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Invited Commentary
February 24, 2020

Antihypertensive Prescribing Cascades as High-Priority Targets for Deprescribing

Author Affiliations
  • 1Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
  • 2Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
  • 3San Francisco Veterans Affairs Medical Center, San Francisco, California
  • 4Division of Geriatrics, University of California, San Francisco, San Francisco
JAMA Intern Med. Published online February 24, 2020. doi:10.1001/jamainternmed.2019.7082

Older adults frequently take many medications, with two-fifths taking 5 or more. While most older adults are exposed to polypharmacy as part of evidence-based treatment of 1 or more chronic conditions, with a rising tide of medications comes higher risk of adverse drug events. One strategy to prevent harms associated with polypharmacy is to identify medications that are unnecessary or inappropriate and proactively deprescribe them. The American Geriatric Society Beers Criteria1 and similar lists have provided a starting point for identifying medications that are most often inappropriate in older adults. However, the appropriateness of many other medications is highly dependent on the clinical context of the individual patient. One potentially valuable strategy for deprescribing efforts is to identify common prescribing cascades, instances in which a second (potentially avoidable) medication is administered in response to an adverse effect or drug reaction caused by another medication. In this issue of JAMA Internal Medicine, Savage and colleagues2 describe an example of a prescribing cascade: the prescription of loop diuretics following calcium channel blocker initiation.2

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