Table 1 (continued from page 1) TABLE 1: 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults AGS BEERS CRITERIA Organ System/ Recommendation, Rationale, FOR POTENTIALLY INAPPROPRIATE Therapeutic Category/Drug(s) Quality of Evidence (QE) & Strength of Recommendation (SR) Antispasmodics Avoid except in short-term palliative care to decrease MEDICATION USE IN OLDER ADULTS n Belladonna alkaloids oral secretions. n Clidinium-chlordiazepoxide FROM THE AMERICAN GERIATRICS SOCIETY n Dicyclomine Highly anticholinergic, uncertain effectiveness. n Hyoscyamine This clinical tool, based on The AGS 2012 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older n Propantheline QE = Moderate; SR = Strong Adults (AGS 2012 Beers Criteria), has been developed to assist healthcare providers in improving medication safety in n Scopolamine older adults. Our purpose is to inform clinical decision-making concerning the prescribing of medications for older adults in order to improve safety and quality of care. Antithrombotics Dipyridamole, oral short-acting* (does not Avoid. Originally conceived of in 1991 by the late Mark Beers, MD, a geriatrician, the Beers Criteria catalogues medications apply to the extended-release combination with May cause orthostatic hypotension; more effective alternatives that cause adverse drug events in older adults due to their pharmacologic properties and the physiologic changes of aspirin) available; IV form acceptable for use in cardiac stress testing. aging. In 2011, the AGS undertook an update of the criteria, assembling a team of experts and funding the develop- QE = Moderate; SR = Strong ment of the AGS 2012 Beers Criteria using an enhanced, evidence-based methodology. Each criterion is rated (qual- Ticlopidine* Avoid. ity of evidence and strength of evidence) using the American College of Physicians’ Guideline Grading System, which Safer, effective alternatives available. is based on the GRADE scheme developed by Guyatt et al. QE = Moderate; SR = Strong The full document together with accompanying resources can be viewed online at www.americangeriatrics.org. Anti-infective Nitrofurantoin Avoid for long-term suppression; avoid in patients with INTENDED USE CrCl <60 mL/min. The goal of this clinical tool is to improve care of older adults by reducing their exposure to Potentially Inappropri- Potential for pulmonary toxicity; safer alternatives available; lack of ate Medications (PIMs). efficacy in patients with CrCl <60 mL/min due to inadequate drug n This should be viewed as a guide for identifying medications for which the risks of use in older adults outweigh concentration in the urine. the benefits. QE = Moderate; SR = Strong n These criteria are not meant to be applied in a punitive manner. n This list is not meant to supersede clinical judgment or an individual patient’s values and needs. Prescribing and Cardiovascular managing disease conditions should be individualized and involve shared decision-making. Alpha1 blockers Avoid use as an antihypertensive. n n These criteria also underscore the importance of using a team approach to prescribing and the use of non- Doxazosin High risk of orthostatic hypotension; not recommended as routine pharmacological approaches and of having economic and organizational incentives for this type of model. n Prazosin treatment for hypertension; alternative agents have superior risk/ n n Implicit criteria such as the STOPP/START criteria and Medication Appropriateness Index should be used in Terazosin benefit profile. a complementary manner with the 2012 AGS Beers Criteria to guide clinicians in making decisions about safe QE = Moderate; SR = Strong medication use in older adults. Alpha agonists Avoid clonidine as a first-line antihypertensive. Avoid oth- n Clonidine ers as listed. The criteria are not applicable in all circumstances (eg, patient’s receiving palliative and hospice care). If a clinician is n Guanabenz* High risk of adverse CNS effects; may cause bradycardia and not able to find an alternative and chooses to continue to use a drug on this list in an individual patient, designation n Guanfacine* orthostatic hypotension; not recommended as routine treatment of the medication as potentially inappropriate can serve as a reminder for close monitoring so that the potential for n Methyldopa* for hypertension. an adverse drug effect can be incorporated into the medical record and prevented or detected early. n Reserpine (>0.1 mg/day)* QE = Low; SR = Strong Antiarrhythmic drugs (Class Ia, Ic, III) Avoid antiarrhythmic drugs as first-line treatment of atrial n Amiodarone fibrillation. TABLE 1: 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults n Dofetilide n Dronedarone Data suggest that rate control yields better balance of benefits and Organ System/ Recommendation, Rationale, n Therapeutic Category/Drug(s) Quality of Evidence (QE) & Strength of Recommendation (SR) Flecainide harms than rhythm control for most older adults. n Ibutilide Anticholinergics (excludes TCAs) n Procainamide Amiodarone is associated with multiple toxicities, including thyroid First-generation antihistamines (as single Avoid. n Propafenone disease, pulmonary disorders, and QT interval prolongation. agent or as part of combination products) n Quinidine QE = High; SR = Strong n Brompheniramine Highly anticholinergic; clearance reduced with advanced age, and n Sotalol n Carbinoxamine tolerance develops when used as hypnotic; increased risk of confu- Disopyramide* Avoid. n Chlorpheniramine sion, dry mouth, constipation, and other anticholinergic effects/ Disopyramide is a potent negative inotrope and therefore may n Clemastine toxicity. induce heart failure in older adults; strongly anticholinergic; other n Cyproheptadine antiarrhythmic drugs preferred. n Dexbrompheniramine Use of diphenhydramine in special situations such as acute treat- QE = Low; SR = Strong n Dexchlorpheniramine ment of severe allergic reaction may be appropriate. n Dronedarone Avoid in patients with permanent atrial fibrillation or Diphenhydramine (oral) heart failure. n Doxylamine QE = High (Hydroxyzine and Promethazine), Moderate (All others); SR n Hydroxyzine = Strong Worse outcomes have been reported in patients taking drone- n Promethazine n darone who have permanent atrial fibrillation or heart failure. In Triprolidine general, rate control is preferred over rhythm control for atrial Antiparkinson agents Avoid. fibrillation. n Benztropine (oral) QE = Moderate; SR = Strong n Trihexyphenidyl Not recommended for prevention of extrapyramidal symptoms Digoxin >0.125 mg/day Avoid. with antipsychotics; more effective agents available for treatment of In heart failure, higher dosages associated with no additional Parkinson disease. benefit and may increase risk of toxicity; decreased renal clearance may increase risk of toxicity. QE = Moderate; SR = Strong QE = Moderate; SR = Strong

PAGE 1 Table 1 (continued on page 2) PAGE 2 Table 1 (continued on page 3) Table 1 (continued from page 2) Table 1 (continued from page 3) TABLE 1: 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults TABLE 1: 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Organ System/ Recommendation, Rationale, Organ System/ Recommendation, Rationale, Therapeutic Category/Drug(s) Quality of Evidence (QE) & Strength of Recommendation (SR) Therapeutic Category/Drug(s) Quality of Evidence (QE) & Strength of Recommendation (SR) Nifedipine, immediate release* Avoid. Nonbenzodiazepine Avoid chronic use (>90 days) hypnotics Benzodiazepine-receptor agonists that have adverse events similar Potential for hypotension; risk of precipitating myocardial ischemia. n Eszopiclone to those of benzodiazepines in older adults (e.g., delirium, falls, QE = High; SR = Strong n Zolpidem fractures); minimal improvement in sleep latency and duration. n Spironolactone >25 mg/day Avoid in patients with heart failure or with a CrCl <30 Zaleplon QE = Moderate; SR = Strong mL/min. Ergot mesylates* Avoid. Isoxsuprine* Lack of efficacy. In heart failure, the risk of hyperkalemia is higher in older adults if QE = High; SR = Strong taking >25 mg/day. QE = Moderate; SR = Strong Endocrine Androgens Avoid unless indicated for moderate to severe Central Nervous System n Methyltestosterone* hypogonadism. Tertiary TCAs, alone or in combination: Avoid. n Testosterone Potential for cardiac problems and contraindicated in men with n Amitriptyline prostate cancer. n Chlordiazepoxide- Highly anticholinergic, sedating, and cause orthostatic hypotension; QE = Moderate; SR = Weak amitriptyline the safety profile of low-dose doxepin (≤6 mg/day) is comparable Desiccated thyroid Avoid. n Clomipramine to that of placebo. Concerns about cardiac effects; safer alternatives available. n Doxepin >6 mg/day QE = Low; SR = Strong n Imipramine QE = High; SR = Strong n Perphenazine-amitriptyline Estrogens with or without progestins Avoid oral and topical patch. Topical vaginal cream: Ac- n Trimipramine ceptable to use low-dose intravaginal estrogen for the management of dyspareunia, lower urinary tract infec- Antipsychotics, first- (conventional) and sec- Avoid use for behavioral problems of dementia unless tions, and other vaginal symptoms. ond- (atypical) generation (see online for full list) non-pharmacologic options have failed and patient is Evidence of carcinogenic potential (breast and endometrium); lack threat to self or others. of cardioprotective effect and cognitive protection in older women. Evidence that vaginal estrogens for treatment of vaginal dryness is Increased risk of cerebrovascular accident (stroke) and mortality in safe and effective in women with breast cancer, especially at dos- persons with dementia. ages of estradiol <25 mcg twice weekly. QE = Moderate; SR = Strong QE = High (Oral and Patch), Moderate (Topical); SR = Strong (Oral and Thioridazine Avoid. Patch), Weak (Topical) Mesoridazine Growth hormone Avoid, except as hormone replacement following pituitary Highly anticholinergic and greater risk of QT-interval prolongation. gland removal. QE = Moderate; SR = Strong Effect on body composition is small and associated with edema, arthralgia, carpal tunnel syndrome, gynecomastia, impaired fasting Barbiturates Avoid. n glucose. Amobarbital* QE = High; SR = Strong n Butabarbital* High rate of physical dependence; tolerance to sleep benefits; n Butalbital greater risk of overdose at low dosages. Insulin, sliding scale Avoid. n Mephobarbital* Higher risk of hypoglycemia without improvement in hyperglyce- n Pentobarbital* QE = High; SR = Strong mia management regardless of care setting. n Phenobarbital QE = Moderate; SR = Strong n Secobarbital* Megestrol Avoid. Benzodiazepines Avoid benzodiazepines (any type) for treatment of insom- Minimal effect on weight; increases risk of thrombotic events and Short- and intermediate-acting: nia, agitation, or delirium. possibly death in older adults. n Alprazolam QE = Moderate; SR = Strong n Estazolam Older adults have increased sensitivity to benzodiazepines and Sulfonylureas, long-duration Avoid. n Lorazepam decreased metabolism of long-acting agents. In general, all ben- n Chlorpropamide Chlorpropamide: prolonged half-life in older adults; can cause n Oxazepam zodiazepines increase risk of cognitive impairment, delirium, falls, n Glyburide prolonged hypoglycemia; causes SIADH n Temazepam fractures, and motor vehicle accidents in older adults. n Glyburide: higher risk of severe prolonged hypoglycemia in older Triazolam adults. Long-acting: May be appropriate for seizure disorders, rapid eye movement QE = High; SR = Strong n Chlorazepate sleep disorders, benzodiazepine withdrawal, ethanol withdrawal, n Chlordiazepoxide severe generalized anxiety disorder, periprocedural anesthesia, Gastrointestinal n Chlordiazepoxide-amitriptyline end-of-life care. Metoclopramide Avoid, unless for gastroparesis. n Clidinium-chlordiazepoxide Can cause extrapyramidal effects including tardive dyskinesia; risk n Clonazepam QE = High; SR = Strong may be further increased in frail older adults. n Diazepam QE = Moderate; SR = Strong n Flurazepam n Quazepam Mineral oil, given orally Avoid. Potential for aspiration and adverse effects; safer alternatives avail- Chloral hydrate* Avoid. able. Tolerance occurs within 10 days and risk outweighs the benefits in QE = Moderate; SR = Strong light of overdose with doses only 3 times the recommended dose. Trimethobenzamide Avoid. QE = Low; SR = Strong One of the least effective antiemetic drugs; can cause extrapyrami- Meprobamate Avoid. dal adverse effects. High rate of physical dependence; very sedating. QE = Moderate; SR = Strong QE = Moderate; SR = Strong

PAGE 3 Table 1 (continued on page 4) PAGE 4 Table 1 (continued on page 5) Table 1 (continued from page 4) Table 2 (continued from page 5) TABLE 1: 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults TABLE 2: 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Due to Drug- Disease or Drug-Syndrome Interactions That May Exacerbate the Disease or Syndrome Organ System/ Recommendation, Rationale, Therapeutic Category/Drug(s) Quality of Evidence (QE) & Strength of Recommendation (SR) Disease or Drug(s) Recommendation, Rationale, Quality of Evidence Syndrome (QE) & Strength of Recommendation (SR) Pain Medications Syncope Acetylcholinesterase inhibitors (AChEIs) Avoid. Meperidine Avoid. Peripheral alpha blockers Not an effective oral analgesic in dosages commonly used; may n Doxazosin Increases risk of orthostatic hypotension or brady- cause neurotoxicity; safer alternatives available. n Prazosin cardia. QE = High; SR = Strong n Terazosin QE = High (Alpha blockers), Moderate (AChEIs, TCAs and Non-COX-selective NSAIDs, oral Avoid chronic use unless other alternatives are not effec- Tertiary TCAs antipsychotics); SR = Strong (AChEIs and TCAs), Weak n Aspirin >325 mg/day tive and patient can take gastroprotective agent (proton- (Alpha blockers and antipsychotics) n Diclofenac pump inhibitor or misoprostol). Chlorpromazine, thioridazine, and olan- n Diflunisal zapine n Etodolac Increases risk of GI bleeding/peptic ulcer disease in high-risk Central Nervous System n Fenoprofen groups, including those ≥75 years old or taking oral or parenteral n Ibuprofen corticosteroids, anticoagulants, or antiplatelet agents. Use of pro- Chronic Bupropion Avoid. n Ketoprofen ton pump inhibitor or misoprostol reduces but does not eliminate seizures or Chlorpromazine n Meclofenamate risk. Upper GI ulcers, gross bleeding, or perforation caused by epilepsy Clozapine Lowers seizure threshold; may be acceptable in n Mefenamic acid NSAIDs occur in approximately 1% of patients treated for 3–6 Maprotiline patients with well-controlled seizures in whom alter- n Meloxicam months, and in about 2%–4% of patients treated for 1 year. These Olanzapine native agents have not been effective. n Nabumetone trends continue with longer duration of use. Thioridazine n Naproxen Thiothixene QE = Moderate; SR = Strong n Oxaprozin QE = Moderate; SR = Strong Tramadol n Piroxicam Delirium All TCAs Avoid. n Sulindac Anticholinergics (see online for full list) n Tolmetin Benzodiazepines Avoid in older adults with or at high risk of delirium Chlorpromazine because of inducing or worsening delirium in older Indomethacin Avoid. Corticosteroids adults; if discontinuing drugs used chronically, taper to Ketorolac, includes parenteral Increases risk of GI bleeding/peptic ulcer disease in high-risk H2-receptor antagonist avoid withdrawal symptoms. groups (See Non-COX selective NSAIDs) Meperidine Of all the NSAIDs, indomethacin has most adverse effects. Sedative hypnotics QE = Moderate; SR = Strong QE = Moderate (Indomethacin), High (Ketorolac); SR = Strong Thioridazine Pentazocine* Avoid. Dementia Anticholinergics (see online for full list) Avoid. Opioid analgesic that causes CNS adverse effects, including confu- & cognitive Benzodiazepines Avoid due to adverse CNS effects. sion and hallucinations, more commonly than other narcotic drugs; impairment H2-receptor antagonists Avoid antipsychotics for behavioral problems of is also a mixed agonist and antagonist; safer alternatives available. Zolpidem dementia unless non-pharmacologic options have QE = Low; SR = Strong Antipsychotics, chronic and as-needed use failed and patient is a threat to themselves or others. Skeletal muscle relaxants Avoid. Antipsychotics are associated with an increased risk n Carisoprodol Most muscle relaxants poorly tolerated by older adults, because of of cerebrovascular accident (stroke) and mortality in n Chlorzoxazone anticholinergic adverse effects, sedation, increased risk of fractures; persons with dementia. n Cyclobenzaprine effectiveness at dosages tolerated by older adults is questionable. QE = High; SR = Strong n Metaxalone QE = Moderate; SR = Strong History Anticonvulsants Avoid unless safer alternatives are not avail- n Methocarbamol of falls or Antipsychotics able; avoid anticonvulsants except for seizure. n Orphenadrine fractures Benzodiazepines Nonbenzodiazepine hypnotics Ability to produce ataxia, impaired psychomotor *Infrequently used drugs. Table 1 Abbreviations: ACEI, angiotensin converting-enzyme inhibitors; ARB, angiotensin n receptor blockers; CNS, central nervous system; COX, cyclooxygenase; CrCl, creatinine clearance; GI, gastroin- Eszopiclone function, syncope, and additional falls; shorter-acting n Zaleplon benzodiazepines are not safer than long-acting ones. testinal; NSAIDs, nonsteroidal anti-inflammatory drugs; SIADH, syndrome of inappropriate antidiuretic hormone n secretion; SR, Strength of Recommendation; TCAs, tricyclic antidepressants; QE, Quality of Evidence Zolpidem QE = High; SR = Strong TCAs/SSRIs TABLE 2: 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Due to Drug- Disease or Drug-Syndrome Interactions That May Exacerbate the Disease or Syndrome Insomnia Oral decongestants Avoid. n Pseudoephedrine Disease or Drug(s) Recommendation, Rationale, Quality of Evidence n Phenylephrine Stimulants CNS stimulant effects. Syndrome (QE) & Strength of Recommendation (SR) n Amphetamine Cardiovascular n Methylphenidate QE = Moderate; SR = Strong Heart failure NSAIDs and COX-2 inhibitors Avoid. n Pemoline Theobromines n Theophylline Nondihydropyridine CCBs (avoid only for Potential to promote fluid retention and/or exacer- n Caffeine systolic heart failure) bate heart failure. Parkinson’s All antipsychotics (see online publica- Avoid. n Diltiazem disease tion for full list, except for quetiapine and Dopamine receptor antagonists with potential to n Verapamil QE = Moderate (NSAIDs, CCBs, Dronedarone), High (Thia- clozapine) worsen parkinsonian symptoms. zolidinediones (glitazones)), Low (Cilostazol); SR = Strong Pioglitazone, rosiglitazone Antiemetics Quetiapine and clozapine appear to be less likely to n Metoclopramide precipitate worsening of Parkinson disease. Cilostazol n Prochlorperazine Dronedarone n Promethazine QE = Moderate; SR = Strong

PAGE 5 Table 2 (continued on page 6) PAGE 6 Table 2 (continued on page 7) Table 2 (continued from page 6) Table 2 (continued from page 7) TABLE 2: 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Due to Drug- TABLE 2: 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Due to Drug- Disease or Drug-Syndrome Interactions That May Exacerbate the Disease or Syndrome Disease or Drug-Syndrome Interactions That May Exacerbate the Disease or Syndrome Disease or Drug(s) Recommendation, Rationale, Quality of Evidence Disease or Drug(s) Recommendation, Rationale, Quality of Evidence Syndrome (QE) & Strength of Recommendation (SR) Syndrome (QE) & Strength of Recommendation (SR) Gastrointestinal Lower Inhaled anticholinergic agents Avoid in men. Chronic Oral antimuscarinics for urinary inconti- Avoid unless no other alternatives. urinary tract constipation nence symptoms, Strongly anticholinergic drugs, except May decrease urinary flow and cause urinary reten- n Darifenacin Can worsen constipation; agents for urinary incon- benign antimuscarinics for urinary incontinence tion. n Fesoterodine tinence: antimuscarinics overall differ in incidence of prostatic (see Table 9 for complete list). n Oxybutynin (oral) constipation; response variable; consider alternative hyperplasia QE = Moderate; SR = Strong (Inhaled agents), Weak (All n Solifenacin agent if constipation develops. others) n Tolterodine Stress or Alpha-blockers Avoid in women. n Trospium QE = High (For Urinary Incontinence), Moderate/Low (All mixed n Doxazosin Others); SR = Strong urinary in- n Prazosin Aggravation of incontinence. Nondihydropyridine CCB continence n Terazosin n Diltiazem QE = Moderate; SR = Strong n Verapamil Table 2 Abbreviations: CCBs, calcium channel blockers; AChEIs, acetylcholinesterase inhibitors; CNS, central ner- First-generation antihistamines as single vous system; COX, cyclooxygenase; NSAIDs, nonsteroidal anti-inflammatory drugs; SR, Strength of Recommenda- agent or part of combination products tion; SSRIs, selective serotonin reuptake inhibitors; TCAs, tricyclic antidepressants; QE, Quality of Evidence n Brompheniramine (various) n Carbinoxamine n TABLE 3: 2012 AGS Beers Criteria for Potentially Inappropriate Medications to Be Used with Caution in Chlorpheniramine Older Adults n Clemastine (various) n Cyproheptadine Drug(s) Recommendation, Rationale, Quality of Evidence (QE) & Strength of Recommenda- n Dexbrompheniramine tion (SR) n Dexchlorpheniramine (various) Aspirin for primary preven- Use with caution in adults ≥80 years old. n Diphenhydramine tion of cardiac events n Doxylamine Lack of evidence of benefit versus risk in individuals ≥80 years old. n Hydroxyzine QE = Low; SR = Weak n Promethazine n Triprolidine Dabigatran Use with caution in adults ≥75 years old or if CrCl <30 mL/min. Anticholinergics/antispasmodics (see online Increased risk of bleeding compared with warfarin in adults ≥75 years old; lack of for full list of drugs with strong anticholinergic evidence for efficacy and safety in patients with CrCl <30 mL/min properties) QE = Moderate; SR = Weak n Antipsychotics Prasugrel Use with caution in adults ≥75 years old. n Belladonna alkaloids n Clidinium-chlordiazepoxide Greater risk of bleeding in older adults; risk may be offset by benefit in highest- n Dicyclomine risk older patients (eg, those with prior myocardial infarction or diabetes). n Hyoscyamine QE = Moderate; SR = Weak n Propantheline Antipsychotics Use with caution. n Scopolamine n Carbamazepine Tertiary TCAs (amitriptyline, clomip- Carboplatin May exacerbate or cause SIADH or hyponatremia; need to monitor sodium level ramine, doxepin, imipramine, and trimip- Cisplatin closely when starting or changing dosages in older adults due to increased risk. ramine) Mirtazapine History of Aspirin (>325 mg/day) Avoid unless other alternatives are not ef- SNRIs QE = Moderate; SR = Strong gastric or Non–COX-2 selective NSAIDs fective and patient can take gastroprotective SSRIs duodenal agent (proton-pump inhibitor or misoprostol). TCAs ulcers Vincristine May exacerbate existing ulcers or cause new/addi- Vasodilators tional ulcers. Use with caution. QE = Moderate; SR = Strong May exacerbate episodes of syncope in individuals with history of syncope. Kidney/Urinary Tract QE = Moderate; SR = Weak Chronic kid- NSAIDs Avoid. Table 3 Abbreviations: CrCl, creatinine clearance; SIADH, syndrome of inappropriate antidiuretic hormone ney disease secretion; SSRIs, selective serotonin reuptake inhibitors; SNRIs, serotonin–norepinephrine reuptake inhibitors; stages IV May increase risk of kidney injury. SR, Strength of Recommendation; TCAs, tricyclic antidepressants; QE, Quality of Evidence and V Triamterene (alone or in combination) May increase risk of acute kidney injury. The American Geriatrics Society gratefully acknowledges the support of the John A. Hartford Foundation, QE = Moderate (NSAIDs), Low (Triamterene); SR = Strong Retirement Research Foundation and Robert Wood Johnson Foundation. (NSAIDs), Weak (Triamterene) Urinary Estrogen oral and transdermal (excludes Avoid in women. incontinence intravaginal estrogen) THE AMERICAN GERIATRICS SOCIETY 40 Fulton Street, 18th Floor (all types) in Aggravation of incontinence. Geriatrics Health Professionals. New York, NY 10038 800-247-4779 ot 212-308-1414 women Leading change. Improving care for older adults. QE = High; SR = Strong AGS www.americangeriatrics.org

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