Diuretics are a medication that I see used on a daily basis. I also encounter these medications causing adverse effects. With adverse effects comes the potential for providers to add medications to treat those adverse effects. Here’s a few examples I’ve seen in my practice regarding diuretics and the prescribing cascade.
Leg Cramp Supplements
Many patients report leg cramps and it can often be attributed to diuretic therapy. Many patients will also be inclined to try various over-the-counter remedies to manage this side effect. If you have a patient who reports leg cramps, be sure to review the medication list for the use of diuretics. I’ve seen medications like quinine (which I wouldn’t recommend), magnesium, vitamin B12, and even prescription medications like gabapentin or cyclobenzaprine.
Urinary Frequency
Diuretics reduce the amount of fluid in the body and that fluid has to go somewhere. The elimination of fluid into the bladder leads to an increase in urinary frequency. Some patients can handle it without the use of medications and others will request something be done. The timing of diuretic dosing is important and it is critical to make sure that these patients aren’t having to get up all night.
The most common class of medication that I see added to treat urinary frequency or symptoms or urge incontinence is urinary anticholinergics. Drugs like tolterodine or oxybutynin are relatively inexpensive and can modestly help with symptoms of urinary frequency. Pay attention to the timing of when these drugs are added. If you see a urinary anticholinergic or mirabegron added shortly after a diuretic is started or increased, recognize that this is likely the prescribing cascade at work.
Hypokalemia
Hypokalemia is a significant concern with the use of diuretics (loops and thiazides). I wouldn’t consider this a traditional example of the prescribing cascade, but it does fit the definition. We are adding a medication to treat an adverse effect of a medication. In clinical practice, this is done intentionally to prevent catastrophic issues from significant hypokalemia.
In many instances, I have been able to successfully reduce potassium supplementation. The most frequent situation where this can be done is if a patient’s diuretic is discontinued. If this is the case and the patient remains on the potassium supplement, we should check a potassium level and assess if it is adequate enough if the potassium was discontinued.
What else would you add to this list of diuretics and the prescribing cascade?
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I would add Budesonide to the list. On Benicar/HCTZ for 6 years and besides diarrhea up to 20 times a day, frequent urination and leg/foot cramps I presented in the ER with hypokalemia, severe dehydration and acute renal failure. GI doctor prescribed Budesonide and I refused. I stopped the medication and recovered. Then went on Amlodipine and Triamterene/HCTZ and after 5 years began having diarrhea and bloating and was diagnosed with gastroparesis so the amlodipine was stopped and again the GI doctor recommended Budesonide but again I refused and my GI symptoms stopped. 1 1/2 years later the diarrhea began again and my lipase levels were twice the high number in the normal range, had pancreatic pain, cramping and diarrhea. CT scan and other tests showed my organs were fine. Stopped the diuretic and within a week lipase levels were in the middle of the normal range. Once again the doctor prescribed Budesonide and once again I refused. So in an attempt to keep my BP under 140/90 I take 1 amlodipine only twice a week which causes my weight to be up 1 pound the following day and 1/2 tablet of the triamterene/HCTZ once or twice a week which causes only mild cramping in my feet. Taking 3 1/2 tabs per week causes pancreatic pain as well. My pharmacogenomic DNA test results indicate that the genes needed to metabolize BP meds are nonfunctional variants, which I’m guessing is the reason I have had adverse reactions when taking them. Also had an adverse reaction to Premarin which I had only taken for a month before ending up in the ER and years prior to starting any BP med.