the prescribing cascade: how women end up understudied and overtreated
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without evidence-based guidelines tailored to women’s physiology, drugs are more likely to be inappropriately dosed, and this can contribute to adverse effects being mistaken for a new medical condition.
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your doctor prescribes medication for high blood pressure. a few weeks later, you notice your ankles are swollen. it’s interpreted as a new condition, and you’re prescribed a diuretic to help your body eliminate excess fluids. you then experience dizziness and are prescribed yet another drug. before long, you’re taking multiple medications when you may have only ever needed one.
this is a prescribing cascade, and if you’re an older woman, you’re caught in instances of potentially inappropriate prescribing more often than men.
over two decades ago, i, along with dr. jerry gurwitz, described the “prescribing cascade” framework to bring attention to this dangerous domino effect that often goes unrecognized. while some drug combinations are necessary and appropriate, potentially inappropriate prescribing cascades are ones where the initiation of subsequent drugs may be unnecessary and potentially harmful.
initially, we identified three prescribing cascades. now, about 200 prescribing cascades have been uncovered from around the world. potentially inappropriate prescribing disproportionately impacts mature women, who generally experience more chronic conditions than men and are more likely to experience polypharmacy.
the consequences extend far beyond the inconvenience of pill burden. each inappropriately prescribed medication can introduce new risks for interactions, adverse effects and complications – which can be so difficult for women already navigating menopause and aging.
why are women so vulnerable? the answer lies in a perfect storm of biological differences and systemic neglect.
women’s bodies process some medications differently than men. yet studies were not required to include women, a practice that continued until the 1990’s this contributes to a knowledge gap on how best to prescribe for women, especially as they age. for example, the optimal dose for some medications is lower for women compared to men, just one of the many contributors to why women experience more adverse drug effects.
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without evidence-based guidelines tailored to women’s physiology, drugs are more likely to be inappropriately dosed, and this can contribute to adverse effects being mistaken for a new medical condition.
this doesn’t have to be our reality.
physicians have a crucial role to play in recognizing and preventing these prescribing cascades. they must be trained to recognize when a symptom could be a drug’s side effect rather than a new condition.
importantly, women should also feel empowered to advocate for themselves; to ask more questions. don’t be afraid to ask whether every medication is necessary, or whether a new symptom might be a side effect of something you already take. if you see multiple specialists, request a comprehensive medication review to ensure nothing is missed.
most critically, we urgently need research to include older women and when they are included to make sure that the information about older women is reported to increase the impact of the research. that call is at the heart of sinai health foundation’s questions campaign, which aims to drive more equitable women’s health research. it’s also the foundation for the weston and o’born centre for mature women’s health, a first-of-its-kind centre that is dedicated to advancing our understanding of menopause and other conditions that impact women’s health as they age. i’m proud to help lead this work as the centre’s director of research.
but one centre cannot close decades of research gaps alone. policymakers must mandate that studies analyze data by sex, gender and age as standard practice. we need to understand not just how a 45-year-old woman responds to medication differently than a 45-year-old man, but how a 70-year-old woman’s response differs from a 50 year old’s.
the solution begins with recognizing that women’s health is not a niche concern. it’s a fundamental issue of equity and evidence-based medicine. until we invest in the research needed to truly understand how women age and how their bodies respond to treatment, we will continue to catch them in preventable prescribing cascades that could lead to harm.
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the time for action is now. women have waited long enough.
dr. paula rochon is director of research at the weston and o’born centre for mature women’s health at sinai health, which is one of the only academic centres globally to make menopause and mature women’s health a strategic priority. she also holds the barry j. goldlist chair in geriatric medicine.
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