Prescription CASCADE

Have you noticed that medical prescriptions hardly ever consist of a single drug but most often comprise a long list of them, even when the symptom that took you to the doctor was just a single one? It is due to a recently recognized phenomenon called Prescription Cascade.

As most drugs have side effects, what the doctor tries to do is to add balancing drugs that would counter them should they occur.

The most common example of this phenomenon is to co prescribe drugs that lower the stomach’s acidity when prescribing pain killers. Most pain killers such as aspirin, ibuprofen, diclofenac, indomethacin or naproxen are plagued by the side effect of causing gastric injury, called gastritis or gastric erosions. Indeed long term use of these agents are associated with the development of ulcers in the stomach or duodenum, that apart from causing stomach ache, can sometimes bleed or perforate  posing a threat to life. Doctors, therefore, often find it more covenient, and perhaps safer to add a drug from the group of PPI (proton pump inhibitor), such as omeprazole, pantoprazole or rabeprazole that would suppress the stomach’s acidity and reduce the chances of gastric erosions or ulcers.

While most of these PPIs are generally innocuous themselves, do add significantly to the cost of therapy. While aspirin for a prologed backache, for example, would cost a mere Rs 2 per day, a PPI would cost around Rs 5. At the end of a month, you would therefore have spent Rs 60/- for your backache, but Rs 300/- to prevent a potential adverse consequence of your primary treatment.

Another example is that of an antibiotic and a probiotic. Antibiotics, prescribed for infections, often cause extensive damage to the numerous “good” healthy bacteria that colonize our intestines and ensure our well being. Hence use of antibiotics is often associated with loose motions, called “antibiotic associated diarrhea”. It has therefore become common place to add a concoction of healthy bacteria, called probiotics, when prescribing antibiotics. These probiotics often cost Rs 30 to Rs 60/- a day, sometime s more than the antibiotics themselves, and often need to be taken for periods longer than the 5 day course of the primary drug, making a big hole in the patient’s pocket.

Several medications  that cause nausea or vomiting, such as anti-amoebic drugs  or anti-cancer drugs are routinely co-prescibed with anti-emetics drugs that counter these effects. The situation often gets complex as these secondary drugs sometimes cause side effects themselves such as abnormal muscular movements (dyskinesia), drowsiness or secretion from the breast, causing more concern than the anticipated problem with the primary drug itself.

 The numerous such examples of the  long prescriptions that we  get from  doctors  has raised a debate as to how much is really too much. While undoubtedly prescription cascades may sometimes help make the primary therapy more tolerable, the additional side effects and the cost multiplier effect needs careful consideration.

Short is usually not bad then, especially when it comes to prescriptions.

As published in HT City( Hindustan Times) dated 19 december, 2010.