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Red flags

• Applying single-disease guidelines uncritically to a patient with many conditions — Boyd 2005 showed a hypothetical 79-year-old with COPD, diabetes, osteoporosis, hypertension and osteoarthritis would land on 12 medications with multiple drug-drug interactions and a treatment burden she could not meet
• Adding a new drug to treat a symptom that is actually an adverse effect of an existing drug — the prescribing cascade (metoclopramide to levodopa; NSAID to additional antihypertensive; donepezil to oxybutynin); always review the causative drug first
• Withholding a beta-blocker in a patient with COPD and heart failure — cardioselective beta-1 blockers (bisoprolol, metoprolol, nebivolol) are safe and beneficial in COPD and reduce mortality in HFrEF; the myth of absolute contraindication costs lives
• The triple whammy — ACE inhibitor plus diuretic plus NSAID in a patient with CKD precipitates acute kidney injury; avoid NSAIDs in the cardio-renal patient and review the whole regimen before adding any new agent
• Pursuing intensive glycaemic or blood pressure targets in a frail older multi-morbid patient — hypoglycaemia from tight HbA1c targets and falls and syncope from intensive blood pressure lowering cause harm that exceeds the long-term benefit when life expectancy is limited
• Deferring the goals-of-care conversation until the patient is too unwell to participate — introduce advance care planning early, document the ceiling of treatment and the surrogate decision-maker, and anchor every treatment decision to the patient's stated priorities
• Allowing a multi-morbid patient to leave hospital on more medications than they were admitted on, with no single clinician owning the overall plan — reconciliation failure is the commonest source of post-discharge adverse drug events
• Failing to estimate renal function in a frail older patient before prescribing renally-cleared drugs — a normal serum creatinine masks a low eGFR because muscle mass is reduced; dose-adjust DOACs, gabapentinoids, metformin, digoxin and allopurinol accordingly