Prescription Analysis Tool Can Help Detect Prescribing Cascades, Prevent Adverse Drug Events

March 29, 2022

Prescribing cascades are like dominoes. One medication is administered to a patient and causes an adverse event or symptom, which is interpreted as a new condition leading to a prescription for another medication. Such a cascade is not only an important clinical issue, contributing to the high prevalence of polypharmacy among the PALTC population; it also is a public health problem.

According to an article in the March issue of JAMDA, a nationwide claims database may help detect prescribing cascades among cardiovascular medications. This can help reduce the number of drugs cardiovascular patients take and prevent or resolve side effects or adverse events.

In Detecting Suspected Prescribing Cascades by Prescription Sequence Symmetry Analysis of Nationwide Real-world Data, the authors deployed a prescription sequence symmetry analysis (PSSA), an effective surveillance tool for drug-induced adverse drug events (ADEs), to explore associations between medications and related ADEs.

A PSSA measures the propensity to initiate a “marker” drug to address a side effect that a first, or “index,” drug is suspected of inducing. For each PSSA set, the researchers identified patients who had both newly initiated index drugs and marker drugs in the outpatient setting between 2014 and 2016.

The authors found that the prescribing cascade existed in most of the drug pairs of cardiovascular medications they identified in a large nationwide population. Among the 12 potential prescription cascade-related drug pairs in an exploratory analysis, nine of them reached statistical significance. These included angiotensin-converting enzyme inhibitors inducing dry cough; statins inducing lower urinary tract symptoms, depression, hepatoxicity, muscle pain, or skin and soft tissue infections; and dihydropyridine calcium channel blockers inducing edema.

While these findings were generally consistent with other studies on this issue, this study offered some novel findings. For instance, the authors found there was a significant but weak signal of prescribing nonsteroidal anti-inflammatory drugs after statin initiation. Overall, they said, “The strength of this study is that it is the first one to use a contemporary population-level, country-specific database to examine the existence of multiple potential prescribing cascades with the PSSA under a unique study algorithm.”

This study was conducted by researchers at the National Taiwan University College of Medicine, Taipei, Taiwan;  Center for Geriatrics and Gerontology, Taipei Veterans Hospital, Taipei, Taiwan; Aging and Health Research Center, National Yang-Ming University, Taipei, Taiwan; Department of Geriatric Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan; Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan; and Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan.

Get more information on the findings above and more details about the study. To contact the researchers or JAMDA editors for an interview, please email





JAMDA is the official journal of AMDA – The Society for Post-Acute and Long-Term Care Medicine. JAMDA publishes peer-reviewed articles including original studies, reviews, clinical experience articles, case reports, and more, on all topics more important to post-acute and long-term care medicine. Visit for more information.


About AMDA – The Society for Post-Acute and Long-Term Care Medicine
AMDA – The Society for Post-Acute and Long-Term Care Medicine is the only medical specialty society representing the community of over 50,000 medical directors, physicians, nurse practitioners, physician assistants, and other practitioners working in the various post-acute and long-term care (PALTC) settings. Dedicated to defining and improving quality, we advance our mission through timely professional development, evidence-based clinical guidance, and tireless advocacy on behalf of members, patients, families, and staff. Visit for more information.