Just like adding medications can lead to adding more medications (prescribing cascade), we can think of this strategy in reverse in an attempt to try to stop polypharmacy. Stopping medications can lead to stopping more medications. Let me provide you with some proof!

Potassium and Diuretics

Loop and thiazide diuretics are well known to deplete potassium levels. This is why you will often see potassium supplement orders that go hand in hand with diuretic orders. This can be a necessary thing to do and an essential use of the prescribing cascade.

However, what I have seen in practice is that the diuretic can no longer be necessary. Once discontinued, we can likely (we need to monitor potassium levels) get away without the potassium supplement as well.

Opioids and Constipation

Laxatives are an essential consideration when patients are taking opioids due to the side effect of constipation. This is again another intentional use of the prescribing cascade. As opioids are reduced or discontinued, there is a decent chance that the laxatives we were using to prevent opioid-induced constipation can be discontinued as well.

Folic Acid and Methotrexate

Methotrexate is most commonly used in the setting of rheumatoid arthritis. Folic acid is a necessary supplement with the use of methotrexate. In certain situations, I have seen methotrexate discontinued. If that is the case, we are likely able to stop the folic acid in a patient who is eating normally, is not alcoholic or malnourished.

Magnesium Supplements with Diuretics or PPI’s

I often see patients try to self manage leg cramps with magnesium. I also see situations where magnesium levels are being monitored and they are suppressed. There are a couple of drugs that can cause low magnesium. Diuretics and PPI’s are two drugs that could deplete these levels. If these magnesium lowering drugs are discontinued, there is the potential that we could get rid of the supplement.

Polypharmacy is huge in geriatrics and is something I’ve spent the majority of my career trying to stop! I talk about this and many other topics in my 10+ hour Guide to Long Term Care Consulting.

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