I. Introduction
As the global population ages, the prevalence of multimorbidity has inevitably led to a sharp increase in polypharmacy among the elderly. In South Korea, the clinical landscape is particularly concerning; as of 2022, 65.4% of elderly patients over 75 are exposed to chronic polypharmacy involving five or more concurrent medications, ranking fourth highest among 15 OECD nations1,2. While polypharmacy is sometimes clinically necessary, extreme polypharmacy substantially elevates the risk of adverse drug events (ADEs). A critical consequence of this is the “prescribing cascade (PC),” a term describing a cycle where an ADE is misinterpreted as a new medical condition, resulting in the prescription of yet another medication3. Classic examples include the administration of prokinetics for dyspepsia, which induces parkinsonian symptoms that are subsequently misdiagnosed as Parkinson’s disease, triggering unnecessary dopaminergic therapy3,4. In frail elderly patients, these cascades can rapidly deteriorate their functional status and lead to life-threatening complications.
This iatrogenic risk is further compounded by compartmentalized or “fragmented” medical care. In South Korea, the absence of a robust primary care system and the structural division between conventional and Korean Medicine (KM) practices in its dual healthcare system often leads patients to visit multiple independent specialists without centralized oversight. Research indicates that such fragmentation significantly increases the likelihood of medical overuse, whereas higher continuity of care is associated with a significant reduction in the odds of undergoing unnecessary procedures5. Consequently, severe pharmacological interactions, such as the induction of drug-induced parkinsonism (DIP) by prokinetics6,7 or critical hypokalemia triggered by the concurrent use of systemic corticosteroids and thiazide diuretics-a combination explicitly flagged as a high-risk interaction in elderly populations8,9-are frequently overlooked. Furthermore, the resulting ADEs are often empirically misdiagnosed as simple age-related frailty, delaying crucial interventions.
Managing these complex, sequential iatrogenic events requires a patient-centered approach rather than conventional single-disease guidelines, which often fail to address the metabolic disruptions seen in frail elderly patients. In this context, KM offers a comprehensive framework that prioritizes restoring the body’s systemic balance (treating the root, or Ben; 本). Central to this approach is the concept of “deprescribing”-a systematic process of identifying and tapering potentially inappropriate medications where the harm outweighs the clinical benefit10. Rather than merely adding alternative therapies, a multimodal KM intervention integrates targeted deprescribing with supportive modalities-such as tailored herbal medicine11-13, acupuncture, and metabolic dietary corrections-to safely rebuild physiological resilience without adding further chemical burdens.
Herein, this report presents the case of an 81-year-old female who suffered a severe, sequential PC-manifesting as dyspepsia, levosulpiride-induced parkinsonism, and ultimately, life-threatening steroid-induced hypokalemia-driven by extreme polypharmacy and fragmented care. This report details how a comprehensive, multimodal KM intervention anchored by strict deprescribing aided in normalizing her critical electrolyte imbalance and functional deficits. Ultimately, this case illustrates the clinical utility of a deprescribing-centered multimodal KM strategy in mitigating the severe harms of sequential PCs in vulnerable geriatric patients.
II. Case Presentation
1. Ethical Statement
This retrospective case report was conducted in accordance with the Declaration of Helsinki. The study protocol was exempted from review by the Public Institutional Review Board designated by the Ministry of Health and Welfare of South Korea (IRB No. P01-202602-01-049), as it involved the secondary analysis of existing, de-identified medical records. Written informed consent was obtained from the patient for the publication of this case report and any accompanying clinical data.
2. Baseline Vulnerability and Dyspepsia (Phase 1)
An 81-year-old female with a history of hypertension, diabetes, and lumbar disc herniation presented to the clinic. A 1-year retrospective review of her Drug Utilization Review (DUR) records revealed a chronic vulnerability to polypharmacy. Notably, during a brief hospitalization for back pain in mid-November 2024, she was prescribed 14 concurrent medications, including non-steroidal anti-inflammatory drugs (NSAIDs) (e.g., celecoxib), opioids (e.g., tramadol), and corticosteroid injections (e.g., triamcinolone acetonide). When combined with her pre-existing maintenance medications for hypertension and other conditions (e.g., amlodipine/ valsartan and choline alfoscerate), her total medication burden reached 17 pharmaceutical products, encompassing 26 active ingredients (Fig. 1). To objectively evaluate the iatrogenic nature of the sequential PC that followed, the causality of each ADE (Phases 1-3) was systematically assessed using the Naranjo algorithm and the World Health Organization-Uppsala Monitoring Centre (WHO-UMC) criteria (Table 1).
Fig. 1
Clinical timeline of the sequential prescribing cascades and multimodal Korean Medicine (KM) intervention.
(A) Chronological sequence of iatrogenic triggers, adverse drug events (Phases 1-3), and targeted deprescribing/KM interventions. The gray shaded area represents the period of cumulative corticosteroid exposure. (B) Corresponding changes in medication burden (left y-axis; tracking pharmaceutical products and active ingredients) and clinical symptom severity scores (right y-axis) throughout the clinical course.
ECOG : Eastern Cooperative Oncology Group, GSRS : Gastrointestinal Symptom Rating Scale, H&Y : Hoehn and Yahr, Inj. : Injection, K⁺ : Potassium, KM : Korean Medicine, MRC : Medical Research Council, NRS : Numeric Rating Scale, Tx : Treatment, URI : Upper Respiratory Infection.
Table 1
Causality Assessment of Adverse Drug Events via the Naranjo Scale and WHO-UMC Criteria
| Parameters | Phase 1* | Phase 2** | Phase 3† |
|---|---|---|---|
| Suspected drugs | NSAIDs (Celecoxib), Opioids (Tramadol/Acetaminophen) | Levosulpiride | Systemic corticosteroids (Triamcinolone, Prednisolone), Thiazide diuretics |
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| WHO-UMC category | Probable/Likely | Probable/Likely | Probable/Likely |
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| Naranjo Questionnaire | |||
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| 1. Are there previous conclusive reports on this reaction? | +1 (Yes) | +1 (Yes) | +1 (Yes) |
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| 2. Did the adverse event appear after the suspected drug was administered? | +2 (Yes) | +2 (Yes) | +2 (Yes) |
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| 3. Did the adverse reaction improve when the drug was discontinued or a specific antagonist was administered? | +1 (Yes) | +1 (Yes) | +1 (Yes) |
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| 4. Did the adverse reaction reappear when the drug was readministered? | 0 (Unknown) | 0 (Unknown) | 0 (Unknown) |
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| 5. Are there alternative causes that could on their own have caused the reaction? | 0 (Unknown) | +2 (No) | 0 (Unknown) |
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| 6. Did the reaction reappear when a placebo was given? | 0 (Unknown) | 0 (Unknown) | 0 (Unknown) |
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| 7. Was the drug detected in the blood or other fluids in concentrations known to be toxic? | 0 (Unknown) | 0 (Unknown) | 0 (Unknown) |
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| 8. Was the reaction more severe when the dose was increased or less severe when the dose was decreased? | 0 (Unknown) | 0 (Unknown) | 0 (Unknown) |
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| 9. Did the patient have a similar reaction to the same or similar drugs in any previous exposure? | 0 (Unknown) | 0 (Unknown) | 0 (Unknown) |
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| 10. Was the adverse event confirmed by any objective evidence? | +1 (Yes) | +1 (Yes) | +1 (Yes) |
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| Total Naranjo Score (Category) | 5 (Probable) | 7 (Probable) | 5 (Probable) |
This substantial polypharmacy burden triggered Phase 1 of the cascade, presenting as functional dyspepsia (Numeric Rating Scale [NRS] 4, Gastrointestinal Symptom Rating Scale [GSRS] 5) that corresponded to the Rome IV criteria for Postprandial Distress Syndrome14-16. Following the immediate deprescribing of the 14 offending orthopedic and pain medications, a multimodal KM intervention was initiated on December 9, 2024. Ojeok-san (Wuji San; 五積散) and Bojungikgi-tang (Buzhong Yiqi Tang; 補中益氣湯) soft extracts (Hanpoong Pharm & Foods Co., Ltd., Jeonju, Republic of Korea) were prescribed to support gastrointestinal recovery. Concurrently, acupuncture treatment was performed using sterile, disposable stainless steel filiform needles (0.16×15 mm; Dongbang Medical, Boryeong, Korea). Needles were inserted bilaterally at LI4(合谷), LR3(太衝), ST36(足三里), GB34(陽陵泉), LI11(曲池), LU5(尺澤), and CV12(中脘) to an approximate depth of 5-10 mm. Following the elicitation of the traditional de qi (得氣) sensation, electroacupuncture stimulation (4 Hz, continuous wave) was applied for 15 minutes per session. A total of four acupuncture sessions were administered between December 9 and December 17, 2024, alongside 100% medication adherence.
As part of the multimodal approach, a stepwise dietary modification protocol was implemented to alleviate the gastrointestinal burden. The patient was instructed to maintain fasting until true hunger emerged. Refeeding was initiated exclusively with clear broths and easily digestible soft proteins (e.g., soft tofu, natural cheeses), while carbohydrates, grains, and refined sugars were restricted17.
By December 17, 2024, her gastrointestinal symptoms had resolved (NRS 0, GSRS 2). Consequently, Bojungikgi-tang was discontinued, while Ojeok-san was maintained in combination with dietary counseling to manage her cardiovascular risk factors, blood glucose levels, and body weight. Subsequently, on January 7, 2025, after observing an improvement in her pulse diagnosis (resolution of the rough pulse, 澁脈), the herbal regimen was transitioned to Socheongryong-tang (Xiao Qinglong Tang; 小靑龍湯) soft extract (Hanpoong Pharm & Foods Co., Ltd., Jeonju, Republic of Korea) for ongoing cardiovascular and blood pressure management.
3. The Priming Phase and Levosulpiride-Induced Parkinsonism (Phase 2)
Despite the initial resolution of dyspepsia, the PC resumed when the patient restarted a regimen of 8 pharmaceutical products (comprising 9 active ingredients) on December 23, 2024, for recurrent left leg numbness and other comorbidities. The resumed medications included orthopedic agents such as NSAIDs (e.g., celecoxib), neuropathic pain medications (e.g., pregabalin), and vasodilators (e.g., limaprost), alongside a gastroprotective H2-receptor antagonist (e.g., roxatidine). Concurrently, her internal medicine prescriptions included antihypertensives (e.g., amlodipine/valsartan), cognitive enhancers (e.g., choline alfoscerate), antifungals (e.g., fluconazole), and crucially, a thiazide diuretic (hydrochlorothiazide).
The iatrogenic burden progressively increased starting with corticosteroid injections (e.g., triamcinolone acetonide) on March 21, 2025, for radiating pain. This was compounded by a course of oral prednisolone for a sore throat on April 16, 2025, and subsequent high-dose oral prednisolone for stomatitis on June 6, 2025. Notably, the treatment for stomatitis also included the continuous, frequent application of a topical gargle containing both prednisolone and antibiotics. This cumulative exposure to systemic and topical corticosteroids- combined with prolonged thiazide diuretic use-increased the patient’s physiological vulnerability, leaving her in a primed state for further ADEs.
On June 21, 2025, levosulpiride (a prokinetic) was prescribed at a local clinic during an ingrown toenail treatment. Given her underlying vulnerability, the introduction of levosulpiride induced DIP4,6,7. By June 23, 2025, she presented with masked facies, slurred speech, and gait disturbance involving subjective leg weakness and an actual fall event (Hoehn and Yahr stage 3), notably without resting tremor18. A brain magnetic resonance imaging (MRI) was immediately performed, which confirmed the absence of acute structural lesions (Fig. 2). Upon identifying the pharmacological culprit, levosulpiride was promptly deprescribed on June 27, 2025, while her baseline Socheongryong-tang was maintained for cardiovascular support. Crucially, to clearly isolate the clinical effect of levosulpiride cessation, acupuncture and other new interventions were deliberately withheld during this phase. Following this targeted discontinuation, her parkinsonian symptoms completely resolved by July 4, 2025 (Hoehn and Yahr stage 0).
Fig. 2
Brain magnetic resonance imaging (MRI) and angiography (MRA) ruling out acute structural pathology during the drug-induced parkinsonism phase (Phase 2)
(A) T1-weighted image shows age-appropriate mild brain atrophy. (B) T2-fluid-attenuated inversion recovery (FLAIR) image demonstrates nonspecific chronic white matter changes. (C) Diffusion-weighted image (DWI) reveals no acute infarction. (D) MRA displays mild diffuse atherosclerosis without acute vascular occlusion. These findings definitively rule out acute structural brain lesions, corroborating the diagnosis of levosulpiride-induced parkinsonism.
DWI : diffusion-weighted imaging, FLAIR : fluid-attenuated inversion recovery, MRA : magnetic resonance angiography, MRI : magnetic resonance imaging
4. Fragmented Care and Steroid-Induced Hypokalemia (Phase 3)
Although the DIP was resolved, the patient’s underlying physiological balance remained vulnerable. She had been taking a thiazide diuretic for a long time, which was stopped on June 11, 2025. However, the delayed effects of prolonged diuretic use, combined with the cumulative exposure to systemic and topical corticosteroids prescribed since March, precipitated a severe electrolyte imbalance9.
On July 8, 2025, experiencing profound fatigue and generalized weakness, she visited another local clinic. At the clinic, her symptoms were evaluated without a fundamental laboratory workup and were empirically attributed to age-related frailty rather than potential ADEs from her complex medication history. Consequently, a vitamin-infused intravenous (IV) fluid was administered.
Although the patient reported a transient, mild subjective improvement following the IV infusion-likely due to temporary volume expansion-this empirical symptom management delayed the identification of the underlying crisis. The critical electrolyte imbalance (hypokalemia) remained undetected and untreated until she visited the KM clinic the following day.
5. Comprehensive, Multimodal Korean Medicine Intervention
The following day (July 9, 2025), she presented to the KM clinic. Notably, the patient did not present with overt signs of severe dehydration, nor did she have any recent history of vomiting or diarrhea that could otherwise account for profound gastrointestinal potassium loss. However, her overall dietary intake had significantly decreased over the preceding weeks due to severe stomatitis and progressing generalized weakness. Her functional status was remarkably deteriorated (Eastern Cooperative Oncology Group [ECOG] Grade 2, Medical Research Council [MRC] Grade 4 in all four extremities)19,20. Blood tests revealed critical hypokalemia (Serum K+ 2.5 mEq/L). Although her blood pressure was elevated, it remained consistent with her baseline hypertensive state. Crucially, she denied any chest pain, dyspnea, or other symptoms suggestive of acute myocardial infarction, presenting solely with profound generalized weakness.
An initial electrocardiogram (ECG) performed at the clinic revealed T-wave inversions. While such repolarization abnormalities might typically prompt cardiac biomarker testing (e.g., CK-MB, Troponin-I) in an acute setting, these findings were consistent with a strain pattern secondary to her pre-existing chronic hypertension and left ventricular hypertrophy (LVH). More importantly, the ECG confirmed the absence of classic malignant morphological alterations associated with critical hypokalemia-such as prominent U waves, ST-segment depression, or prolonged QT intervals-as well as any acute arrhythmias21,22. Therefore, further invasive cardiac testing was deemed unnecessary, and the profound muscular weakness was directly attributed to the severe hypokalemia.
A serum potassium level of 2.5 mEq/L typically warrants consideration for an emergency department transfer for IV potassium replacement. However, several critical factors justified a cautious, outpatient-based multimodal approach in this specific case. First, despite her generalized weakness, her clinical appearance did not suggest an impending cardiopulmonary crisis-a deceptively stable presentation that had even led another local clinic to manage her conservatively with simple vitamin infusions just the day prior. Furthermore, upon presentation to the KM clinic, her vital signs remained stable, and her initial ECG corroborated the absence of immediate, life-threatening cardiac threats.
Second, rather than an immediate transfer, the physician engaged in a thorough shared decision-making process with the patient and her family. The inherent risks of aggressive IV potassium replacement in a frail octogenarian-such as fluid overload and rebound fatal arrhythmias- were carefully explained and weighed against the potential safety and efficacy of a conservative, outpatient multimodal KM approach. Following this comprehensive risk-benefit counseling, the patient and her family fully agreed with the medical assessment and provided informed consent to proceed with close outpatient monitoring and intervention rather than emergency hospitalization.
The cornerstone of this multimodal intervention was the immediate deprescribing of all remaining systemic and topical corticosteroids, which halted further iatrogenic potassium depletion. However, halting the prescribing cascade alone was insufficient for a frail patient with critically depleted physiological reserves. To actively facilitate metabolic rehabilitation, as a vital supportive measure alongside deprescribing, a customized herbal decoction, modified Cheonmagudeung-eum (Tianma Gouteng Yin; 天麻鉤藤飮) (detailed in Table 3), was formulated based on the traditional KM diagnosis of Wei syndrome (痿證) complicated by Liver and Kidney deficiency with Liver Yang hyperactivity (肝腎不足 肝陽上亢). This decoction was designed using mineral-rich herbs to safely support the restoration of serum potassium levels and neuromuscular function, while concurrently managing her underlying hypertension without inducing rapid fluid shifts11-13,23.
Table 2
Timeline of Cumulative Corticosteroid Exposure (March to July 2025)
This table outlines the cumulative exposure to systemic and topical corticosteroids prescribed across multiple independent clinics. The overlapping administration of injectable, oral, and topical formulations-including the dose escalation of oral triamcinolone and the 14-day continuous use of oral prednisolone-contributed to a substantial mineralocorticoid burden. This concurrent exposure, alongside the prolonged use of a thiazide diuretic (hydrochlorothiazide) until June 11, served as the primary pharmacological trigger for the severe hypokalemia observed in Phase 3.
Table 3
Composition of Modified Cheonmagudeung-eum (Tianma Gouteng Yin)
The herbal decoction was prepared by extracting 21 cheops [136.5 g per cheop] with water to produce 42 packets [100 mL each]. The patient was instructed to take one packet twice daily for 21 consecutive days. Patient compliance was closely monitored and confirmed to be 100%. Specific modifications included the strategic addition of herbs reported to have high potassium contents [e.g., Achyranthis Radix, Angelicae Acutilobae Radix, Dioscoreae Rhizoma, and Cnidii Rhizoma] and the dose reduction of cold-natured herbs [Gardeniae Fructus and Scutellariae Radix]. These modifications were intended to synergistically support metabolic recovery while accommodating the patient’s profound physical exhaustion. However, because the final potassium concentration in the decocted fluid was not quantitatively measured, their precise pharmacokinetic contribution to electrolyte replenishment remains a mechanistic hypothesis rather than a direct equivalent to pharmaceutical intravenous replacement.
Beyond pharmacological deprescribing and herbal medicine, targeted nutritional and lifestyle counseling was an essential component of this intervention. To address the electrolyte imbalance and concurrent mild hypoproteinemia observed in her blood tests, the patient was instructed to increase her dietary sodium intake using natural sea salt and to consume a diet rich in high-quality animal proteins (e.g., eggs, natural cheeses). Furthermore, to prevent further metabolic burden and potential polypharmacy interactions, she was advised to withhold her oral antifungal medication (fluconazole) for onychomycosis and rely solely on topical treatments, which aligns with the overarching deprescribing strategy detailed in Supplementary Table 1.
During the acute phase of Wei syndrome (July 9 and 15), acupuncture was deliberately withheld to prioritize patient safety given her state of extreme frailty. Once her serum potassium levels recovered and subjective symptoms improved, acupuncture was safely resumed (on July 23, August 6, and August 20), reinstating the long-term maintenance protocol established since December 24, 2024 (Table 4). Acupuncture treatment was performed using sterile, disposable stainless steel filiform needles (0.16×15 mm; Dongbang Medical, Boryeong, Korea). Needles were inserted bilaterally at LI4 (合谷), LR3 (太衝), LI11 (曲池), LU5 (尺澤), LI6 (偏歷), ST36(足三里), GB34 (陽陵泉), SP9 (陰陵泉), KI3 (太溪), and SP6 (三陰交) to an approximate depth of 5-10 mm. Following the elicitation of the traditional de qi (得氣) sensation, electroacupuncture stimulation (4 Hz, continuous wave) was applied for 15 minutes per session. This specific acupoint selection, which had been consistently utilized prior to the hypokalemic crisis, was maintained to manage her underlying hypertension associated with Liver and Kidney deficiency with Liver Yang hyperactivity.
Table 4
Summary of Multimodal Korean Medicine Interventions and Clinical Rationales
This table outlines the specific components, timelines, and rationales of the multimodal Korean Medicine approach. The interventions were dynamically adjusted according to the patient’s evolving clinical status and physiological reserve.
ADE : adverse drug event, b.i.d. : bis in die [twice a day], BP : blood pressure, cap. : capsule, CV : Conception Vessel, DIP : drug-induced parkinsonism, ECOG : Eastern Cooperative Oncology Group, GB : Gallbladder, GI : gastrointestinal, KI : Kidney, K⁺ : potassium, LI : Large Intestine, LR : Liver, LU : Lung, q.d. : quaque die [once a day], SP : Spleen, ST : Stomach, t.i.d. : ter in die [three times a day]. Acupuncture points are named according to the World Health Organization standard nomenclature
6. Clinical Outcomes
Following the comprehensive, multimodal KM intervention, the patient demonstrated a steady clinical recovery. Within two weeks (July 23, 2025), her serum potassium levels safely normalized to 3.5 mEq/L (Table 5), and her profound generalized weakness completely resolved from an initial ECOG Grade 2 and MRC Grade 4 to an ECOG Grade 0 and MRC Grade 5, respectively (Table 6).
Table 5
Changes in Laboratory Parameters and Electrocardiogram Findings
Bold font highlights the critical hypokalemia level at the initial presentation. N/A indicates that the specific test was not performed on that date. ECG findings consistently showed a normal sinus rhythm with baseline left ventricular hypertrophy and T-wave inversion related to pre-existing hypertension. Notably, no acute hypokalemia-induced arrhythmias or specific morphological changes [e.g., prominent U waves] were observed throughout the clinical course.
ALT : alanine aminotransferase, AST : aspartate aminotransferase, BUN : blood urea nitrogen, CKD-EPI : Chronic Kidney Disease Epidemiology Collaboration, ECG : electrocardiogram, eGFR : estimated glomerular filtration rate [calculated via the CKD-EPI 2021 equation], F/U : follow-up, LVH : left ventricular hypertrophy, N/A : not assessed, NSR : normal sinus rhythm, RBC : red blood cell count
Table 6
Changes in Clinical Symptoms and Functional Status
This table outlines the functional recovery following the targeted deprescribing of offending agents and the multimodal Korean Medicine interventions. H&Y Stage 3 indicates mild to moderate bilateral disease with some postural instability; Stage 0 indicates no signs of disease. ECOG Grade 2 indicates that the patient is ambulatory and capable of all self-care but unable to carry out any work activities [up and about more than 50% of waking hours]; Grade 0 indicates fully active status. MRC Grade 4 indicates active movement against gravity and some resistance; Grade 5 indicates normal power against full resistance. The MRC evaluation was consistently performed on all four extremities, confirming generalized symmetrical weakness and its subsequent complete resolution.)
Subsequent follow-up laboratory tests on August 6, 2025, confirmed that her potassium levels had further improved to 3.9 mEq/L, demonstrating that physiological stability was well-maintained even after the completion of the herbal decoction on July 30, 2025. Following the completion of the acute rehabilitative decoction, a stepwise maintenance therapy was introduced to optimize cardiovascular stability and manage persistent fatigue (Table 4). From July 31, Simjeokhwan (心適丸, originally known as Fufang Danshen Diwan [复方丹参滴丸]; Hamsoa Pharm Co., Ltd., Seoul, Republic of Korea) and customized Mahwang (Ephedrae Herba; 麻黃) capsules (Hokburi External Herb Dispensary, Republic of Korea; containing 20 mg of total ephedrine alkaloids per 500 mg extract capsule) were administered. Given the patient’s age and underlying hypertension, the potential cardiovascular risks of ephedrine alkaloids-present in her baseline Socheongryong-tang, the modified Cheonmagudeung-eum decoction, and the customized capsules-were meticulously managed across all treatment phases. The total daily intake of ephedrine alkaloids from any combination of these herbal sources was continuously calculated and strictly capped at under 60 mg/day throughout the clinical course. This maximum cumulative exposure remains substantially below the established maximum safe limits (120-150 mg/day) approved by international guidelines and recent safety evaluations24,25. Throughout its administration, the patient’s blood pressure and resting heart rate were closely monitored and remained remarkably stable within her pre-existing baseline ranges, without any hypertensive spikes or tachycardic episodes. Notably, no adverse cardiovascular events-such as palpitations, tremors, or chest pain-were observed, confirming the clinical safety of this strictly monitored regimen. Additionally, her anemia-related markers (red blood cell count and hemoglobin) recovered to near-normal levels. Although her serum protein level showed a slight improvement (from 6.1 to 6.2 g/dL), it remained marginally below the normal range, for which ongoing dietary protein supplementation was advised.
Furthermore, serial ECG monitoring was conducted from the initial presentation of critical hypokalemia through the recovery phase. The ECG consistently revealed a normal sinus rhythm with baseline left ventricular hypertrophy LVH and T-wave inversion, which were attributed to her pre-existing chronic hypertension. Notably, no acute hypokalemia-induced arrhythmias or distinct morphological alterations, such as prominent U waves or ST-segment depression, were observed at any point, confirming cardiac electrical stability throughout the KM intervention.
Ultimately, this multimodal strategy-integrating targeted deprescribing, tailored herbal medicine, and metabolic dietary correction-was associated with the successful resolution of the sequential PCs. By addressing the underlying iatrogenic triggers, this approach facilitated a safe functional recovery, avoiding the pitfalls of isolated symptom management.
III. Discussion
The modern healthcare system’s reliance on fragmented, single-disease paradigms can transform polypharmacy into a significant iatrogenic hazard for frail elderly patients. This case report describes the clinical course of a sequential PC-progressing from functional dyspepsia to levosulpiride-induced DIP, and ultimately to steroid-induced hypokalemia. These cascading events were fueled by a fragmented prescribing pattern, resulting in a cumulative exposure to 17 pharmaceutical products (encompassing 26 active ingredients) across multiple independent clinics. The repeated misinterpretation of ADEs as new, independent pathologies, coupled with empirical symptom management without fundamental laboratory evaluations, highlights the blind spots inherent in compartmentalized clinical practices3,5. In South Korea’s dual healthcare system, where conventional medicine and KM practices are structurally divided, cross-disciplinary medication tracking is notoriously challenging. Thus, to overcome this systemic fragmentation, the proactive utilization of the national DUR system by KM practitioners serves not merely as an administrative step, but as an essential clinical safeguard. In this case, it served as a critical diagnostic tool; comprehensively tracking the patient’s multi-clinic medication history enabled the physician to successfully identify the hidden iatrogenic triggers that single-disease approaches had overlooked. The resolution of this complex crisis underscores the potential utility of a comprehensive, multimodal KM approach. By establishing targeted deprescribing as the primary intervention-and synergistically integrating supportive herbal medicine, safety-guided acupuncture, and dietary correction-this strategy effectively interrupted the PC and aided in safely restoring the patient’s physiological balance.
The clinical decline progressed through distinct but sequentially interconnected phases of iatrogenesis. Initially, the massive polypharmacy burden-comprising 17 pharmaceutical products (26 active ingredients)-triggered functional dyspepsia in Phase 1 (NRS 4, GSRS 5). Following the resolution of her dyspepsia (NRS 0, GSRS 2), the subsequent resumption of 8 pharmaceutical products (9 active ingredients) for orthopedic and internal comorbidities re-established a highly vulnerable physiological state. The specific catalyst for Phase 2 was the administration of levosulpiride-a substituted benzamide prescribed as a prokinetic agent following an ingrown toenail treatment. While effective for gastrointestinal symptoms, its potent dopamine D2 receptor antagonistic activity poses a high risk of inducing movement disorders in elderly women4,7. In this patient, the rapid onset of DIP-characterized by a masked face, slurred speech, and gait disturbances (Hoehn and Yahr Stage 3)-exemplifies a classic PC trigger3. Following a neurological evaluation and a brain MRI that successfully ruled out acute structural lesions, the offending agent was promptly discontinued. Her Parkinsonian symptoms completely resolved (Hoehn and Yahr Stage 0) within a week. Crucially, to objectively isolate and validate the clinical effect of levosulpiride cessation, acupuncture and new herbal interventions were deliberately withheld during this specific recovery period. This rapid recovery not only aligns with the typical clinical course of DIP upon cessation of the offending agent but also provides definitive evidence that the most critical therapeutic intervention was the timely recognition and targeted withdrawal of levosulpiride (deprescribing), rather than the addition of new therapies.
This underlying vulnerability was further compounded during Phase 3. The patient developed critical hypokalemia (K⁺ 2.5 mEq/L), presenting as profound generalized weakness (ECOG Grade 2, MRC Grade 4). Although her prolonged use of a thiazide diuretic had been discontinued on June 11, 2025, its delayed potassium-wasting effects collided with an uncoordinated accumulation of corticosteroids prescribed across multiple independent clinics. Furthermore, her significantly reduced dietary intake secondary to severe stomatitis acted as a crucial contributing factor, further exacerbating this iatrogenic electrolyte imbalance. As explicitly detailed in the timeline of cumulative corticosteroid exposure (Table 2) and her comprehensive medication history (Supplementary Table 1), between March and July 2025, the patient was subjected to a severe cumulative burden from systemic injections, oral steroids, and crucially, the continuous application of a topical steroid-antibiotic gargle. The AGS Beers Criteria explicitly warns against the combination of corticosteroids and diuretics in older adults due to the synergistically amplified risk of severe fluid and electrolyte imbalances8. Despite her presenting with profound weakness, another local clinic empirically administered IV vitamin fluids without conducting a basic metabolic panel or a comprehensive medication review via the DUR system. This empirical management not only delayed the critical diagnosis but also placed the frail patient in a precarious metabolic state9,22, starkly illustrating how fragmented care fails to connect discrete pharmacological dots.
When confronted with critical hypokalemia (K⁺ 2.5 mEq/L), aggressive IV potassium replacement in an emergency setting is typically warranted. However, careful clinical assessment-including initial ECG monitoring that confirmed the absence of malignant arrhythmias-allowed for a more calibrated approach. Recognizing the inherent risks of fluid overload and fatal rebound arrhythmias associated with rapid IV replacement in frail octogenarians26,27, the physician engaged in a thorough shared decision-making process. With informed consent from the patient and her family, a conservative, outpatient-based multimodal KM intervention was prioritized over an emergency transfer. The absolute cornerstone of this recovery was the immediate cessation of all offending corticosteroids. While the modified Cheonmagudeung-eum (Tianma Gouteng Yin) decoction and dietary corrections were implemented to support metabolic recovery, the immediate cessation of all offending corticosteroids was undoubtedly the primary driver of the rapid potassium normalization. In alignment with the logical deduction from Phase 2-where the withdrawal of levosulpiride alone resolved the parkinsonism-the herbal and dietary interventions in Phase 3 should be viewed as playing a vital supportive role in metabolic rehabilitation, rather than acting as independent curative agents.
As systematically detailed in the Summary of Multimodal KM Interventions Table 4, a modified Cheonmagudeung-eum decoction was meticulously formulated. Rather than acting as a standalone therapy, this decoction was designed to adjunctively assist electrolyte recovery alongside dietary corrections. Drawing upon pharmacological research highlighting the high mineral contents of specific medicinal herbs13, potassium-rich botanicals-such as Achyranthis Radix (牛膝), Angelicae Acutilobae Radix (當歸), Cnidii Rhizoma (川芎), and Dioscoreae Rhizoma (山藥)-were strategically incorporated. Furthermore, to protect her depleted physiological state, the dosages of cold-natured herbs (Gardeniae Fructus [梔子] and Scutellariae Radix [黃芩]) were deliberately reduced. This customized herbal and dietary formulation safely supported the normalization of her serum potassium (from 2.5 to 3.5 mEq/L) and stabilized her baseline hypertension, effectively avoiding the dangerous fluid shifts associated with IV therapy. Beyond electrolyte correction, Cheonmagudeung-eum has established clinical evidence for managing essential hypertension11,12 and has demonstrated neuroprotective properties in Parkinson’s disease models23. Thus, its administration may have adjunctively contributed to stabilizing her central nervous system following the severe DIP episode while safely managing her baseline hypertension.
The comprehensive nature of this multimodal KM intervention extended beyond acute herbal pharmacotherapy to include strategically paced acupuncture and metabolic dietary corrections, and long-term maintenance planning. Given the patient’s critical state of generalized weakness upon her initial presentation with hypokalemia, acupuncture treatment was temporarily withheld. This clinical decision was deliberately made to prioritize patient safety and prevent any further depletion of her severely compromised physiological reserve, as vigorous stimulation in extremely frail or exhausted patients is traditionally contraindicated to avoid adverse autonomic responses28. Once serum potassium levels normalized and neuromuscular function was sufficiently restored (ECOG Grade 0, MRC Grade 5), acupuncture was safely reintroduced. As detailed in Table 4, this step reinstated the long-term antihypertensive maintenance protocol-utilizing the same specific acupoint selection established since December 24, 2024-to consistently manage her underlying baseline conditions.
Concurrently, nutritional counseling was implemented as a crucial component of her metabolic recovery. Adequate dietary intake of high-quality proteins and natural sea salt was strongly advised to address her borderline hypoproteinemia and support long-term physiological resilience, consistent with current geriatric guidelines29. Simultaneously, her oral antifungal medication was discontinued to minimize hepatic burden and reduce polypharmacy. Furthermore, following the completion of the acute rehabilitative decoction, the patient transitioned to a stepwise maintenance therapy utilizing Simjeokhwan (Fufang Danshen Diwan) and customized Mahwang (Ephedrae Herba) capsules. It is noteworthy that the patient had already demonstrated clinical tolerability to low-dose ephedrine through her baseline use of Socheongryong-tang prior to the PC. When navigating through the acute rehabilitative decoction (which included 4 g of Ephedrae Herba per daily dose) to the subsequent maintenance therapy, the cumulative ephedrine alkaloid load from all prescribed herbal medicines was meticulously calculated. By strictly capping the maximum total daily alkaloid dose to under 60 mg across all treatment phases-well below the 120-150 mg/day safety threshold24,25-the potential cardiovascular risks were preemptively minimized. Throughout its administration, the patient’s blood pressure and resting heart rate were closely monitored and remained remarkably stable within her pre-existing baseline ranges, without any hypertensive spikes or tachycardic episodes. Notably, no adverse cardiovascular events-such as palpitations, tremors, or chest pain-were observed, confirming the clinical safety of this strictly monitored regimen. This tailored regimen safely supported her metabolic rate and vitality without overburdening her cardiovascular system. Importantly, throughout the entire duration of this multimodal KM intervention, no adverse reactions were observed. Through this multifaceted approach-integrating targeted deprescribing, customized herbal medicine, safety-guided acupuncture, and lifestyle modifications-the vicious cycle of the PC was successfully resolved. This stable clinical trajectory highlights the value of a patient-centered paradigm that prioritizes restoring systemic physiological balance (Ben; 本) over additive pharmacological symptom management.
Despite the positive clinical outcomes, this case report has several limitations that must be acknowledged. First, as a single retrospective case study, the findings cannot be broadly generalized to the wider geriatric population. Second, although formal adverse drug reaction causality assessments were systematically conducted using the Naranjo scale and WHO-UMC criteria (Table 1), these standardized tools have inherent limitations when applied to complex PCs. They are primarily designed to evaluate direct, single drug-event pairs and often struggle to fully quantify the synergistic iatrogenesis seen in massive polypharmacy-such as the overlapping delayed effects of thiazide diuretics combined with cumulative corticosteroid formulations. For instance, evaluating the entire 14-drug regimen as a single suspected cause for Phase 1 dyspepsia deviates from the strict single-agent evaluation method. However, because multiple gastrointestinal irritants (e.g., NSAIDs) and motility-altering agents (e.g., opioids) were initiated simultaneously, isolating a single pharmacological culprit was practically impossible. Furthermore, while functional dyspepsia in the elderly has numerous alternative causes, such as age-related motility decline, the abrupt temporal correlation with this extreme pharmacological load necessitated assessing the aggregate burden as the primary iatrogenic trigger. Third, quantitative serum drug concentrations of the offending agents were not measured, and while serum electrolytes and hepatic panels were closely monitored, follow-up evaluations for renal function parameters (e.g., blood urea nitrogen, serum creatinine, and estimated glomerular filtration rate) were inadvertently omitted after the initial baseline assessment. This omission represents a significant clinical shortcoming in the outpatient management of this patient. While serial potassium and ECG monitoring ensured immediate safety, managing critical hypokalemia (K⁺ 2.5 mEq/L) without comprehensive metabolic tracking limits the rigorous assessment of her full physiological recovery. This critical oversight underscores the necessity of mandating comprehensive metabolic panels in future outpatient protocols for severe electrolyte imbalances. Fourth, although the multimodal KM intervention was well-tolerated, herbal medicines inherently contain complex bioactive compounds that carry a potential for herb-drug interactions. Because this was a real-world clinical intervention rather than a controlled trial, the specific pharmacological effects of the herbal decoction cannot be entirely isolated from the profound physiological benefits of deprescribing and dietary corrections. Nevertheless, the serial monitoring of serum potassium levels and the stable ECG findings provided reliable safety parameters throughout the recovery phase. Ultimately, this case highlights that early ADE recognition, targeted deprescribing, and meticulous care coordination-facilitated by centralized tools like the DUR system-are paramount in geriatric care. When integrated with a supportive, patient- centered KM approach, these core strategies successfully resolved a life-threatening iatrogenic crisis. This underscores the critical need for modern healthcare to prioritize the systemic root of PCs over the fragmented management of isolated symptoms.
IV. Conclusion
In conclusion, this case highlights the severe consequences of sequential prescribing cascades in an elderly patient exposed to extreme polypharmacy and fragmented medical care. Misinterpreting adverse drug reactions-such as levosulpiride-induced parkinsonism and steroid/diuretic-induced hypokalemia-as new age-related conditions perpetuates a vicious cycle of iatrogenic harm. The findings suggest that a comprehensive, multimodal KM strategy-anchored by targeted deprescribing alongside dietary correction and supportive herbal medicine-may be helpful in managing medication-related harm and restoring physiological balance in selected patients. Ultimately, this case underscores the urgent need to shift from a compartmentalized approach to a holistic, patient-centered paradigm to optimize the care of geriatric patients.
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