Association of a calcium channel blocker and diuretic prescribing cascade with adverse events: A population-based cohort study

J Am Geriatr Soc. 2024 Feb;72(2):467-478. doi: 10.1111/jgs.18683. Epub 2023 Nov 27.


Background: Prescribing cascades occur when a drug adverse event is misinterpreted as a new medical condition and a second, potentially unnecessary drug, is prescribed to treat the adverse event. The population-level consequences of prescribing cascades remain unknown.

Methods: This population-based cohort study used linked health administrative databases in Ontario, Canada. The study included community-dwelling adults, 66 years of age or older with hypertension and no history of heart failure (HF) or diuretic use in the prior year, newly dispensed a calcium channel blocker (CCB). Individuals subsequently dispensed a diuretic within 90 days of incident CCB dispensing were classified as the prescribing cascade group, and compared to those not dispensed a diuretic, classified as the non-prescribing cascade group. Those with and without a prescribing cascade were matched one-to-one on the propensity score and sex. The primary outcome was a serious adverse event (SAE), which was the composite of emergency room visits and hospitalizations in the 90-day follow-up period. We estimated hazard ratios (HRs) with 95% confidence intervals (CI) for SAE using an Andersen-Gill recurrent events regression model.

Results: Among 39,347 older adults with hypertension and no history of HF who were newly dispensed a CCB, 1881 (4.8%) had a new diuretic dispensed within 90 days after CCB initiation. Compared to the non-prescribing cascade group, those in the prescribing cascade group had higher rates of SAEs (HR: 1.21, 95% CI: 1.02-1.43).

Conclusions: The CCB-diuretic prescribing cascade was associated with an increased rate of SAEs, suggesting harm beyond prescribing a second drug therapy. Our study raises awareness of the downstream impact of the CCB-diuretic prescribing cascade at a population level and provides an opportunity for clinicians who identify this prescribing cascade to review their patients' medications to determine if they can be optimized.

Keywords: older adults; prescribing cascade; serious adverse events.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Calcium Channel Blockers / adverse effects
  • Cohort Studies
  • Diuretics / adverse effects
  • Heart Failure* / drug therapy
  • Humans
  • Hypertension* / chemically induced
  • Hypertension* / drug therapy
  • Ontario


  • Calcium Channel Blockers
  • Diuretics