The prescribing cascade: When medications create new “diseases”

• A “prescribing cascade” occurs when a drug’s side effects are mistaken for a new illness, leading to unnecessary additional prescriptions.
• A recent study found only 4% of doctors correctly identified the drug gabapentin as the cause of new leg swelling in patients, most instead prescribing diuretics.
• This phenomenon is widespread, affecting many common drug classes like NSAIDs, blood pressure medications and antidepressants, disproportionately harming older adults.
• Beyond physical side effects, common medications can also alter personality and behavior, affecting empathy, aggression and impulse control.
• Patients are advised to maintain detailed medication lists, question new symptoms after starting a drug, and utilize pharmacists to avoid harmful cascades.

In a troubling pattern plaguing modern healthcare, the very medications prescribed to heal are increasingly implicated in causing new symptoms that doctors mistake for separate illnesses. This leads to a perilous “prescribing cascade,” where patients are trapped in a cycle of additional drugs to treat side effects from the original prescription. A stark example emerged in a December 2025 study, which found that when older veterans developed leg swelling after starting the widely used drug gabapentin, only about 4% of their physicians identified the medication as the culprit. The rest diagnosed heart or vein problems, prescribing diuretics that then caused dizziness, electrolyte imbalances and emergency room visits. This case underscores a systemic failure to recognize medication side effects, resulting in unnecessary polypharmacy and patient harm.

Why the connection is missed

Gabapentin, an anti-seizure drug commonly prescribed off-label for pain and insomnia, lists peripheral edema (swelling) among its two dozen potential side effects—a symptom also characteristic of heart failure. The study’s finding that most doctors missed this link is, unfortunately, unsurprising to many pharmacotherapy specialists. Clinicians often have a “knee-jerk reaction” to diagnose a new health condition rather than consider a drug side effect, a problem compounded when multiple providers are involved. If the doctor who prescribed the initial medication is not the one evaluating the new symptom, the temporal connection can be easily overlooked, setting the cascade in motion.

Common culprits in the medication cascade

The problem extends far beyond a single drug. Research indicates that in over 80% of prescribing cascade scenarios, the risks of adding another medication outweigh the benefits. Several common drug classes are frequent triggers:

• NSAIDs (e.g., ibuprofen): Can cause fluid retention and high blood pressure, leading to prescriptions for antihypertensives, and acid reflux, leading to acid-blocking drugs linked to dementia and nutrient deficiencies.
• Calcium channel blockers (e.g., amlodipine): Often cause leg swelling mistaken for heart failure, resulting in unnecessary diuretic prescriptions.
• Diuretics (“water pills”): Can cause urinary incontinence, prompting prescriptions for overactive bladder medications, which themselves may cause cognitive impairment.
• Antidepressants (e.g., bupropion): May cause insomnia or jitteriness, leading to sleep or anti-anxiety medications.
• Albuterol inhalers: Overuse can cause tremors and nervousness misdiagnosed as an anxiety disorder.

The hidden psychological side effects

Beyond physical symptoms, a parallel and often underreported crisis involves the subtle yet profound impact of common medications on personality and behavior—effects that can also fuel misdiagnosis. Cholesterol-lowering statins have been linked in studies to increased aggression and irritability. The common painkiller acetaminophen (paracetamol) has been shown to reduce empathy and positive feelings for others. Antidepressants may directly alter fundamental personality traits like neuroticism. Parkinson’s drugs that affect dopamine levels are well-documented to sometimes cause severe impulse control disorders, leading to pathological gambling or hypersexuality. When these psychological changes occur, they are rarely attributed to the medication, potentially leading to prescriptions for additional psychotropic drugs instead of an adjustment of the original regimen.

A path forward for patient safety

The historical context of pharmaceutical marketing, which has often promoted a “one-size-fits-all” dosing strategy and a disease-model for complex human distress, has contributed to an over-reliance on medication as a first-line solution. This approach overlooks a fundamental root cause: nutrient deficiency, which can be the source of both the original condition and the adverse reactions mistaken for new diseases. Today, with an aging population frequently on multiple prescriptions and prescription drugs themselves ranking as a leading cause of death and hospitalization, recognizing and halting prescribing cascades is critical. Patients can protect themselves by maintaining an updated list of all medications and supplements, noting when each was started and any new symptoms that followed. Consulting a pharmacist for a comprehensive medication review is a powerful, underutilized step. Patients must feel empowered to ask their prescriber two key questions: “Could this new symptom be a side effect of my medication?” and “Could a nutrient deficiency be contributing to my health issues?”

Breaking the cycle

The prescribing cascade reveals a critical flaw in a healthcare system that often prioritizes rapid diagnosis and pharmacological intervention over careful detective work. Treating drug side effects or underlying nutrient deficiencies as new, separate diseases not only increases patient risk but also obscures the true source of their suffering. As evidence mounts regarding both the physical and psychological side effects of ubiquitous medications—many of which can deplete essential nutrients or mimic deficiency states—a paradigm shift is urgently needed. This shift must view new symptoms first through the lens of existing treatments and the potential for nutritional imbalance. Ultimately, breaking this dangerous cycle requires greater clinician awareness of nutrient-drug interactions, patient advocacy and a renewed commitment to the principle of “first, do no harm.” This commitment begins with a thorough consideration of the pills already in the bottle and a deeper investigation into the nutritional foundations of health.

Sources for this article include:

TheEpochTimes.com

AGSjournals.com

BBC.com

Longdom.org