TABLE 1. 2019 American Geriatrics 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, Drug(s) (QE), Strength of Recommendation (SR) A POCKET GUIDE TO THE Anticholinergics * First-generation Avoid ® antihistamines: Highly anticholinergic; clearance reduced with advanced age, 2019 AGS BEERS CRITERIA ■ Brompheniramine and tolerance develops when used as hypnotic; risk of confusion, This guide has been developed as a tool to assist healthcare providers in improving ■ Carbinoxamine dry mouth, constipation, and other anticholinergic effects or medication safety in older adults. The role of this guide is to inform clinical decision- ■ Chlorpheniramine toxicity making, research, training, quality measures and regulations concerning the prescribing of ■ Clemastine Use of diphenhydramine in situations such as acute treatment of ■ medications for older adults to improve safety and quality of care. It is based on The 2019 Cyproheptadine severe allergic reaction may be appropriate ■ Dexbrompheniramine AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. ■ Dexchlorpheniramine QE = Moderate; SR = Strong Originally conceived of in 1991 by the late Mark Beers, MD, a geriatrician, the Beers ■ Dimenhydrinate Criteria catalogues medications that cause side effects in older adults due to the ■ Diphenhydramine (oral) physiologic changes of aging. In 2011, the AGS sponsored its first update of the criteria, ■ Doxylamine assembling a team of experts and using an enhanced, evidence-based methodology. ■ Hydroxyzine Since 2011, the AGS has been the steward of the criteria and has produced updates ■ Meclizine using an evidence-based methodology and rating each Criterion (quality of evidence ■ Promethazine and strength of evidence) using the American College of Physicians’ Guideline Grading ■ Pyrilamine System, which is based on the GRADE scheme developed by Guyatt et al. ■ Triprolidine Antiparkinsonian agents Avoid The full document, along with accompanying resources, can be found in its entirety online ■ Benztropine (oral) Not recommended for prevention of extrapyramidal symptoms at geriatricscareonline.org. ■ Trihexyphenidyl with antipsychotics; more effective agents available for treatment of Parkinson disease INTENDED USE QE = Moderate; SR = Strong The goal of this guide is to improve care of older adults by reducing their exposure to Antispasmodics: Avoid Potentially Inappropriate Medications (PIMs). ■ Atropine (excludes Highly anticholinergic, uncertain effectiveness ■ This should be viewed as a guideline for identifying medications for which the risks ophthalmic) QE = Moderate; SR = Strong of their use in older adults outweigh the benefits. ■ Belladonna alkaloids ■ Clidinium- ■ These criteria are not meant to be applied in a punitive manner. Chlordiazepoxide ■ This list is not meant to supersede clinical judgment or an individual patient’s values ■ Dicyclomine and needs. Prescribing and managing disease conditions should be individualized ■ Homatropine (excludes and involve shared decision-making. ophthalmic) ■ These criteria also underscore the importance of using a team approach to ■ Hyoscyamine prescribing and the use of non-pharmacological approaches and of having ■ Methscopolamine economic and organizational incentives for this type of model. ■ Propantheline ■ A companion piece that addresses the best way for patients, providers, and health ■ Scopolamine ® systems to use (and not use) the AGS Beers Criteria was also developed. The Antithrombotics document can be found on geriatricscareonline.org. ■ Dipyridamole, oral Avoid The criteria are not applicable in all circumstances (i.e. patients receiving palliative and short-acting (does not Rationale: May cause orthostatic hypotension; more effective hospice care). If a provider is not able to find an alternative and chooses to continue to apply to the extended- alternatives available; IV form acceptable for use in cardiac use a drug on this list in an individual patient, designation of the medication as potentially release combination stress testing inappropriate can serve as a reminder for close monitoring so that adverse drug effects with aspirin) QE = Moderate; SR = Strong can be incorporated into the electronic health record and prevented or detected early.
*See also criterion on highly anticholinergic antidepressants CNS=central nervous system; NSAIDs=nonsteroidal anti-inflammatory drugs; SIADH, syndrome of THE AMERICAN GERIATRICS SOCIETY inappropriate antidiuretic hormone. Geriatrics Health Professionals. Leading change. Improving care for older adults. AGS ✃
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 Digoxin for first-line Avoid this rate control agent as first-line therapy for atrial ■ Nitrofurantoin Avoid in individuals with creatinine clearance <30 mL/min or treatment of atrial fibrillation. Avoid as first-line therapy for heart failure. If used for long-term suppression fibrillation or of heart for atrial fibrillation or heart failure, avoid dosages >0.125 mg/d failure Potential for pulmonary toxicity, hepatoxicity, and peripheral Use in atrial fibrillation: should not be used as a first-line agent neuropathy, especially with long-term use; safer alternatives available in atrial fibrillation, because there are safer and more effective alternatives for rate control supported by high-quality evidence. QE = Low; SR = Strong Use in heart failure: evidence for benefits and harms of digoxin is conflicting and of lower quality; most but not all of the evidence Cardiovascular concerns use in heart failure with reduced ejection fraction Peripheral alpha-1 Avoid use as an antihypertensive (HFrEF). There is strong evidence for other agents as first-line blockers for treatment of High risk of orthostatic hypotension and associated harms, therapy to reduce hospitalizations and mortality in adults wiht hypertension especially in older adults; not recommended as routine HFrEF. In heart failure, higher dosages are not associated with ■ Doxazosin treatment for hypertension; alternative agents have superior additional benefit and may increase toxicity. ■ Prazosin risk/benefit profile Decreased renal clearance of digoxin may lead to increased ■ Terazosin QE = Moderate; SR = Strong risk of toxic effects; further dose reduction may be necessary in Central-alpha agonists Avoid clonidine as first-line antihypertensive. Avoid other CNS those with Stage 4 or 5 chronic kidney disease. Clonidine for first-line alpha-agonists as listed QE = Atrial fibrillation: Low. Heart failure: Low. treatment of hypertension High risk of adverse CNS effects; may cause bradycardia and Dosage >0.125 mg/d: Moderate; SR = Atrial fibrillation: Strong. Heart failure: Strong. Dosage >0.125 mg/d: Strong Other CNS alpha-agonists orthostatic hypotension; not recommended as routine treatment ■ Guanabenz for hypertension Nifedipine, immediate Avoid ■ Guanfacine QE = Low; SR = Strong release Potential for hypotension; risk of precipitating myocardial ■ Methyldopa ischemia ■ Reserpine (>0.1 mg/d) QE = High; SR = Strong Disopyramide Avoid May induce heart failure in older adults because of potent Amiodarone Avoid as first-line therapy for atrial fibrillation unless the patient negative inotropic action; strongly anticholinergic; other has heart failure or substantial left ventricular hypertrophy antiarrhythmic drugs preferred Effective for maintaining sinus rhythm but has greater toxicities QE = Low; SR = Strong than other antiarrhythmics used in atrial fibrillation; may be reasonable first-line therapy in patients with concomitant heart Avoid in individuals with permanent atrial fibrillation or severe Dronedarone failure or substantial left ventricular hypertrophy if rhythm or recently decompensated heart failure control is preferred over rate control Worse outcomes have been reported in patients taking QE = High; SR = Strong dronedarone who have permanent atrial fibrillation or severe or recently decompensated heart failure Central nervous system QE = High; SR = Strong Antidepressants, alone or Avoid in combination: Highly anticholinergic, sedating, and cause orthostatic ■ Amitriptyline hypotension; safety profile of low-dose doxepin ≤( 6 mg/d) ■ Amoxapine comparable to that of placebo ■ Clomipramine QE = High; SR = Strong ■ Desipramine ■ Doxepin >6 mg/d ■ Imipramine ■ Nortriptyline ■ Paroxetine ■ Protriptyline
■ Trimipramine ✃
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 Antipsychotics, first- Avoid, except in schizophrenia, bipolar disorder, or for short- Ergoloid mesylates Avoid (conventional) and term use as antiemetic during chemotherapy (dehydrogenated ergot Lack of efficacy second- (atypical) Increased risk of cerebrovascular accident (stroke) and greater alkaloids) QE = High; SR = Strong generation rate of cognitive decline and mortality in persons with dementia Isoxsuprine Avoid antipsychotics for behavioral problems of dementia or Endocrine delirium unless nonpharmacological options (e.g., behavioral Androgens Avoid unless indicated for confirmed hypogonadism with interventions) have failed or are not possible and the older adult ■ Methyltestosterone clinical symptoms is threatening substantial harm to self or others ■ Testosterone Potential for cardiac problems; contraindicated in men with QE = Moderate; SR = Strong prostate cancer Barbiturates Avoid QE = Moderate; SR = Weak ■ Amobarbital High rate of physical dependence, tolerance to sleep benefits, Desiccated thyroid Avoid ■ Butabarbital greater risk of overdose at low dosages ■ Concerns about cardiac effects; safer alternatives available Butalbital QE = High; SR = Strong ■ Mephobarbital QE = Low; SR = Strong ■ Pentobarbital Estrogens with or without Avoid systemic estrogen (eg, oral and topical patch). Vaginal ■ Phenobarbital progestins cream or vaginal tablets: acceptable to use low-dose ■ Secobarbital intravaginal estrogen for management of dyspareunia, recurrent Benzodiazepines Avoid lower urinary tract infections, and other vaginal symptoms Short- and intermediate- Older adults have increased sensitivity to benzodiazepines and Evidence of carcinogenic potential (breast and endometrium); acting: decreased metabolism of long-acting agents; in general, all lack of cardioprotective effect and cognitive protection in older ■ Alprazolam benzodiazepines increase risk of cognitive impairment, delirium, women. ■ Estazolam falls, fractures, and motor vehicle crashes in older adults Evidence indicates that vaginal estrogens for the treatment of ■ Lorazepam May be appropriate for seizure disorders, rapid eye movement vaginal dryness are safe and effective; women with a history of ■ Oxazepam sleep behavior disorder, benzodiazepine withdrawal, ethanol breast cancer who do not respond to nonhormonal therapies ■ Temazepam withdrawal, severe generalized anxiety disorder, and are advised to discuss the risk and benefits of low-dose vaginal ■ Triazolam periprocedural anesthesia estrogen (dosages of estradiol <25 mcg twice weekly) with their Long-acting: QE = Moderate; SR = Strong healthcare provider ■ Chlordiazepoxide (alone QE = Oral and patch: High. Vaginal cream or tablets: Moderate.; or in combination SR = Oral and patch: Strong. Topical vaginal cream or tablets: Weak with amitriptyline or clidinium) Growth hormone Avoid, except for patients rigorously diagnosed by evidence-based criteria with growth hormone deficiency due to an established ■ Clonazepam etiology ■ Clorazepate ■ Diazepam Impact on body composition is small and associated with edema, ■ Flurazepam arthralgia, carpal tunnel syndrome, gynecomastia, impaired fasting ■ Quazepam glucose Meprobamate Avoid QE = High; SR = Strong High rate of physical dependence; sedating Insulin, sliding scale Avoid QE = Moderate; SR = Strong (insulin regimens Higher risk of hypoglycemia without improvement in hyperglycemia containing only short- or management regardless of care setting; Avoid insulin regimens that Nonbenzodiazepine, Avoid rapid-acting insulin dosed include only short- or rapid-acting insulin dosed according to current benzodiazepine receptor Nonbenzodiazepine benzodiazepine-receptor agonist hypnotics according to current blood glucose levels without concurrent use of basal or long-acting agonist hypnotics (ie, “Z drugs”) have adverse events similar to those of blood gluclose levels insulin. This recommendation does not apply to regimens that contain (ie, “Z-drugs”) benzodiazepines in older adults (e.g., delirium, falls, fractures); without concurrent use basal insulin or long-acting insulin. ■ Eszopiclone increased emergency room visits/hospitalizations; motor vehicle of basal or long-acting QE = Moderate; SR = Strong ■ Zaleplon crashes; minimal improvement in sleep latency and duration insulin) ■ Zolpidem QE = Moderate; SR = Strong Megestrol Avoid Minimal effect on weight; increases risk of thrombotic events and possibly death in older adults
QE = Moderate; SR = Strong ✃
PAGE 5 Table 1 (continued on page 6) PAGE 6 Table 1 (continued on page 7) 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 Sulfonylureas, long-acting Avoid ■ Indomethacin Avoid ■ Chlorpropamide Chlorpropamide: prolonged half-life in older adults; can cause ■ Ketorolac, includes Increased risk of gastrointestinal bleeding/peptic ulcer disease, ■ Glimeperide prolonged hypoglycemia; causes SIADH parenteral and acute kidney injury in older adults ■ Glyburide (also known Glimepiride and Glyburide: higher risk of severe prolonged Indomethacin is more likely than other NSAIDs to have adverse as glibenclamide) CNS effects. Of all the NSAIDs, indomethacin has the most hypoglycemia in older adults adverse effects. QE = High; SR = Strong QE = Moderate; SR = Strong Gastrointestinal Skeletal muscle relaxants Avoid Metoclopramide Avoid, unless for gastroparesis with duration of use not to ■ Carisoprodol Most muscle relaxants poorly tolerated by older adults because exceed 12 weeks except in rare cases ■ Chlorzoxazone some have anticholinergic adverse effects, sedation, increased ■ Cyclobenzaprine risk of fractures; effectiveness at dosages tolerated by older Can cause extrapyramidal effects, including tardive dyskinesia; ■ Metaxalone adults questionable risk may be greater in frail older adults and with prolonged ■ Methocarbamol QE = Moderate; SR = Strong exposure ■ Orphenadrine QE = Moderate; SR = Strong Genitourinary Mineral oil, given orally Avoid Desmopressin Avoid for treatment of nocturia or nocturnal polyuria Potential for aspiration and adverse effects; safer alternatives High risk of hyponatremia; safer alternative treatments available QE = Moderate; SR = Strong QE = Moderate; SR = Strong ® Proton-pump inhibitors Avoid scheduled use for >8 weeks unless for high-risk patients TABLE 2. 2019 American Geriatrics Society Beers Criteria for Potentially Inappropriate (e.g., oral corticosteroids or chronic NSAID use), erosive Medication Use in Older Adults Due to Drug–Disease or Drug–Syndrome Interactions That esophagitis, Barrett’s esophagitis, pathological hypersecretory May Exacerbate the Disease or Syndrome condition, or demonstrated need for maintenance treatment (e.g., because of failure of drug discontinuation trial or H2- Recommendation, Rationale, receptor antagonists Disease or Quality of Evidence (QE), Strength Risk of C difficile infection and bone loss and fractures Syndrome Drug(s) of Recommendation (SR) QE = High; SR = Strong Cardiovascular Pain medications Heart failure Avoid: Cilostazol As noted, avoid or use with caution Meperidine Avoid Avoid in heart failure with Potential to promote fluid retention Oral analgesic not effective in dosages commonly used; may reduced ejection fraction: Non- and/or exacerbate heart failure have higher risk of neurotoxicity, including delirium, than other dihydropyridine CCBs (diltiazem, (NSAIDs and COX-2 inhibitors, opioids; safer alternatives available verapamil) non-dihydropyridine CCBs, QE = Moderate; SR = Strong Use with caution in patients with thiazoildinediones); potential to Non-cyclooxygenase- Avoid chronic use, unless other alternatives are not effective heart failure who are asymptomatic; increase mortality in older adults selective NSAIDs, oral: and patient can take gastroprotective agent (proton-pump avoid in patients with symptomatic with heart failure (cilostazol and ■ Aspirin >325 mg/d inhibitor or misoprostol) heart failure: dronedarone) ■ Diclofenac Increased risk of gastrointestinal bleeding or peptic ulcer QE = Cilostazol: Low Non- ■ Diflunisal NSAIDs and COX-2 inhibitors disease in high-risk groups, including those aged >75 or taking dihydropyridine CCBs: Moderate ■ Etodolac Thiazolidinediones (pioglitazone, oral or parenteral corticosteroids, anticoagulants, or antiplatelet NSAIDs: Moderate COX-2 inhibitors: ■ Fenoprofen agents; use of proton-pump inhibitor or misoprostol reduces rosiglitazone) ■ Ibuprofen Low. Thiazolidinediones: High. but does not eliminate risk. Upper gastrointestinal ulcers, gross Dronedarone ■ Ketoprofen bleeding, or perforation caused by NSAIDs occur in ~1% of Dronedarone: High; SR = Strong ■ Meclofenamate patients treated for 3–6 months and in ~2–4% of patients treated ■ Mefenamic acid for 1 year; these trends continue with longer duration of use. ■ Meloxicam Also can increase blood pressure and induce kidney injury. Risks *See Table 7 in full criteria available on www.geriatricscareonline.org. ■ Nabumetone are dose-related. a ■ Naproxen May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health conditions but QE = Moderate; SR = Strong should be prescribed in the lowest effective dose and shortest possible duration. ■ Oxaprozin b ■ Piroxicam Excludes inhaled and topical forms. Oral and parenteral corticosteroids may be required for conditions such as ■ Sulindac exacerbation of COPD but should be prescribed in the lowest effective dose and for the shortest possible duration. ■ Tolmetin CCB=calcium channel blocker; AChEI=acetylcholinesterase inhibitor; CNS=central nervous system; COX=cyclooxygenase; NSAIDs=nonsteroidal antiinflammatory drug; SNRI=serotoninnorepinephrine
reuptake inhibitor; SSRI=selective serotonin reuptake inhibitor; TCAs=tricyclic antidepressant. ✃
PAGE 7 Table 1 (continued on page 8) 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 Syncope Acetylcholinesterase inhibitors Avoid History of Antiepileptics Avoid unless safer alternatives are (AChEIs) AChEIs cause bradycardia and should falls or Antipsychoticsa not available; avoid antiepileptics Non-selective peripheral alpha-1 be avoided in older adults whose fractures Benzodiazepines except for seizure and mood disorders. blockers (ie, doxazosin, prazosin, syncope may be due to bradycardia. Nonbenzodiazepine, Opioids: avoid except for pain terazosin) Non-selective peripheral alpha-1 benzodiazepine receptor agonist management in the setting of severe Tertiary TCAs blockers cause orthostatic blood hypnotics acute pain, eg, recent fractures or joint Antipsychotics pressure changes and should be ■ Eszopiclone replacement ■ Chlorpromazine avoided in older adults whose syncope ■ Zaleplon May cause ataxia, impaired ■ Thioridazine may be due to orthostatic hypotension. ■ Zolpidem psychomotor function, syncope, ■ Olanzapine Tertiary TCAs and the antipsychotics Antidepressants additional falls; shorter-acting listed increase the risk of orthostatic ■ TCAs benzodiazepines are not safer than hypotension or bradycardia. ■ SSRIs long-acting ones QE = AChEIs, TCAs and antipsychotics: ■ SNRIs If one of the drugs must be used, High. Non-selective peripheral alpha-1 Opioids consider reducing use of other CNS- blockers: High; SR = AChEIs, TCAs: active medications that increase risk Strong. Non-selective peripheral of falls and fractures (ie, antiepileptics, alpha-1 blockers, antipsychotics: Weak opioid-receptor agonists, antipsychotics, antidepressants, nonbenzodiazepine Central nervous system and benzodiazepine-receptor agonists, Delirium Anticholinergics* Avoid other sedatives/hypnotics) and Antipsychoticsa Avoid in older adults with or at high implement other strategies to reduce Benzodiazepines risk of delirium because of potential of fall risk. Data for antidepressants are Corticosteroids (oral and inducing or worsening delirium mixed but no compelling evidence that b parenteral) Avoid antipsychotics for behavioral certain antidepressants confer less fall H2-receptor antagonists problems of dementia and/or delirium risk than others. ■ Cimetidine unless nonpharmacological options QE = Opioids: Moderate. All others: ■ Famotidine (e.g., behavioral interventions) have High; SR = Strong ■ Nizatidine failed or are not possible and the Parkinson Antiemetics Avoid ■ Ranitidine older adult is threatening substantial disease ■ Metoclopramide Dopamine-receptor antagonists with Meperidine harm to self or others. Antipsychotics ■ Prochlorperazine potential to worsen parkinsonian Nonbenzodiazepine, are associated with greater risk of ■ Promethazine symptoms benzodiazepine receptor agonist cerebrovascular accident (stroke) and All antipsychotics (except mortality in persons with dementia Exceptions: Pimavanserin and clozapine hypnotics: eszopiclone, zaleplon, quetiapine, clozapine, appear to be less likely to precipitate zolpidem QE = H2-receptor antagonists: Low. pimavanserin) worsening of Parkinson disease. All others: Moderate; SR = Strong Quetiapine has only been studied in Dementia Anticholinergics* Avoid low quality clinical trials with efficacy or cognitive Benzodiazepines Avoid because of adverse CNS effects comparable to that of placebo in 5 trials impairment and to that of clozapine in 2 others. Nonbenzodiazepine, Avoid antipsychotics for behavioral benzodiazepine receptor agonist problems of dementia and/or delirium QE = Moderate; SR = Strong hypnotics unless nonpharmacological options Gastrointestinal ■ Eszopiclone (e.g., behavioral interventions) have History of Aspirin (>325 mg/d) Avoid unless other alternatives are ■ Zaleplon failed or are not possible and the gastric or Non-COX-2 selective NSAIDs not effective and patient can take ■ Zolpidem older adult is threatening substantial duodenal gastroprotective agent (ie, proton- Antipsychotics, chronic and as- harm to self or others. Antipsychotics ulcers pump inhibitor or misoprostol) needed usea are associated with greater risk of May exacerbate existing ulcers or cerebrovascular accident (stroke) and cause new/additional ulcers mortality in persons with dementia QE = Moderate; SR = Strong
QE = Moderate; SR = Strong ✃
PAGE 9 Table 2 (continued on page 10) PAGE 10 Table 2 (continued on page 11) Table 2 Continued Table 3 Continued Disease or Prasugrel Use with caution in adults ≥75 years old Syndrome Drug(s) Recommendation, Rationale, QE, SR Increased risk of bleeding in older adults; benefit in highest-risk older Kidney/Urinary tract adults (e.g., those with prior myocardial infarction or diabetes mellitus) Chronic NSAIDs (non-COX and COX- Avoid may offset risk when used for its approved indication of acute coronary kidney selective, oral and parenteral, May increase risk of acute kidney syndrome to be managed with percutaneous coronary intervention disease Stage nonacetylated salicylates) injury and further decline of renal QE = Moderate; SR = Weak IV or higher function Antipsychotics Use with caution (creatinine QE = Moderate; SR = Strong clearance <30 Carbamazepine May exacerbate or cause SIADH or hyponatremia; monitor sodium mL/min) Diuretics level closely when starting or changing dosages in older adults Mirtazapine QE = Moderate; SR = Strong Oxcarbazepine Urinary Estrogen oral and transdermal Avoid in women SNRIs incontinence (excludes intravaginal estrogen) Lack of efficacy (oral estrogen) and SSRIs (all types) in Peripheral alpha-1 blockers aggravation of incontinence (alpha-1 TCAs women ■ Doxazosin blockers) Tramadol ■ Prazosin QE = Estrogen: High. Peripheral alpha-1 Dextromethorphan/ Use with caution ■ Terazosin blockers: Moderate; SR = Estrogen: quinidine Limited efficacy in patients with behavioral symptoms of dementia Strong. Peripheral alpha-1 blockers: (does not apply to treatment of PBA). May increase risk of falls and Strong concerns with clinically significant drug interactions. Does not apply to Lower Strongly anticholinergic drugs, Avoid in men treatment of pseudobulbar affect. urinary tract except antimuscarinics for urinary May decrease urinary flow and cause QE = Moderate; SR = Strong symptoms, incontinence.* urinary retention Trimethoprim- Use with caution in patients on ACEI or ARB and decreased benign QE = Moderate; SR = Strong sulfamethoxazole creatinine clearance. prostatic hyperplasia Increased risk of hyperkalemia when used concurrently with an ACEI or ARB in presence of decreased creatinine clearance. QE = Low; SR = Strong TABLE 3. 2019 American Geriatrics Society Beers Criteria® for Potentially Inappropriate Medications to Be Used with Caution in Older Adults ACEI= angiotensin-converting enzyme inhibitor; ARB=angiotensin receptor blocker; CrCl= creatinine clearance; SIADH= syndrome of inappropriate antidiuretic hormone secretion; SNRIs = Serotonin- Recommendation, Rationale, Quality of Evidence (QE), nonrepinephrine reuptake inhibitors; SSRIs = Selective serotonin reuptake inhibitors; TCA=tricyclic Drug(s) Strength of Recommendation (SR) antidepressant; VTE=venous thromboembolism Aspirin for primary Use with caution in adults ≥70 years old prevention of Risk of major bleeding from aspirin increases markedly in older age. ® cardiovascular Several studies suggest lack of net benefit when used for primary TABLE 4. 2019 American Geriatrics Society Beers Criteria for Potentially Clinically Important disease and prevention in older adult with cardiovascular risk factors, but evidence Drug–Drug Interactions That Should Be Avoided in Older Adults colorectal cancer is not conclusive. Aspirin is generally indicated for secondary Interacting Drug Recommendation, Risk Rationale, Quality of Evidence prevention in older adults with established cardiovascular disease. Object Drug and Class and Class (QE), Strength of Recommendation (SR) QE = Moderate; SR = Strong RAS inhibitor Another RAS Avoid routine use in those with chronic kidney Use with caution for treatment of VTE or atrial fibrillation in adults 75 (ACEIs, ARBs, inhibitor disease Stage 3a or higher Dabigatran ≥ aliskiren) or (ACEIs, ARBs, Rivaroxaban years old Increased risk of hyperkalemia potassium-sparing aliskiren) QE = Moderate; SR = Strong Increased risk of gastrointestinal bleeding compared with warfarin diuretics (amiloride, and reported rates with other direct oral anticoagulants when used triamterene) for long-term treatment of venous thromboembolism (VTE) or atrial Opioids Benzo- Avoid fibrillation in adults≥ 75 years old. diazepines Increased risk of overdose
QE = Moderate; SR = Strong QE = Moderate; SR = Strong ✃
PAGE 11 Table 3 (continued on page 12) PAGE 12 Table 4 (continued on page 13) Table 4 Continued Warfarin Ciprofloxacin Avoid when possible; if used together, monitor INR Table 4 Continued closely Increased risk of bleeding Opioids Gabapentin, Avoid; exceptions are when transitioning from opioid QE = Moderate; SR = Strong pregabalin therapy to gabapentin or pregabalin, or when using Warfarin Macrolides Avoid when possible; if used together, monitor INR gabapentinoids to reduce opioid dose, although (excluding closely caution should be used in all circumstances. azithromycin) Increased risk of bleeding Increased risk of severe sedation-related adverse QE = Moderate; SR = Strong events, including respiratory depression and death Warfarin Trimethoprim- Avoid when possible; if used together, monitor INR QE = Moderate; SR = Strong sulfamethox- closely Anticholinergic Anticholinergic Avoid, minimize number of anticholinergic drugs azole Increased risk of bleeding Increased risk of cognitive decline QE = Moderate; SR = Strong QE = Moderate; SR = Strong Warfarin NSAIDs Avoid when possible; if used together, monitor closely Antidepressants Any Avoid total of ≥3 CNS-active drugsa; minimize number for bleeding (TCAs, SSRIs, and combination of CNS-active drugs Increased risk of bleeding SNRIs) of ≥3 of these Increased risk of falls (all) and of fracture QE = High; SR = Strong Antipsychotics CNS-active (benzodiazepines and nonbenzodiazepine, drugsa benzodiazepine receptor agonist hypnotics) Antiepileptics TABLE 5. 2019 American Geriatrics Society Beers Criteria® for Medications That Should Benzodiazepines QE: Combinations including benzodiazepines and and nonbenzodiaz- nonbenzodiazepine, benzodiazepine receptor agonist Be Avoided or Have Their Dosage Reduced with Varying Levels of Kidney Function in Older epine, benzodi- hypnotics or opioids: High. All other combinations: Adults azepine receptor Moderate; SR: Strong agonist hypnotics Creatinine Clearance, (ie, “Z-drugs”) Medication Class mL/min, at Which Recommendation, Rationale, Quality of Evidence (QE), Opioids and Medication Action Required Strength of Recommendation (SR) Corticosteroids, NSAIDs Avoid; if not possible, provide gastrointestinal Anti-infective oral or parenteral protection Ciprofloxacin <30 Doses used to treat common infections typically Increased risk of peptic ulcer disease or require reduction when CrCl <30 mL/min gastrointestinal bleeding Increased risk of CNS effects (eg, seizures, confusion) QE = Moderate; SR = Strong and tendon rupture Lithium ACEIs Avoid, monitor lithium concentrations QE = Moderate; SR = Strong Increased risk of lithium toxicity Trimethoprim- <30 CrCl 15-29 mL/min:Reduce Dose QE = Moderate; SR = Strong sulfamethox- <15 mL/min: Avoid Lithium Loop diuretics Avoid, monitor lithium concentrations azole Increased risk of worsening of renal function and Increased risk of lithium toxicity hyperkalemia QE = Moderate; SR = Strong QE = Moderate; SR = Strong Peripheral Loop diuretics Avoid in older women, unless conditions warrant alpha-1 blockers both drugs aCentral nervous system (CNS)-active drugs: antiepileptics, antipsychotics; benzodiazepines; nonbenzodiazepine, Increased risk of urinary incontinence in older women benzodiazepine receptor agonist hypnotics; tricyclic antidepressants (TCAs); selective serotonin reuptake inhibitors QE = Moderate; SR = Strong (SSRIs); serotonin-norepinephrine reuptake inhibitors (SNRIs); and opioids Phenytoin Trimethoprim- Avoid ACEIs=angiotensin-converting enzyme inhibitors; ARBs=angiotensin receptor blockers; INR=international sulfamethox- Increased risk of phenytoin toxicity normalized ratio; NSAIDs=nonsteroidal anti-inflammatory drugs; RAS=renin-angiotensin system azole QE = Moderate; SR = Strong Copyright © 2019 by the American Geriatrics Society. All rights reserved. Except where authorized, no part Theophylline Cimetidine Avoid of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any Increased risk of theophylline toxicity means, electronic, mechanical, photocopying, recording, or otherwise without written permission of the QE = Moderate; SR = Strong American Geriatrics Society, 40 Fulton Street, 18th Floor, New York, NY 10038. The Criteria published by The American Geriatrics Society (AGS) incorporate data obtained from a literature review of the most recent Theophylline Ciprofloxacin Avoid studies available at the time. As with all clinical reference resources, they reflect the best understanding Increased risk of theophylline toxicity of the science of medicine at the time of publication, but they should be used with the clear understanding QE = Moderate; SR = Strong that continued research may result in new knowledge and recommendations. The Criteria are intended for general information only, are not medical advice, and do not replace professional medical care and Warfarin Amiodarone Avoid when possible; if used together, monitor INR physician advice, which always should be sought for any specific condition. closely Increased risk of bleeding
QE = Moderate; SR = Strong ✃
PAGE 13 Table 4 (continued on page 14) PAGE 14 Table 5 (continued on page 15) Table 5 Continued Table 5 Continued Creatinine Clearance, Creatinine Clearance, Medication Class mL/min, at Which Medication Class mL/min, at Which and Medication Action Required Recommendation, Rationale, QE, SR and Medication Action Required Recommendation, Rationale, QE, SR Cardiovascular or hemostasis Central nervous system and analgesics Amiloride <30 Avoid Duloxetine <30 Avoid Increased potassium and decreased sodium Increased gastrointestinal adverse effects (nausea, QE = Moderate; SR = Strong diarrhea) Apixaban <25 Avoid QE = Moderate; SR = Weak Lack of evidence for efficacy and safety in patients Gabapentin <60 Reduce dose with a CrCl <25 mL/min CNS adverse effects QE = Moderate; SR = Strong QE = Moderate; SR = Strong Dabigatran <30 Avoid; dose adjustment advised when CrCl >30 mL/ Levetiracetam ≤80 Reduce dose min in the presence of drug-drug interactions CNS adverse effects Lack of evidence for efficacy and safety in individuals QE = Moderate; SR = Strong with a CrCl <30 mL/min. Label dose for patients with a Pregabalin <60 Reduce dose CrCl 15-30 mL/min based on pharmacokinetic data. CNS adverse effects QE = Moderate; SR = Strong QE = Moderate; SR = Strong Dofetilide <60 CrCl 20-59 mL/min: Reduce dose Tramadol <30 Immediate release: Reduce dose CrCl <20 mL/min: Avoid Extended release: avoid QTc prolongation and torsades de pointes CNS adverse effects QE = Moderate; SR = Strong QE = Low; SR = Weak Edoxaban 15–50 CrCl 15-50: Reduce dose Gastrointestinal <15 or >95 CrCl <15 or >95: Avoid Cimetidine <50 Reduce dose Lack of evidence of efficacy or safety in patients with a CrCl <30 mL/min Mental status changes QE = Moderate; SR = Strong QE = Moderate; SR = Strong Reduce dose Enoxaparin <30 Reduce dose Famotidine <50 Mental status changes Increased risk of bleeding QE = Moderate; SR = Strong QE = Moderate; SR = Strong Nizatidine <50 Reduce dose Fondaparinux <30 Avoid Mental status changes Increased risk of bleeding QE = Moderate; SR = Strong QE = Moderate; SR = Strong Ranitidine <50 Reduce dose Rivaroxaban <50 Nonvalvular atrial fibrillation: reduce dose if CrCl 15-50 mL/min; avoid if CrCl <15 mL/min Mental status changes Venous thromboembolism treatment and for VTE QE = Moderate; SR = Strong prophylaxis with hip or knee replacement: avoid if Hyperuricemia CrCl <30 mL/min Colchicine <30 Reduce dose; monitor for adverse effects Lack of efficacy or safety evidence in patients with a Gastrointestinal, neuromuscular, bone marrow toxicity CrCl <30 mL/min QE = Moderate; SR = Strong QE = Moderate; SR = Strong Probenecid <30 Avoid Spironolactone <30 Avoid Loss of effectiveness Increased potassium QE = Moderate; SR = Strong QE = Moderate; SR = Strong CNS=central nervous system; QTc=corrected QT interval; CrCl=creatinine clearance Triamterene <30 Avoid The primary target audience is the practicing clinician. The intentions of the criteria include 1) improving Increased potassium and decreased sodium the selection of prescription drugs by clinicians and patients; 2) evaluating patterns of drug use within QE = Moderate; SR = Strong populations; 3) educating clinicians and patients on proper drug usage; and 4) evaluating health-outcome,
quality-of-care, cost, and utilization data. ✃
PAGE 15 Table 5 (continued on page 16) PAGE 16