, her routine was the same: she visited with friends, went for her daily walk, and even made sure to keep her coffee consumption low, especially in the after- noons. Her medications hadn't changed either. She’d been taking her regular medications for depression, high choles- terol and high blood pressure for several years. Hoping it would help her get a good night’s sleep, Mrs. Reynolds bought a small box of sleeping pills (Sleep-Eze®


)


off the shelf of her pharmacy. She took one that same eve- ning, without success. Although it didn’t help, she thought it would be worth trying them a little longer. Perhaps they would start working eventually. Over the next few days, however, Mrs. Reynolds noticed her mouth started feel- ing dry, which forced her to keep a glass of water on the bedside table. And in the mornings, she woke up feeling groggy and was more constipated than usual. Meanwhile, her sleep hadn’t really improved. Feeling frustrated, Mrs. Reynolds decided to talk to her pharmacist Nadia about these new symptoms as well as the trouble she was having sleeping, which wasn’t getting any better. After carefully listening to Mrs. Reynolds’s story, Na-


dia told her the cause of her dry mouth, constipation and daytime grogginess was most likely the new sleeping pill (Sleep-Eze®) she’d purchased at the pharmacy. Then, after taking a close look at her file, Nadia told Mrs. Reynolds it was also possible one of her antidepressant medications, bupropion, was causing her insomnia. “Treating the side effect of one medication with another medication creates what we call a prescribing cascade. In your case, your insomnia symptoms may be caused by your bupropion medication. So, when you treat it with a new medication, the sleeping pill (Sleep-Eze®


), this creates


a prescribing cascade.” Mrs. Reynolds was puzzled. She had been taking the


bupropion for over two years at the same dose. Was it pos- sible new side effects could appear after so much time had passed? The pharmacist's response was clear: "Yes. You can get a new medication side effect at any point in time." Examples of prescribing cascades


Does this story sound familiar? Prescribing cascades are common. See above chart for examples.


Identifying side effects to prevent prescribing cascades The more medications we take, the more our risk of ex-


periencing harmful effects increases. This is what happened to Mrs. Reynolds: when she took a sleeping pill to treat her insomnia, she ended up with new side effects, including dry mouth, constipation and a foggy brain. Identifying medication side effects is essential to being able to treat them effectively and to avoid prescribing cas- cades. When you have a new symptom, always ask, “Could this be a side effect from one of my medications?”. When the answer to that question is “yes,” you should consid-


Are you the victim of a prescribing cascade? A


Camille Gagnon First medication


Medication A Medication B Medication C


Medication D Medication E


Possible side effect caused by first medication


Constipation


Leg or foot swelling Nausea


Cough Stomach ache or reflux A chart explaining how a prescription cascade could happen.


care professional identify a prescribing cascade, it would be appropriate for you to ask whether deprescribing is an option. Together with your healthcare professional, you can discuss whether stopping or reducing the dose of a medication, and putting in place a tapering plan, would be a good option for you. • Are there alternatives? Could other, safer approaches (medication or non-medication) help treat this health con- dition?


Back to Mrs. Reynolds Following their discussion, Mrs. Reynolds's pharmacist Mrs. Reynolds


er deprescribing with your doctor, nurse or pharmacist. Deprescribing means reducing or stopping medications that may not be beneficial or that may be causing harm, in a planned and supervised manner. The goal of deprescrib- ing is to maintain or improve quality of life. How can you help prevent prescribing cascades? By making sure you have good communication with your healthcare professional(s), you can help prevent pre- scribing cascades: • Ask questions. Have you noticed a new symptom? Ask a healthcare professional: “Could this be a side effect from one of my medications?” • The more medications you take, the greater your risk of side effects, and the greater your risk of creating a prescribing cascade. Do not assume your doctor, phar- macist or nurse is aware of everything. If you have a doubt about a medication, ask about it! • Don’t forget your non-prescription medications.


Non-prescription medications (also known as over-the- counter medications) and natural health products can also cause side effects and prescribing cascades. Be sure to in- clude them on your list of medications and to share this information with your healthcare provider(s). • Stay alert and get your medications checked on


a regular basis. New medication side effects can appear several months or even years after taking the same medi- cation, even if it’s at the same dose. Over time, even if nothing has changed on paper, your body, life and health status change. This can affect the way your body processes medications. Be sure to review your medications with a healthcare professional at least once a year, and whenever there is a change in your medications. • Consider deprescribing. When you and your health-


offered to contact her family doctor to suggest they reduce the dose of her antidepressant (bupropion) to see if this would improve her sleep. While waiting for the doctor's re- sponse, Nadia recommended that Mrs. Reynolds stop tak- ing the sleeping pills she had been taking over the last few days (Sleep-Eze®


), and gave her an educational brochure


describing effective, evidence-based strategies to help her sleep well without medication. A few days later, Mrs. Reynolds’s family doctor con-


firmed it would be appropriate to try to reduce the dose of her antidepressant and asked her to follow up with him in a few weeks to check on her mood. Fortunately for Mrs. Reynolds, the side effects from the sleeping pills went away a few days after stopping them. And about two weeks after reducing the dose of her antidepressant, Mrs. Reynolds no- ticed a definite improvement in her sleep. She also found some of the techniques described in the sleep brochure to be helpful, like waking up at the same time every day and reducing her naps. Mrs. Reynolds was satisfied! And at her follow-up appointment to assess her sleep and mood, her family doctor was too. Together, they agreed on a plan to continue monitoring Mrs. Reynolds’s mood over time. What was Mrs. Reynolds’s conclusion? To avoid starting medications unnecessarily in future, when a new symptom appeared, she would always make sure to ask, “Could this be a side effect from one of my medications?”. Always consult with your doctor, nurse or pharma- cist before stopping or changing any of your medica- tions. To learn more about managing medications safely, visit www.deprescribingnetwork.ca


Camille Gagnon is the Assistant Director of the Canadian Deprescribing Network. She is a clinical pharmacist and works in a primary care clinic. She has experience in clinical program management, community pharmacy and teaching to pharmacy students and technicians. She is a passionate medication safety advocate.


New medication added to treat side effect


Laxative (e.g. Senokot® Diuretic (water pill)


) Medication for nausea (e.g. Gravol®


Cough syrup (e.g. Benylin® Antacid medication


) )


June 2020


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