Decision-Making and Downstream Outcomes of the Gabapentinoid-Diuretic Prescribing Cascade

Area of Science:

• Gerontology
• Clinical Pharmacology
• Health Services Research

Background:

• Prescribing cascades, a significant contributor to polypharmacy in older adults, remain poorly understood regarding clinical decision-making and outcomes.
• The gabapentinoid-loop diuretic (LD) cascade serves as a critical exemplar for investigating these complex interactions.

Purpose of the Study:

• To examine the clinical reasoning behind prescribing cascades, specifically the gabapentinoid-LD cascade.
• To identify downstream consequences, such as falls and electrolyte abnormalities, associated with this cascade.

Main Methods:

• A retrospective cohort study of US veterans aged 66 years or older (January 2013-August 2019).
• Medical records were reviewed to assess clinical decision-making processes within 30 days prior to and 60 days after LD initiation.
• Secondary analyses explored the impact of dementia on decision-making and outcomes.

Main Results:

• The study included 120 patients, with 23.3% experiencing adverse events post-LD initiation.
• Common downstream events included worsening kidney function (7.5%), orthostasis (5.8%), electrolyte abnormalities (5.0%), and falls (4.2%).
• Clinicians infrequently documented gabapentinoids in differential diagnoses for edema (3.3%).

Conclusions:

• Clinicians seldom considered gabapentinoid adverse effects when treating edema in patients experiencing the gabapentinoid-LD cascade.
• The findings highlight the commonality of downstream harms from this prescribing cascade, emphasizing the need for clinical attention.
• Addressing prescribing cascades is crucial for improving patient safety and managing polypharmacy in older adults.