ArticleJournal of the American Geriatrics Society2024
Which older adults are at highest risk of prescribing cascades? A national study of the gabapentinoid-loop diuretic cascade.
Article in Journal of the American Geriatrics Society, 2024. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 7 papers, 1 of them a synthesis that pooled it.
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Who cites it
7 citing papers in PubMed, 1 synthesis or guideline pooled it.
- Prescribing Cascades: An Umbrella Review and Updated Systematic Review.Drugs & aging · 2026Pooled it
- Dose-dependent relationships in potential prescribing cascades: a cohort study using community pharmacy dispensing data.International journal of clinical pharmacy · 2026Article
- Predictors of a Gabapentinoid-Loop-Diuretic Prescribing Cascade in U.S. Nursing Home Residents.Journal of the American Geriatrics Society · 2026Article
- Decision-Making and Downstream Outcomes of the Gabapentinoid-Diuretic Prescribing Cascade.JAMA network open · 2025Article
- Loop diuretics and subsequent use of urinary symptom medications in older adults: evaluation of a possible prescribing cascade.The journals of gerontology. Series A, Biological sciences and medical sciences · 2025Article
- Emerging Clinical Roles of Gabapentin and Adverse Effects, Including Weight Gain, Obesity, Depression, Suicidal Thoughts and Increased Risk of Opioid-Related Overdose and Respiratory Depression: A Narrative Review.Current pain and headache reports · 2025Review
- Identifying and quantifying potentially problematic prescribing cascades in clinical practice: A mixed-methods study.Journal of the American Geriatrics Society · 2024Article
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Authors and funding
8 authors.
Funding
Abstract
backgroundPrescribing cascades are important contributors to polypharmacy. Little is known about which older adults are at highest risk of experiencing prescribing cascades. We explored which older veterans are at highest risk of the gabapentinoid (including gabapentin and pregabalin)-loop diuretic (LD) cascade, given the dramatic increase in gabapentinoid prescribing in recent years.
methodsUsing Veterans Affairs and Medicare claims data (2010-2019), we performed a prescription sequence symmetry analysis (PSSA) to assess loop diuretic initiation before and after gabapentinoid initiation among older veterans (≥66 years). To identify the cascade, we calculated the adjusted sequence ratio (aSR), which assesses the temporality of LD relative to gabapentinoid initiation. To explore high-risk groups, we used multivariable logistic regression with prescribing order modeled as a binary dependent variable. We calculated adjusted odds ratios (aORs), measuring the extent to which factors are associated with one prescribing order versus another.
resultsOf 151,442 veterans who initiated a gabapentinoid, there were 1,981 patients who initiated a LD within 6 months after initiating a gabapentinoid compared to 1,599 patients who initiated a LD within 6 months before initiating a gabapentinoid. In the gabapentinoid-LD group, the mean age was 73 years, 98% were male, 13% were Black, 5% were Hispanic, and 80% were White. Patients in each group were similar across patient and health utilization factors (standardized mean difference <0.10 for all comparisons). The aSR was 1.23 (95% CI: 1.13, 1.34), strongly suggesting the cascade's presence. People age ≥85 years were less likely to have the cascade (compared to 66-74 years; aOR 0.74, 95% CI: 0.56-0.96), and people taking ≥10 medications were more likely to have the cascade (compared to 0-4 drugs; aOR 1.39, 95% CI: 1.07-1.82).
conclusionsAmong older adults, those who are younger and taking many medications may be at higher risk of the gabapentinoid-LD cascade, contributing to worsening polypharmacy and potential drug-related harms. We did not identify strong predictors of this cascade, suggesting that prescribing cascade prevention efforts should be widespread rather than focused on specific subgroups.
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