International panel compiles list of potentially inappropriate prescribing cascades

An international panel of 12 experts has reached consensus on 65 potentially inappropriate prescribing cascades that can be used to help identify possible inappropriate prescribing in older adults. The expert panel consisted of physicians, pharmacologists and pharmacists from eight countries (Australia, Belgium, Canada, Ireland, Israel, Italy, The Netherlands, United States). The panel included Canadian pharmacist and researcher, Dr Lisa McCarthy, who earlier spearheaded the development of ThinkCascades, a nine-item list of the most clinically important prescribing cascades affecting older adults. A prescribing cascade occurs when a drug therapy is started and an adverse drug event develops that is mistaken for a new medical condition; this leads to the initiation of another drug therapy to manage the new medical condition. Prescribing cascades are known to be an important contributor to polypharmacy and potentially inappropriate prescribing, particularly among older adults.To prepare the list of potentially inappropriate prescribing cascades, the panel of experts participated in a modified Delphi consensus process, completing two questionnaire rounds and one discussion round. By following this process, the panel narrowed down a total of 107 published prescribing cascades to 65 potentially inappropriate prescribing cascades. The final list has been endorsed by the European Geriatric Medicine Society, with representatives from more than 60 countries.The authors note that this comprehensive list of potentially inappropriate prescribing cascades adds to other valuable pharmacologic risk assessment tools designed to optimize prescribing for older adults, such as the STOPP/START criteria, Beers criteria and the Drug Burden Index. The list can be used to complement these other risk assessment tools when conducting routine medication reviews in older people with multiple morbidities exposed to varying degrees of polypharmacy.Table 1 summarizes some of the 65 common potentially inappropriate prescribing cascades included in the final list compiled by the expert panel. Table 1 Some potentially inappropriate prescribing cascades1Initial drugAdverse effect Added drug Angiotensin converting enzyme inhibitor (e.g., enalapril)CoughCough remedyBeta-blocker (particularly lipophilic, e.g., propranolol) Depression AntidepressantDiuretic Urinary incontinenceOveractive bladder medicationHMG Co-A reductase inhibitor (e.g., atorvastatin)Myalgia/myositisQuinine sulfateAntipsychotic agentExtrapyramidal symptomsAntiparkinsonian agentBenzodiazepine Cognitive impairmentCholinesterase inhibitorCholinesterase inhibitor Insomnia Sleep agentGabapentinoid Peripheral edema DiureticTricyclic antidepressant Cognitive impairment Cholinesterase inhibitorDipeptidyl peptidase 4 (DPP-4) inhibitor (e.g., sitagliptin, saxagliptin)Joint pain Nonsteroidal anti-inflammatory drugBisphosphonate GastritisGastroprotective agentNonsteroidal anti-inflammatory drug Worsening of heart failure Heart failure agentCarbapenem (e.g., imipenem, meropenem, ertapenem) Seizures AnticonvulsantThe list of 65 potentially inappropriate prescribing cascades is intended to draw attention to an important and underrecognized aspect of unsafe prescribing in older people. The list can be used by clinicians to detect potentially inappropriate prescribing patterns and to improve medication safety in older adults.References:Rochon PA, O’Mahony D, Cherubini A, et al. International expert panel’s potentially inappropriate prescribing cascades (PIPC) list. Eur Geriatr Med 2025. Published online July 31, 2025 ahead of print. doi: 10.1007/s41999-025-01215-x.Rochon PA, O’Mahony D, Cherubini A, et al. International expert panel’s potentially inappropriate prescribing cascades (PIPC) list. Supplementary appendix.

International panel compiles list of potentially inappropriate prescribing cascades

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