Hypertension Prescribing Cascade – 3 Common Examples

Hypertension is one of the most common disease states that can lead to an increase in cardiovascular risk and other complications. Because of the risks of elevated blood pressure, we are often forced to use pharmacotherapy to reduce those risks. When a medication is started (or increased), we encounter risk in the form of adverse effects. Those adverse effects may go unrecognized and lead to new medications treating those adverse effects. Here are the three most common examples of the hypertension prescribing cascade that I’ve encountered in my practice.

ACE inhibitors are one of the most commonly used antihypertensive agents. In addition to lowering blood pressure, they also have incredibly important compelling indications. Patients may not be aware or recognize that a newly developed cough may be an adverse effect from ACE inhibitors. Be aware of any patients who begin to take cough suppressants on a chronic basis, they may be experiencing an ACE inhibitor induced cough.

Calcium channel blockers such as amlodipine are one of the first-line antihypertensive agents like ACE inhibitors. Peripheral edema is a common adverse effect. I’ve encountered numerous cases of diuretics being added to manage edema. You must ensure that calcium channel blocker induced edema is not occurring. Whenever I see a new order for a diuretic or a patient reporting swollen ankles, I always look to the medication list to ensure an adverse effect isn’t causing this issue.

My last hypertension prescribing cascade example is associated with thiazide diuretics. Medications like hydrochlorothiazide and chlorthalidone are frequently used to manage blood pressure but also have a significant side effect profile. Urinary frequency from thiazide diuretics may also be diagnosed as overactive bladder. Overactive bladder symptoms may cause providers to prescribe medications like urinary anticholinergics or beta agonists. Anticholinergic medications are notorious for contributing to the prescribing cascade and if you’d like more examples on this topic, check out this previous post!

Honorable Mention: Hypertension Prescribing Cascade