Medicines upon medicines: The Prescribing Cascade

1 December 2011

A ‘prescribing cascade’ occurs when a new medicine is prescribed to ‘treat’ side effects to another medicine in the mistaken belief that a new medical condition has developed, according to an article in the December edition of Australian Prescriber.

Lisa Kalisch and colleagues from the University of South Australia write that recognising and preventing all types of side effects is a priority, especially given that 10% of patients visiting general practices will have had side effects in the previous six months.

“Failure to recognise side effects can make poor health worse, particularly when the patient's reaction is mistaken for a symptom of a new health problem,” write the authors.

“More than 1.5 million people are affected by an adverse reaction to a medicine each year in Australia, and this results in at least 190,000 hospital admissions annually.

“If the side effects of a medicine are subsequently treated with another medicine, a prescribing cascade results, which can make the original side effect even more difficult to recognise and puts the patient at further risk of potentially harmful effects.

“The key to preventing a prescribing cascade lies in avoiding and quickly detecting adverse reactions, and an increased awareness and recognition of the potential for these to happen,” write the authors.

Some patients, particularly the elderly, take multiple medicines and in some cases not all of these medicines may be appropriate or needed. A home medicines review by a pharmacist should be considered for those patients who take multiple medicines and for those at high risk of having an adverse reaction, where there is the potential for a prescribing cascade.

Many adverse reactions go unrecognised and unreported, so it is important to be 'medicinewise': that is, know what medicines you are taking and why, ask questions of your health professional and tell them what else you are taking.

NPS provides a phone service for people to report and discuss side effects that might be related to their medicine – the Adverse Medicine Events (AME) Line (1300 134 237). Any possible side effects reported through the AME Line are reported to the Therapeutic Goods Administration (TGA).

To read this article and others in this issue, visit


Australian Prescriber is an independent peer-reviewed journal providing critical commentary on therapeutic topics for health professionals, particularly doctors in general practice. It is published by NPS, an independent, not-for-profit organisation for quality use of medicines funded by the Australian Government Department of Health and Ageing. Australian Prescriber is published every two months, in hard copy that is distributed to health professionals free of charge, and online in full text at