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TABLE 1. 2015 American Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults

From THE AMERICAN GERIATRICS SOCIETY Organ System, Therapeutic Recommendation, Rationale, Quality of Evidence Category, (s) (QE), Strength of Recommendation (SR) A POCKET GUIDE TO THE First-generation Avoid : Highly ; clearance reduced with advanced age, AGS 2015 BEERS CRITERIA ■ and tolerance develops when used as ; risk of confusion, ■ This guide has been developed as a tool to assist healthcare providers in improving dry mouth, , and other anticholinergic effects or ■ Chlorpheniramine toxicity medication safety in older adults. The role of this guide is to inform clinical decision- ■ Use of in situations such as acute treatment of ■ making, research, training, quality measures and regulations concerning the prescribing of severe allergic reaction may be appropriate medications for older adults to improve safety and quality of care. It is based on The AGS ■ QE = Moderate; SR = Strong 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. ■ ■ Originally conceived of in 1991 by the late Mark Beers, MD, a geriatrician, the Beers ■ Diphenhydramine (oral) Criteria catalogues medications that cause side effects in the elderly due to the ■ physiologic changes of aging. In 2011, the AGS sponsored its fi rst update of the criteria, ■ assembling a team of experts and using an enhanced, evidence-based methodology. In ■ 2015, the AGS again funded the development of the Updated Criteria using an evidence- ■ ■ based methodology and rating each Criterion (quality of evidence and strength of Antiparkinsonian agents Avoid evidence) using the American College of Physicians’ Guideline Grading System, which is ■ Benztropine (oral) based on the GRADE scheme developed by Guyatt et al. Not recommended for prevention of extrapyramidal symptoms ■ with antipsychotics; more-effective agents available for The full document, along with accompanying resources can be viewed in their entirety treatment of Parkinson disease online at geriatricscareonline.org. QE = Moderate; SR = Strong

INTENDED USE Antispasmodics: Avoid ■ (excludes Highly anticholinergic, uncertain effectiveness The goal of this guide is to improve care of older adults by reducing their exposure to ophthalmic) QE = Moderate; SR = Strong Potentially Inappropriate Medications (PIMS). ■ Belladonna ■ This should be viewed as a guideline for identifying medications for which the risks ■ Clidinium- Chlordiazepoxide of their use in older adults outweigh the benefi ts. ■ Dicyclomine ■ These criteria are not meant to be applied in a punitive manner. ■ ■ This list is not meant to supersede clinical judgment or an individual patient’s values ■ Propantheline and needs. Prescribing and managing disease conditions should be individualized ■ and involve shared decision-making. Antithrombotics ■ These criteria also underscore the importance of using a team approach to ■ Dipyridamole, oral Avoid prescribing and the use of non-pharmacological approaches and of having short-acting (does not May cause orthostatic hypotension; more effective alternatives economic and organizational incentives for this type of model. apply to the extended- available; IV form acceptable for use in cardiac stress testing release combination ■ Two companion pieces were developed for the 2015 update. The fi rst addresses QE = Moderate; SR = Strong the best way for patients, providers, and health systems to use (and not use) the with aspirin) 2015 AGS Beers Criteria. The second is a list of alternative medications included in the current use of High-Risk Medications in the Elderly and Potentially Harmful ■ Ticlopidine Avoid Drug-Disease Interactions in the Elderly quality measures. Both pieces can be found Safer, effective alternatives available on geriatricscareonline.org. QE = Moderate; SR = Strong The criteria are not applicable in all circumstances (i.e. patient’s receiving palliative and hospice care). If a provider is not able to fi nd an alternative and chooses to continue to CNS=central ; NSAIDs=nonsteroidal anti-infl ammatory ; SIADH, syndrome of use a drug on this list in an individual patient, designation of the medication as potentially inappropriate antidiuretic hormone. inappropriate can serve as a reminder for close monitoring so that adverse drug effects can be incorporated into the electronic health record and prevented or detected early.

THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals. AGS Leading change. Improving care for older adults. ✃ PAGE 1 PAGE 2 Table 1 (continued on page 3) Table 1 Continued Table 1 Continued Organ System, Therapeutic Organ System, Therapeutic Category, Drug(s) Recommendation, Rationale, QE, SR Category, Drug(s) Recommendation, Rationale, QE, SR Anti-infective Nifedipine, immediate Avoid ■ Nitrofurantoin Avoid in individuals with creatinine clearance <30 mL/min or release Potential for hypotension; risk of precipitating myocardial for long-term suppression of bacteria ischemia Potential for pulmonary toxicity, hepatoxicity, and peripheral QE = High; SR = Strong neuropathy, especially with long-term use; safer alternatives available QE = Low; SR = Strong Amiodarone Avoid amiodarone as fi rst-line therapy for atrial fi brillation unless the patient has heart failure or substantial left ventricular Cardiovascular hypertrophy Peripheral -1 Avoid use as an antihypertensive Amiodarone is effective for maintaining sinus rhythm but has blockers High risk of orthostatic hypotension; not recommended as greater toxicities than other antiarrhythmics used in atrial ■ Doxazosin routine treatment for hypertension; alternative agents have fi brillation; it may be reasonable fi rst-line therapy in patients ■ Prazosin superior risk/benefi t profi le with concomitant heart failure or substantial left ventricular ■ Terazosin QE = Moderate; SR = Strong hypertrophy if rhythm control is preferred over rate control QE = High; SR = Strong Central alpha Avoid clonidine as fi rst-line antihypertensive. Avoid others as ■ Clonidine listed Central nervous system ■ Guanabenz High risk of adverse CNS effects; may cause bradycardia and ■ Guanfacine , alone or Avoid orthostatic hypotension; not recommended as routine treatment in combination ■ Methyldopa for hypertension Highly anticholinergic, sedating, and cause orthostatic ■ ■ Reserpine (>0.1 mg/d) hypotension; safety profi le of low-dose (≤6 mg/d) QE = Low; SR = Strong ■ comparable with that of placebo ■ QE = High; SR = Strong Disopyramide Avoid ■ Disopyramide is a potent negative inotrope and therefore may ■ Doxepin >6 mg/d induce heart failure in older adults; strongly anticholinergic; ■ other antiarrhythmic drugs preferred ■ QE = Low; SR = Strong ■ ■ Dronedarone Avoid in individuals with permanent atrial fi brillation or severe ■ or recently decompensated heart failure Antipsychotics, fi rst- Avoid, except for schizophrenia, bipolar disorder, or short-term Worse outcomes have been reported in patients taking (conventional) and use as during chemotherapy dronedarone who have permanent atrial fi brillation or severe or second- (atypical) Increased risk of cerebrovascular accident (stroke) and greater recently decompensated heart failure generation rate of cognitive decline and mortality in persons with QE = High; SR = Strong Avoid antipsychotics for behavioral problems of dementia and/ or unless nonpharmacological options (e.g., behavioral Digoxin Avoid as fi rst-line therapy for atrial fi brillation. Avoid as fi rst- interventions) have failed or are not possible and the older adult line therapy for heart failure. If used for atrial fi brillation or is threatening substantial harm to self or others heart failure, avoid dosages >0.125 mg/d QE = Moderate; SR = Strong Use in atrial fi brillation: should not be used as a fi rst-line agent in atrial fi brillation, because more-effective alternatives exist and it may be associated with increased mortality Avoid Use in heart failure: questionable effects on risk of hospitalization ■ High rate of physical dependence, tolerance to sleep benefi ts, and may be associated with increased mortality in older adults ■ Butabarbital greater risk of overdose at low dosages ■ Butalbital with heart failure; in heart failure, higher dosages not associated QE = High; SR = Strong with additional benefi t and may increase risk of toxicity ■ Mephobarbital ■ Decreased renal clearance of digoxin may lead to increased ■ risk of toxic effects; further dose reduction may be necessary in ■ those with Stage 4 or 5 chronic disease. QE = Atrial fi brillation: moderate. Heart failure: low. Dosage >0.125 mg/d: moderate; SR = Atrial fi brillation: strong.

Heart failure: strong. Dosage >0.125 mg/d: strong ✃

PAGE 3 Table 1 (continued on page 4) PAGE 4 Table 1 (continued on page 5) Table 1 Continued Table 1 Continued Organ System, Therapeutic Organ System, Therapeutic Category, Drug(s) Recommendation, Rationale, QE, SR Category, Drug(s) Recommendation, Rationale, QE, SR Avoid Estrogens with or without Avoid oral and topical patch. Vaginal cream or tablets: Short- and intermediate- Older adults have increased sensitivity to benzodiazepines and progestins acceptable to use low-dose intravaginal estrogen for acting: decreased metabolism of long-acting agents; in general, all management of dyspareunia, lower urinary tract infections, and ■ benzodiazepines increase risk of cognitive impairment, delirium, other vaginal symptoms ■ falls, fractures, and motor vehicle crashes in older adults Evidence of carcinogenic potential (breast and endometrium); ■ May be appropriate for disorders, rapid eye movement lack of cardioprotective effect and cognitive protection in older ■ sleep disorders, withdrawal, withdrawal, women. ■ severe generalized anxiety disorder, and periprocedural Evidence indicates that vaginal estrogens for the treatment of ■ vaginal dryness are safe and effective; women with a history of Long-acting: QE = Moderate; SR = Strong breast cancer who do not respond to nonhormonal therapies ■ Clorazepate are advised to discuss the risk and benefi ts of low-dose vaginal ■ Chlordiazepoxide (alone estrogen (dosages of estradiol <25 mcg twice weekly) with their or in combination health care provider with amitriptyline or clidinium) QE = Oral and patch: high. Vaginal cream or tablets: moderate.; SR = Oral and patch: strong. Topical vaginal cream or tablets: weak ■ Clonazepam ■ Diazepam Growth hormone Avoid, except as hormone replacement following pituitary gland ■ removal ■ Impact on body composition is small and associated with edema, Meprobamate Avoid arthralgia, carpal tunnel syndrome, gynecomastia, impaired fasting High rate of physical dependence; very sedating glucose QE = Moderate; SR = Strong QE = High; SR = Strong Insulin, sliding scale Avoid , Avoid Higher risk of hypoglycemia without improvement in hyperglycemia management regardless of care setting; refers benzodiazepine receptor Benzodiazepine-receptor agonists have adverse events similar to sole use of short- or rapid-acting insulins to manage or avoid to those of benzodiazepines in older adults (e.g., delirium, falls, hyperglycemia in absence of basal or long-acting insulin; does ■ fractures); increased emergency room visits/hospitalizations; not apply to titration of basal insulin or use of additional short- or ■ motor vehicle crashes; minimal improvement in sleep latency rapid-acting insulin in conjunction with scheduled insulin (ie, ■ and duration correction insulin) QE = Moderate; SR = Strong QE = Moderate; SR = Strong Megestrol Avoid Ergoloid mesylates Avoid Minimal effect on weight; increases risk of thrombotic events (dehydrogenated ergot Lack of effi cacy and possibly death in older adults alkaloids) QE = High; SR = Strong QE = Moderate; SR = Strong Isoxsuprine Sulfonylureas, long- Avoid Endocrine duration Chlorpropamide: prolonged half-life in older adults; can cause Androgens Avoid unless indicated for confi rmed hypogonadism with ■ Chlorpropamide prolonged hypoglycemia; causes SIADH ■ Methyltestosterone clinical symptoms ■ Glyburide Glyburide: higher risk of severe prolonged hypoglycemia in older ■ Testosterone Potential for cardiac problems; contraindicated in men with adults prostate cancer QE = High; SR = Strong QE = Moderate; SR = Weak Gastrointestinal Avoid, unless for gastroparesis Desiccated thyroid Avoid Can cause extrapyramidal effects, including tardive dyskinesia; Concerns about cardiac effects; safer alternatives available risk may be greater in frail older adults QE = Low; SR = Strong QE = Moderate; SR = Strong Mineral oil, given orally Avoid Potential for aspiration and adverse effects; safer alternatives available

QE = Moderate; SR = Strong ✃

PAGE 5 Table 1 (continued on page 6) PAGE 6 Table 1 (continued on page 7) Table 1 Continued TABLE 2. 2015 American Geriatrics Society Beers Criteria for Potentially Inappropriate Organ System, Therapeutic Medication Use in Older Adults Due to Drug–Disease or Drug–Syndrome Interactions That Category, Drug(s) Recommendation, Rationale, QE, SR May Exacerbate the Disease or Syndrome Proton-pump inhibitors Avoid scheduled use for >8 weeks unless for high-risk patients (e.g., oral corticosteroids or chronic NSAID use), erosive Recommendation, Rationale, esophagitis, Barrett’s esophagitis, pathological hypersecretory Disease or Quality of Evidence (QE), Strength condition, or demonstrated need for maintenance treatment Syndrome Drug(s) of Recommendation (SR) (e.g., due to failure of drug discontinuation trial or H2 blockers) Cardiovascular Risk of C diffi cile infection and bone loss and fractures Heart failure NSAIDs and COX-2 inhibitors Avoid QE = High; SR = Strong Nondihydropyridine CCBs (diltiazem, Potential to promote fl uid retention and Pain medications verapamil)—avoid only for heart exacerbate heart failure Meperidine Avoid, especially in those with chronic kidney disease failure with reduced ejection QE = NSAIDs: moderate. CCBs: Not effective oral in dosages commonly used; may fraction moderate. Thiazolidinediones: high. have higher risk of neurotoxicity, including delirium, than other ; safer alternatives available Thiazolidinediones (pioglitazone, Cilostazol: low. Dronedarone: high; rosiglitazone) SR = Strong QE = Moderate; SR = Strong Cilostazol Non-cyclooxygenase- Avoid chronic use, unless other alternatives are not effective selective NSAIDs, oral: and patient can take gastroprotective agent (proton-pump Dronedarone (severe or recently ■ Aspirin >325 mg/d inhibitor or misoprostol) decompensated heart failure) ■ Diclofenac Increased risk of gastrointestinal bleeding or peptic ulcer Syncope Acetylcholinesterase inhibitors Avoid ■ Difl unisal disease in high-risk groups, including those aged >75 or (AChEIs) ■ Etodolac taking oral or parenteral corticosteroids, anticoagulants, or Increases risk of orthostatic ■ Fenoprofen antiplatelet agents; use of proton-pump inhibitor or misoprostol Peripheral alpha-1 blockers hypotension or bradycardia ■ Ibuprofen reduces but does not eliminate risk. Upper gastrointestinal ■ Doxazosin QE = Peripheral alpha-1 blockers: ■ Ketoprofen ulcers, gross bleeding, or perforation caused by NSAIDs occur ■ Prazosin high. TCAs, AChEIs, antipsychotics: ■ Meclofenamate in approximately 1% of patients treated for 3–6 months and in ■ Terazosin moderate; SR = AChEIs, TCAs: ■ Mefenamic acid ~2–4% of patients treated for 1 year; these trends continue with ■ Meloxicam longer duration of use Tertiary TCAs strong. Peripheral alpha-1 blockers, ■ Nabumetone ■ antipsychotics: weak QE = Moderate; SR = Strong ■ Naproxen ■ ■ Oxaprozin ■ ■ Piroxicam ■ Sulindac Central nervous system ■ Tolmetin Chronic Bupropion Avoid ■ Indomethacin Avoid or Chlorpromazine Lowers seizure threshold; may be ■ Ketorolac, includes Indomethacin is more likely than other NSAIDs to have adverse epilepsy acceptable in individuals with well- parenteral CNS effects. Of all the NSAIDs, indomethacin has the most controlled seizures in whom alternative adverse effects. Olanzapine agents have not been effective Thioridazine Increased risk of gastrointestinal bleeding/peptic ulcer disease, QE = Low; SR = Strong and acute kidney injury in older adults Thiothixene QE = Moderate; SR = Strong Avoid Delirium Anticholinergics* Avoid analgesic that causes CNS adverse effects, including Antipsychotics Avoid in older adults with or at high confusion and , more commonly than other opioid Benzodiazepines risk of delirium because of potential of analgesic drugs; is also a mixed agonist and antagonist; safer Chlorpromazine inducing or worsening delirium alternatives available Corticosteroidsa QE = Low; SR = Strong Avoid antipsychotics for behavioral H2-receptor antagonists problems of dementia and/or delirium Skeletal muscle relaxants Avoid ■ Cimetidine ■ unless nonpharmacological options Carisoprodol Most muscle relaxants poorly tolerated by older adults because ■ Famotidine ■ Chlorzoxazone (e.g., behavioral interventions) have some have anticholinergic adverse effects, sedation, increased ■ Nizatidine ■ failed or are not possible and the risk of fractures; effectiveness at dosages tolerated by older ■ Ranitidine ■ Metaxalone adults questionable older adult is threatening substantial ■ Methocarbamol QE = Moderate; SR = Strong Meperidine harm to self or others. Antipsychotics ■ hypnotics are associated with greater risk of Genitourinary cerebrovascular accident (stroke) and Desmopressin Avoid for treatment of nocturia or nocturnal polyuria mortality in persons with dementia High risk of hyponatremia; safer alternative treatments QE = Moderate; SR = Strong

QE = Moderate; SR = Strong ✃

PAGE 7 PAGE 8 Table 2 (continued on page 9) Table 2 Continued Table 2 Continued Disease or Disease or Syndrome Drug(s) Recommendation, Rationale, QE, SR Syndrome Drug(s) Recommendation, Rationale, QE, SR Dementia Anticholinergics* Avoid Parkinson All antipsychotics (except Avoid or cognitive Benzodiazepines Avoid due to adverse CNS effects disease aripiprazole, , clozapine) Dopamine-receptor antagonists with impairment potential to worsen parkinsonian H2-receptor antagonists Avoid antipsychotics for behavioral ■ symptoms Nonbenzodiazepine, problems of dementia and/or delirium Metoclopramide ■ benzodiazepine receptor agonist unless nonpharmacological options Quetiapine, aripiprazole, clozapine ■ hypnotics (e.g., behavioral interventions) have Promethazine appear to be less likely to precipitate ■ Eszopiclone failed or are not possible and the worsening of Parkinson disease ■ Zolpidem older adult is threatening substantial QE = Moderate; SR = Strong ■ Zaleplon harm to self or others. Antipsychotics are associated with greater risk of Antipsychotics, chronic and as- cerebrovascular accident (stroke) and Gastrointestinal needed use mortality in persons with dementia History of Aspirin (>325 mg/d) Avoid unless other alternatives are QE = Moderate; SR = Strong gastric or Non-COX-2 selective NSAIDs not effective and patient can take duodenal gastroprotective agent (ie, proton- ulcers pump inhibitor or misoprostol) History of Anticonvulsants Avoid unless safer alternatives are falls or not available; avoid anticonvulsants May exacerbate existing ulcers or Antipsychotics cause new/additional ulcers fractures Benzodiazepines except for seizure and mood disorders. Nonbenzodiazepine, Opioids: avoid, excludes pain QE = Moderate; SR = Strong benzodiazepine receptor agonist management due to recent fractures or hypnotics joint replacement Kidney/Urinary tract ■ Eszopiclone May cause ataxia, impaired Chronic NSAIDs (non-COX and COX- Avoid ■ Zaleplon psychomotor function, syncope, kidney selective, oral and parenteral) May increase risk of acute kidney ■ Zolpidem additional falls; shorter-acting disease benzodiazepines are not safer than injury and further decline of renal TCAs Stages function SSRIs long-acting ones IV or less QE = Moderate; SR = Strong Opioids If one of the drugs must be used, (creatinine consider reducing use of other CNS- clearance <30 active medications that increase risk of mL/min) falls and fractures (ie, anticonvulsants, opioid-receptor agonists, antipsychotics, Urinary Estrogen oral and transdermal antidepressants, benzodiazepine- Avoid in women incontinence (excludes intravaginal estrogen) receptor agonists, other / Aggravation of incontinence (all types) in hypnotics) and implement other Peripheral Alpha-1 blockers QE = Estrogen: High. Peripheral alpha-1 women strategies to reduce fall risk ■ Doxazosin blockers: Moderate; SR = Estrogen: ■ Prazosin QE = High. Opioids: Moderate; Strong. Peripheral alpha-1 blockers: ■ Terazosin SR = Strong. Opioids: Strong Strong

Insomnia Oral decongestants Avoid Lower Strongly anticholinergic drugs, Avoid in men ■ Pseudoephedrine CNS effects urinary tract except antimuscarinics for urinary May decrease urinary fl ow and cause ■ symptoms, incontinence.* QE = Moderate; SR = Strong benign QE = Moderate; SR = Strong ■ prostatic ■ Armodafi nil hyperplasia ■ ■ Modafi nil aexcludes inhaled and topical forms. Oral and parenteral corticosteroids may be required for conditions such as ■ Theobromines exacerbations of COPD but should be prescribed in the lowest effective dose and for the shortest possible duration. ■ Theophylline CCB=calcium channel blocker; AChEI=acetylcholinesterase inhibitor; CNS=central nervous system; ■ Caffeine COX=cyclooxygenase; NSAIDs=nonsteroidal antiinflammatory drug; TCAs=tricyclic . *See Table 7 in*See full Tablecriteria 7 in available full criteria on www.geriatricscareonline.org.available on www.geriatricscareonline.org. a excludes inhaleda excludes and topical inhaled forms. and Oraltopical and forms. parenteral Oral and corticosteroids parenteral corticosteroids may be required may for be conditions required forsuch conditions as exacerbations such as exacerbations of COPD but should of COPD be prescribedbut should bein theprescribed lowest effective in the lowest dose effectiveand for the dose shortest and for possible the shortest duration. possible duration.

CCB=calciumCCB=calcium channel blocker; channel AChEI=acetylcholinesterase blocker; AChEI=acetylcholinesterase inhibitor; CNS=central inhibitor; CNS=centralnervous system; nervous COX=cyclooxygenase; system; COX=cyclooxygenase; NSAIDs=nonsteroidal NSAIDs=nonsteroidal antiinfl ammatory antiinfl drug; ammatory TCAs=tricyclic drug; TCAs=. antidepressant. ✃

PAGE 9 Table 2 (continued on page 10) PAGE 10 Table 2 (continued on page 11) TABLE 3. 2015 American Geriatrics Society Beers Criteria for Potentially Inappropriate TABLE 4. 2015 American Geriatrics Society Beers Criteria for Potentially Clinically Important Medications to Be Used with Caution in Older Adults Non-anti-infective Drug–Drug Interactions That Should Be Avoided in Older Adults

Recommendation, Rationale, Quality of Evidence (QE), Interacting Drug Recommendation, Risk Rationale, Quality of Evidence Drug(s) Strength of Recommendation (SR) Object Drug and Class and Class (QE), Strength of Recommendation (SR) Aspirin for primary Use with caution in adults ≥80 years old ACEIs Amiloride or Avoid routine use; reserve for patients with triamterene demonstrated hypokalemia while taking an ACEI prevention of Lack of evidence of benefi t versus risk in adults ≥80 years old cardiac events Increased risk of hyperkalemia QE = Low; SR = Strong QE = Moderate; SR = Strong Anticholinergic Anticholinergic Avoid, minimize number of anticholinergic drugs Dabigatran Use with caution in adults ≥75 years old and in patients with CrCl <30 Increased risk of cognitive decline mL/min QE = Moderate; SR = Strong Increased risk of gastrointestinal bleeding compared with warfarin and Antidepressants (ie, ≥2 other CNS- Avoid total of ≥3 CNS-active drugsa; minimize number reported rates with other target-specifi c oral anticoagulants in adults TCAs and SSRIs) active drugsa of CNS-active drugs ≥75 years old; lack of evidence of effi cacy and safety in individuals with Increased risk of falls CrCl <30 mL/min QE = Moderate; SR = Strong QE = Moderate; SR = Strong Antipsychotics ≥2 other CNS- Avoid total of ≥3 CNS-active drugsa; minimize number active drugsa of CNS active drugs Increased risk of falls Prasugrel Use with caution in adults aged ≥75 QE = Moderate; SR = Strong Increased risk of bleeding in older adults; benefi t in highest-risk older Benzodiazepines ≥2 other CNS- Avoid total of ≥3 CNS-active drugsa; minimize number adults (e.g., those with prior myocardial infarction or diabetes mellitus) and active drugsa of CNS active drugs may offset risk nonbenzodiazepine, Increased risk of falls and fractures QE = Moderate; SR = Weak benzodiazepine receptor agonist QE = High; SR = Strong hypnotics Antipsychotics Use with caution Corticosteroids, NSAIDs Avoid; if not possible, provide gastrointestinal Diuretics May exacerbate or cause SIADH or hyponatremia; monitor sodium oral or parenteral protection Carbamazepine level closely when starting or changing dosages in older adults Increased risk of peptic ulcer disease or Carboplatin QE = Moderate; SR = Strong gastrointestinal bleeding Cyclophosphamide QE = Moderate; SR = Strong Cisplatin Lithium ACEIs Avoid, monitor lithium concentrations Oxcarbazepine Increased risk of lithium toxicity SNRIs QE = Moderate; SR = Strong SSRIs Lithium Loop diuretics Avoid, monitor lithium concentrations TCAs Increased risk of lithium toxicity Vincristine QE = Moderate; SR = Strong Opioid receptor ≥2 other CNS- Avoid total of ≥3 CNS-active drugsa; minimize number of Vasodilators Use with caution. agonist active drugsa CNS drugs May exacerbate episodes of syncope in individuals with history of Increased risk of falls syncope QE = High; SR = Strong QE = Moderate; SR = Weak Peripheral Alpha-1 Loop diuretics Avoid in older women, unless conditions warrant blockers both drugs Increased risk of urinary incontinence in older women CrCl= creatinine clearance; SNRIs = Serotonin-nonrepinephrine reuptake inhitibors; QE = Moderate; SR = Strong SSRIs = Selective serotonin reuptake inhitibors; TCA=tricyclic antidepressant. Theophylline Cimetidine Avoid Increased risk of theophylline toxicity QE = Moderate; SR = Strong Warfarin Amiodarone Avoid when possible; monitor INR closely Increased risk of bleeding QE = Moderate; SR = Strong Warfarin NSAIDs Avoid when possible; if used together, monitor for bleeding closely Increased risk of bleeding QE = High; SR = Strong aCentral nervous system (CNS)-active drugs: antipsychotics; benzodiazepines; nonbenzodiazepine, benzodiazepine receptor agonist hypnotics; tricyclic antidepressants (TCAs); selective serotonin reuptake inhibitors (SSRIs); and opioids.

✃ ACEI = angiotensin-converting inhibitor; NSAID=nonsteroidal antiinflammatory drug. PAGE 11 PAGE 12 TABLE 5. 2015 American Geriatrics Society Beers Criteria for Non-Anti-Infective Medications Table 5 Continued That Should Be Avoided or Have Their Dosage Reduced with Varying Levels of Kidney Creatinine Clearance, Function in Older Adults Medication Class mL/min, at Which and Medication Action Required Recommendation, Rationale, QE, SR Creatinine Clearance, Levetiracetam ≤80 Reduce dose Medication Class mL/min, at Which Recommendation, Rationale, Quality of Evidence (QE), and Medication Action Required Strength of Recommendation (SR) CNS adverse effects Cardiovascular or hemostasis QE = Moderate; SR = Strong Amiloride <30 Avoid Pregabalin <60 Reduce dose Increased potassium and decreased sodium CNS adverse effects QE = Moderate; SR = Strong QE = Moderate; SR = Strong Apixaban <25 Avoid Tramadol <30 Immediate release: Reduce dose Extended release: avoid Increased risk of bleeding CNS adverse effects QE = Moderate; SR = Strong QE = Low; SR = Weak Dabigatran <30 Avoid Gastrointestinal Increased risk of bleeding Cimetidine <50 Reduce dose QE = Moderate; SR = Strong Mental status changes Edoxaban 30–50 CrCl 30-50: Reduce dose <30 or >95 CrCl <30 or >95: Avoid QE = Moderate; SR = Strong Increased risk of bleeding Famotidine <50 Reduce dose QE = Moderate; SR = Strong Mental status changes Enoxaparin <30 Reduce dose QE = Moderate; SR = Strong Increased risk of bleeding Nizatidine <50 Reduce dose QE = Moderate; SR = Strong Mental status changes Fondaparinux <30 Avoid QE = Moderate; SR = Strong Increased risk of bleeding Ranitidine <50 Reduce dose QE = Moderate; SR = Strong Mental status changes Rivaroxaban 30–50 CrCl 30-50: Reduce dose QE = Moderate; SR = Strong <30 CrCl <30: Avoid Hyperuricemia Increased risk of bleeding Colchicine <30 Reduce dose; monitor for adverse effects QE = Moderate; SR = Strong Gastrointestinal, neuromuscular, bone marrow toxicity Spironolactone <30 Avoid QE = Moderate; SR = Strong Increased potassium Probenecid <30 Avoid QE = Moderate; SR = Strong Loss of effectiveness Triamterene <30 Avoid QE = Moderate; SR = Strong Increased potassium and decreased sodium CNS=central nervous system. QE = Moderate; SR = Strong Central nervous system and analgesics Duloxetine <30 Avoid Increased gastrointestinal adverse effects (, diarrhea) QE = Moderate; SR = Weak The primary target audience is the practicing clinician. The intentions of the criteria include 1) improving <60 Reduce dose the selection of prescription drugs by clinicians and patients; 2) evaluating patterns of drug use within populations; 3) educating clinicians and patients on proper drug usage; and 4) evaluating health-outcome, CNS adverse effects quality-of-care, cost, and utilization data. QE = Moderate; SR = Strong Copyright © 2015 by the American Geriatrics Society. All rights reserved. Except where authorized, no part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise without written permission of the

American Geriatrics Society, 40 Fulton Street, 18th Floor, New York, NY 10038. ✃

PAGE 13 Table 5 (continued on page 14) PAGE 14