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CLINICAL INVESTIGATION
American Geriatrics Society 2019 Updated AGS Beers Criteria®
for Potentially Inappropriate Medication Use in Older Adults By the 2019 American Geriatrics Society Beers Criteria® Update Expert Panel*
The American Geriatrics Society (AGS) Beers Criteria®
(AGS Beers Criteria®) for Potentially Inappropriate Medica- tion (PIM) Use in Older Adults are widely used by clini- cians, educators, researchers, healthcare administrators, and regulators. Since 2011, the AGS has been the steward of the criteria and has produced updates on a 3-year cycle. The AGS Beers Criteria® is an explicit list of PIMs that are typi- cally best avoided by older adults in most circumstances or under specific situations, such as in certain diseases or con- ditions. For the 2019 update, an interdisciplinary expert panel reviewed the evidence published since the last update (2015) to determine if new criteria should be added or if existing criteria should be removed or undergo changes to their recommendation, rationale, level of evidence, or strength of recommendation. J Am Geriatr Soc 00:1– 21, 2019.
Key words: medications; drugs; older adults; Beers list; Beers Criteria
The American Geriatrics Society (AGS) Beers Criteria ®
(AGS Beers Criteria®) for Potentially Inappropriate Medication (PIM) Use in Older Adults are widely used by clinicians, educators, researchers, healthcare administrators, and regulators. Since 2011, the AGS has been the steward of the criteria and has produced updates on a 3-year cycle that began in 2012.1,2 The AGS Beers Criteria® are an explicit list of PIMs that are typically best avoided by older adults in most circumstances or under specific situations, such as in certain diseases or conditions.
For the 2019 update, an interdisciplinary expert panel reviewed the evidence published since the last update (2015) to determine if new criteria should be added or if existing criteria should be removed or undergo changes to their recommendation, rationale, level of evidence, or strength of recommendation. Each of the five types of cri- teria in the 2015 update were retained in this 2019 update: medications that are potentially inappropriate in most older adults, those that should typically be avoided in older adults with certain conditions, drugs to use with caution, drug-drug interactions, and drug dose adjustment based on kidney function.
OBJECTIVES
The specific aim was to update the 2015 AGS Beers Criteria®
using a comprehensive, systematic review and grading of the evidence on drug-related problems and adverse events in older adults. The strategies to achieve this aim were to:
• Incorporate new evidence on PIMs included in the 2015 AGS Beers Criteria® and evidence regarding new criteria or modifi- cations of existing criteria being considered for the 2019 update.
• Grade the strength and quality of each PIM statement based on the level of evidence and strength of recommendation.
• Convene an interdisciplinary panel of 13 experts in geriatric care and pharmacotherapy who would apply a modified Delphi method, informed by the systematic review and grading, to reach consensus on the 2019 update.
• Incorporate exceptions in the AGS Beers Criteria® that the panel deemed clinically appropriate. These exceptions would be designed to make the criteria more individualized to clinical practice and be more relevant across settings of care.
INTENT OF CRITERIA
The primary target audience for the AGS Beers Criteria®
is practicing clinicians. The criteria are intended for use in adults 65 years and older in all ambulatory, acute, and institutionalized settings of care, except for the hospice and palliative care settings. Consumers, researchers, phar- macy benefits managers, regulators, and policymakers also widely use the AGS Beers Criteria®. The intention of the AGS Beers Criteria® is to improve medication selection;
From the *American Geriatrics Society, New York, New York.
Address correspondence to Mary Jordan Samuel, American Geriatrics Society, 40 Fulton St, 18th Floor, New York, NY 10038. E-mail: [email protected]
See related editorial by Michael Steinman et al.
DOI: 10.1111/jgs.15767
JAGS 00:1–21, 2019 © 2019 The American Geriatrics Society 0002-8614/18/$15.00
educate clinicians and patients; reduce adverse drug events; and serve as a tool for evaluating quality of care, cost, and patterns of drug use of older adults.
As with previously published AGS Beers Criteria®, the goal of the 2019 update continues to be improving the care of older adults by reducing their exposure to PIMs that have an unfavorable balance of benefits and harms com- pared with alternative treatment options. This is accom- plished by using the AGS Beers Criteria® as both an educational tool and a quality measure—two uses that are not always in agreement—and the panel considered and vigorously deliberated both. The AGS Beers Criteria® are not meant to be applied in a punitive manner. Prescribing decisions are not always clear-cut, and clinicians must con- sider multiple factors, including discontinuation of medica- tions no longer indicated. Quality measures must be clearly defined, easily applied, and measured with limited informa- tion and, thus, although useful, cannot perfectly distinguish appropriate from inappropriate care. The panel’s review of evidence at times identified subgroups of individuals who should be exempt from a given criterion or to whom a spe- cific criterion should apply. Such a criterion may not be eas- ily applied as a quality measure, particularly when such subgroups cannot be easily identified through structured and readily accessible electronic health data. As an exam- ple, the panel thought that a criterion should not be expanded to include all adults 65 years and older when only certain subgroups have an adverse balance of benefits vs harms for the medication, or conversely when a sizable subgroup of older adults may be appropriate candidates for a medication that is otherwise problematic.
Despite past and current efforts to translate the cri- teria into practice, some controversy and myths about their use in practice and policy continue to prevail. The panel addressed these concerns and myths by writing a companion article to the 2015 update of the AGS Beers Criteria® and an updated 2019 short piece, which remains the best way to advise patients, providers, and health sys- tems on how to use (and not use) the 2019 AGS Beers Criteria®.3
METHODS
Methods used for the 2019 update of the AGS Beers Criteria®
were similar to those used in the 2015 update, with additional emphasis on extending the rigor of the evidence review and synthesis process.2 These methods were based on the Grading of Recommendations Assessment, Development and Evalua- tion (GRADE) guidelines for clinical practice guideline devel- opment and are consistent with recommendations from the National Academy of Medicine.4,5
Panel Composition
The AGS Beers Criteria® expert update panel comprised 13 clinicians and included physicians, pharmacists, and nurses, each of whom had participated in the 2015 update. Panelists had experience in different practice settings, including ambulatory care, home care, acute hospital care, skilled-nursing facility, and long-term care. In addition, the panel included ex-officio representatives from the Cen- ters for Medicare and Medicaid Services, the National
Committee for Quality Assurance, and the Pharmacy Quality Alliance. Potential conflicts of interest were dis- closed at the beginning of the process and before each full panel call and are listed in the disclosures section of this article. Panelists were recused from discussion in areas in which they had a potential conflict of interest.
Literature Review
Literature searches were conducted in PubMed and the Cochrane Library from January 1, 2015, to September 30, 2017. Search terms for each criterion included individ- ual drugs, drug classes, specific conditions, and combina- tions thereof, each with a focus on “adverse drug events” and “adverse drug reactions.” Medications believed to have low utilizations (eg, meprobamate and central α-agonist antihypertensives other than clonidine) or no longer avail- able in the United States were excluded from the literature search. Searches targeted controlled clinical trials, observa- tional studies, and systematic reviews and meta-analyses, with filters for human participants, 65 years and older, and English language. Clinical reviews and guidelines were also included to provide context. Case reports, case series, letters to the editor, and editorials were excluded.
Searches identified 17,627 references; 5403 abstracts were sent to panelists for review, of which 1422 references were selected for full-text review. Among these, 377 articles were abstracted into evidence tables, including 67 systematic reviews and/or meta-analyses, 29 controlled clinical trials, and 281 observational studies.
Development Process
Between February 2016 and May 2018, the full panel con- vened for a series of conference calls and 1 full-day, in- person meeting. In addition, the panel divided into four work groups, each assigned a subset of the criteria. Each work group led the review and synthesis of evidence for its subset of the criteria, convening via conference calls and electronically via e-mail.
The development process began by soliciting ideas from the panelists about criteria that should be explored for addi- tion, modification, or removal. Suggestions from others were also welcomed. To guide the evidence selection, review, and synthesis process, each work group then under- took an exercise to identify a priori which clinical out- comes, indications, and comparison groups were most relevant when considering evidence for each criterion (ie, the “desired evidence” for reviewing each criterion). These discussions were not considered binding but provided guidance for keeping the evidence review and synthesis focused on what was most clinically relevant.
Each work group reviewed abstracts from the literature searches for the criteria in its purview and collectively selected a subset for full-text review. This selection process considered the methodologic quality of each study, its rele- vance to older adults, and its concordance with the desired evidence noted above. After reviewing the full text of each selected article, the work group then decided by consensus which articles represented the best available evidence, based on a balance of these same three key criteria (methodologic quality, relevance to older adults, and concordance with
2 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL MONTH 2019–VOL. 00, NO. 00 JAGS
desired evidence). Special emphasis was placed on selecting systematic reviews and meta-analyses when available, because resource constraints precluded the panel from con- ducting these types of comprehensive analyses. In general, a study was considered relevant to older adults if the mean or median age of participants was older than 65 years, and especially relevant if most or all participants were older than this age threshold.
Articles comprising the best available evidence were abstracted by AGS staff into evidence tables. These tables summarized the design, population, and findings of each study, and identified markers of methodologic quality highlighted by the GRADE criteria for clinical trials and observational studies and by A MeaSurement Tool to Assess Systematic Reviews (AMSTAR).6–8 Each work group then synthesized evidence for each criterion from the 2015 to 2017 literature reviews based on GRADE guidelines and the American College of Physicians’ evidence grading framework (Table 1).6,9
Using evidence from the 2015 to 2017 literature review, evidence findings from previous updates in 2012 and 2015, and clinical judgment, each work group pre- sented to the full panel its findings and suggestions for changes (or no change) to the criteria, with ensuing discus- sion. For most criteria, a consensus emerged, to leave an existing criterion from the 2015 update unchanged, to mod- ify it, to remove it entirely, or to add a new criterion. Poten- tial modifications included the drug(s) included in the criterion, the recommendation, the rationale, the quality of evidence, and the strength of recommendation. As noted in the GRADE guidelines, strength of recommendation ratings incorporate a variety of considerations, including expert opinion and clinical judgment and context, and thus do not always align with quality of evidence ratings.
After discussion of proposed changes, an anonymous Del- phi process was used to ascertain panel consensus, using a five-point Likert scale with anchors of “strongly disagree” and “strongly agree.” As a general rule, criteria receiving “agree” or strongly agree ratings from more than 90% of panelists were included. The remainder were brought back for group discussion, with final decisions resolved through consensus.
In addition to changes made on the basis of evidence, the panel decided on several modifications to improve clar- ity and usability of the AGS Beers Criteria®. These included removing a number of medications that are used only rarely. These removals should not be interpreted as condon- ing use of these medications but rather are intended to “declutter” the AGS Beers Criteria® and not distract from information on more commonly used medications. In selected cases, the panel changed the wording of certain cri- teria, recommendations, and rationale statements to improve clarity and avoid potential misinterpretations.
The final set of criteria was reviewed by the AGS Exec- utive Committee and Clinical Practice and Models of Care Committee and subsequently released for public comment. Comments were solicited from the general public and sent to 39 organizations. Comments were accepted over a 3-week period from August 13, 2018, until September 4, 2018. A total of 244 comments were received from 47 individuals (79 comments), 6 pharmaceutical companies (10 comments), and 22 peer organizations (155 comments). All comments were reviewed and discussed by the panel
cochairs. All comments along with proposed changes to the criteria were shared with the entire panel for final approval.
RESULTS
Noteworthy Changes to PIMs for Older Adults
Tables 2 through 6 show the 2019 criteria. Table 7 lists those drugs with strong anticholinergic properties that are sometimes referenced in Tables 2 through 6. Compared with the 2015 criteria, several drugs were removed from Table 2 (medications that are potentially inappropriate in most older adults), Table 3 (medications that are potentially inappropriate in older adults with certain conditions), and Table 4 (medications that should be used with caution). These removals are summarized in Table 8 and include removal of drugs no longer available in the United States (ticlopidine, oral pentazocine). In other cases, the recom- mendation was removed entirely because the panel decided the drug-related problem was not sufficiently unique to older adults (eg, using stimulating medications in patients with insomnia or avoiding medications that can lower the seizure threshold in patients with a seizure disorder). These removals do not imply that these medications are now con- sidered safe for older adults; rather, they were made to help keep the AGS Beers Criteria® streamlined and focused on medications particularly problematic for older adults.
The H2-receptor antagonists were removed from the “avoid” list in patients with dementia or cognitive impair- ment. This is because evidence for adverse cognitive effects in these conditions is weak, and because the panel expressed concern that the intersection of this criterion with another criterion that discourages chronic use of proton- pump inhibitors in the absence of strong indications would overly restrict therapeutic options for older adults with dementia who have gastroesophageal reflux or similar issues. However, H2-receptor antagonists remain on the cri- teria as “avoid” in patients with delirium. In addition, wording of this criterion was modified to affirm that non- benzodiazepine, benzodiazepine receptor agonist hypnotics (ie, the “Z drugs”: zolpidem, eszopiclone, and zaleplon) should be avoided in older adults with delirium.
Two drugs with strong anticholinergic properties, pyri- lamine and methscopolamine, were added to the list of anti- cholinergic drugs to avoid. Changes to criteria on cardiovascular drugs include minor updates to the rationale and a minor change to clarify the recommendation for avoiding digoxin as first-line therapy for atrial fibrillation and heart failure (Table 2). The rationale to avoid sliding- scale insulin has been revised to clarify its meaning and intent (Table 2). Glimepiride has been added to the list of sulfonylureas with a greater risk of severe prolonged hypo- glycemia (Table 2). The duration of use of metoclopramide has been added to be consistent with US Food and Drug Administration labeling (Table 2).
The serotonin-norepinephrine reuptake inhibitors (SNRIs) have been added to the list of drugs to avoid in patients with a history of falls or fractures (Table 3). Fol- lowing a principle that applies to all criteria, the panel rec- ognizes there may be situations when SNRIs, other antidepressants, and other medications listed in this crite- rion may be appropriate for people with a history of falls
JAGS MONTH 2019–VOL. 00, NO. 00 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL 3
or fractures, based on potential benefits and the lack of availability of safer alternatives. After reviewing and dis- cussing the evidence on antipsychotics to treat psychosis in patients with Parkinson disease, the panel decided to remove aripiprazole as preferred and add pimavanserin. Thus, the 2019 AGS Beers Criteria® recognize quetiapine, clozapine, and pimavanserin as exceptions to the general recommendation to avoid all antipsychotics in older adults with Parkinson disease (Table 3). However, none of these three excepted drugs is close to ideal in either efficacy or safety, each having its own limitations and concerns.
The criteria on drugs to avoid in older adults with heart fail- ure were reorganized to add clinical nuance based on evidence, other guideline recommendations, and clinical considerations. The updated recommendations are that nondihydropyridine cal- cium channel blockers should be avoided in older adults who have heart failure with reduced ejection fraction; that nonsteroi- dal anti-inflammatory drug (NSAIDs), cyclooxygenase-2 inhibi- tors, thiazolidinediones (“glitazones”), and dronedarone should
be used with caution in older adults with heart failure who are asymptomatic (ie, excellent control of heart failure signs and symptoms, with or without use of medications) and avoided in older adults who are symptomatic; and that cilostazol should continue to be avoided in older adults with heart failure of any type.
Drugs To Be Used With Caution
Table 4 contains drugs to be used with caution in older adults. The purpose of this table is to identify drugs for which there is some cause for concern, but for which the evidence and/or clinical context is as of yet insufficient to merit inclusion in the main tables. Compared with the pre- vious update, the following changes and additions were made:
• The age threshold beyond which extra caution is advised for using aspirin for primary prevention of cardiovascular disease
Table 1. Designations of Quality of Evidence and Strength of Recommendationsa
Quality of Evidence Quality of evidence ratings for each criterion are based on synthetic assessment of two complementary approaches to evaluating the quality of evidence.
ACP-based approach9 GRADE-based approach4
High-quality evidence “Evidence…obtained from 1 or more well- designed and well-executed randomized, controlled trials (RCTs) that yield consistent and directly applicable results. This also means that further research is very unlikely to change our confidence in the estimate of effect.”
Consider the following five factors for the studies that comprise the best-available evidence for a given criterion: 1. Risk of bias: Severity of threats to studies’
internal validity (eg, randomized vs observational design, potential for confounding, bias in measurement)
2. Inconsistency: Do different studies provide similar or different estimates of effect size
3. Indirectness: How relevant are the studies to the clinical question at hand (eg, nature of study of population, comparison group, type of outcomes measured)
4. Imprecision: Precision of estimates of effect 5. Publication bias: Risk of bias due to selective
publication of results
Moderate-quality evidence “Evidence…obtained from RCTs with important limitations…. In addition, evidence from well- designed controlled trials without randomization, well-designed cohort or case-control analytic studies, and multiple time series with or without intervention are in this category. Moderate- quality evidence also means that further research will probably have an important effect on our confidence in the estimate of effect and may change the estimate.”
Low-quality evidence “Evidence obtained from observational studies would typically be rated as low quality because of the risk for bias. Low-quality evidence means that further research is very likely to have an important effect on our confidence in the estimate of effect and will probably change the estimate. However, the quality of evidence may be rated as moderate or even high, depending on circumstances under which evidence is obtained from observational studies.”
# # # # # Overall quality of evidence that supports a given criterion: high, moderate, low
Strength of Evidence Strength of evidence ratings for each criterion are based on synthetic integration of the quality of evidence, the frequency and severity of potential adverse events and relationship to potential benefits, and clinical judgment. Strong Harms, adverse events, and risks clearly outweigh benefits. Weak Harms, adverse events, and risks may not outweigh benefits.
Abbreviations: ACP, American College of Physicians; GRADE, Grading of Recommendations Assessment, Development and Evaluation. aAdapted from: Qaseem A, Snow V, Owens DK, et al. The development of clinical practice guidelines and guidance statements of the American College of Physicians: summary of methods. Ann Intern Med. 2010;153:194-–199. Guyatt G, Oxman AD, Sultan S, et al. GRADE guidelines,: 11.: making an overall rating of confidence in effect estimates for a single outcome and for all outcomes. J Clin Epidemiol. 2013;66(2):151-–157. Andrews JC, Schünemann HJ, Oxman AD, et al. GRADE guidelines,: 15.: going from evidence to recommendation-determinants of a recommendation’s direction and strength. J Clin Epi- demiol. 2013;66(7):726–735.
4 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL MONTH 2019–VOL. 00, NO. 00 JAGS
T ab
le 2 . 2 0 1 9 A m er ic an
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ci et y B ee rs
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JAGS MONTH 2019–VOL. 00, NO. 00 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL 5
T ab
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in h e a rt fa ilu re : e vi d e n ce
fo r b e n e fi ts
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s o f
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co n fl ic tin
g a n d o f lo w e r q u a lit y;
m o st
b u t n o t a ll
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co n ce
rn s u se
in H F rE F . T h e re
is st ro n g
e vi d e n ce
fo r o th e r a g e n ts
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re d u ce
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ita liz a tio
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a d u lts
w ith
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h e a rt fa ilu re , h ig h e r d o sa
g e s a re
n o t a ss o ci a te d w ith
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ri sk
o f to xi ci ty .
D e cr e a se
d re n a lc
le a ra n ce
o f d ig o xi n m a y le a d to
in cr e a se
d ri sk
o f to xi c e ff e ct s;
fu rt h e r d o se
re d u ct io n m a y
b e n e ce
ss a ry
in th o se
w ith
st a g e 4 o r 5 ch
ro n ic
ki d n e y
d is e a se
.
A vo
id th is
ra te
co n tr o la
g e n t a s fi rs t-
lin e th e ra p y fo r a tr ia lfi
b ri lla tio
n
A vo
id a s fi rs t- lin e th e ra p y fo r h e a rt
fa ilu re
If u se
d fo r a tr ia lfi
b ri lla tio
n o r h e a rt
fa ilu re , a vo
id d o sa
g e s > 0 .1 2 5 m g /d a y
A tr ia lfi
b ri lla tio
n :
lo w
H e a rt fa ilu re :
lo w
D o sa
g e
> 0 .1 2 5 m g /d a y:
m o d e ra te
A tr ia lfi b ril la tio n :
st ro n g
H e a rt fa ilu re :
st ro n g
D o sa
g e
> 0 .1 2 5 m g /d a y:
st ro n g
N ife
d ip in e , im
m e d ia te
re le a se
P o te n tia
lf o r h yp
o te n si o n ; ri sk
o f p re ci p ita
tin g m yo
ca rd ia l
is ch
e m ia
A vo
id H ig h
S tr o n g
A m io d a ro n e
E ff e ct iv e fo r m a in ta in in g si n u s rh yt h m
b u t h a s g re a te r
to xi ci tie
s th a n o th e r a n tia
rr h yt h m ic s u se
d in
a tr ia l
fi b ri lla tio
n ; m a y b e re a so
n a b le
fi rs t- lin e th e ra p y in
p a tie
n ts
w ith
co n co
m ita
n t h e a rt fa ilu re
o r su
b st a n tia
ll e ft
ve n tr ic u la r h yp
e rt ro p h y if rh yt h m
co n tr o li s p re fe rr e d o ve
r ra te
co n tr o l
A vo
id a s fi rs t- lin e th e ra p y fo r a tr ia l
fi b ri lla tio
n u n le ss
p a tie
n t h a s h e a rt
fa ilu re
o r su
b st a n tia
ll e ft ve
n tr ic u la r
h yp
e rt ro p h y
H ig h
S tr o n g
C e n tr a ln
e rv o u s sy st e m
A n tid
e p re ss a n ts , a lo n e o r in
co m b in a tio
n A m itr ip ty lin e
A m o xa
p in e
C lo m ip ra m in e
D e si p ra m in e
D o xe
p in
> 6 m g /d a y
Im ip ra m in e
H ig h ly
a n tic h o lin e rg ic , se
d a tin
g , a n d ca
u se
o rt h o st a tic
h yp
o te n si o n ; sa
fe ty
p ro fi le
o f lo w -d o se
d o xe
p in
(≤ 6 m g /d a y)
co m p a ra b le
to th a t o f p la ce
b o
A vo
id H ig h
S tr o n g
6 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL MONTH 2019–VOL. 00, NO. 00 JAGS
T ab
le 2 (C
o n td .)
O rg an
Sy st em
, Th er ap eu tic
Ca te go ry , D ru g( s)
R at io na le
R ec om
m en da tio
n Q ua lit y of
Ev id en ce
St re ng th
of R ec om
m en da tio
n
N o rt ri p ty lin e
P a ro xe
tin e
P ro tr ip ty lin e
T ri m ip ra m in e
A n tip
sy ch
o tic s,
fi rs t (c o n ve
n tio
n a l) a n d
se co
n d (a ty p ic a l) g e n e ra tio
n In cr e a se
d ri sk
o f ce
re b ro va
sc u la r a cc id e n t (s tr o ke
) a n d
g re a te r ra te
o f co
g n iti ve
d e cl in e a n d m o rt a lit y in
p e rs o n s
w ith
d e m e n tia
A vo
id a n tip sy ch
o tic s fo r b e h a vi o ra lp ro b le m s o fd
e m e n tia
o r
d e lir iu m
u n le ss
n o n p h a rm
a co
lo g ic a lo p tio n s (e g ,b
e h a vi o ra l
in te rv e n tio n s)
h a ve
fa ile d o r a re
n o tp
o ss ib le a n d th e o ld e r
a d u lt is th re a te n in g su
b st a n tia lh a rm
to se
lf o r o th e rs
A vo
id , e xc e p t in
sc h iz o p h re n ia
o r
b ip o la r d is o rd e r, o r fo r sh
o rt -t e rm
u se
a s a n tie
m e tic
d u ri n g ch
e m o th e ra p y
M o d e ra te
S tr o n g
B a rb itu
ra te s
A m o b a rb ita
l B u ta b a rb ita
l B u ta lb ita
l M e p h o b a rb ita
l P e n to b a rb ita
l P h e n o b a rb ita
l S e co
b a rb ita
l
H ig h ra te
o f p h ys ic a ld
e p e n d e n ce
, to le ra n ce
to sl e e p
b e n e fi ts , g re a te r ri sk
o f o ve
rd o se
a t lo w
d o sa
g e s
A vo
id H ig h
S tr o n g
B e n zo
d ia ze
p in e s
S h o rt a n d in te rm
e d ia te
a c tin
g :
A lp ra zo
la m
E st a zo
la m
L o ra ze
p a m
O xa
ze p a m
T e m a ze
p a m
T ri a zo
la m
L o n g a c tin
g :
C h lo rd ia ze
p o xi d e (a lo n e o r in
co m b in a tio
n w ith
a m itr ip ty lin e o r cl id in iu m )
C lo n a ze
p a m
C lo ra ze
p a te
D ia ze
p a m
F lu ra ze
p a m
Q u a ze
p a m
O ld e r a d u lts
h a ve
in cr e a se
d se
n si tiv ity
to b e n zo
d ia ze
p in e s a n d d e cr e a se
d m e ta b o lis m
o f lo n g -
a ct in g a g e n ts ; in
g e n e ra l, a ll b e n zo
d ia ze
p in e s in cr e a se
ri sk
o f co
g n iti ve
im p a ir m e n t, d e lir iu m , fa lls , fr a ct u re s,
a n d
m o to r ve
h ic le
cr a sh
e s in
o ld e r a d u lts
M a y b e a p p ro p ri a te
fo r se
iz u re
d is o rd e rs , ra p id
e ye
m o ve
m e n t sl e e p b e h a vi o r d is o rd e r, b e n zo
d ia ze
p in e
w ith
d ra w a l, e th a n o lw
ith d ra w a l, se
ve re
g e n e ra liz e d
a n xi e ty
d is o rd e r, a n d p e ri p ro ce
d u ra la
n e st h e si a
A vo
id M o d e ra te
S tr o n g
M e p ro b a m a te
H ig h ra te
o f p h ys ic a ld
e p e n d e n ce
; se
d a tin
g A vo
id M o d e ra te
S tr o n g
N o n b e n zo
d ia ze
p in e , b e n zo
d ia ze
p in e
re ce
p to r a g o n is t h yp
n o tic s (i e , “Z -d ru g s” )
E sz o p ic lo n e
Z a le p lo n
Z o lp id e m
N o n b e n zo
d ia ze
p in e b e n zo
d ia ze
p in e re ce
p to r a g o n is t
h yp
n o tic s (i e , Z d ru g s)
h a ve
a d ve
rs e e ve
n ts
si m ila r to
th o se
o fb
e n zo
d ia ze
p in e s in
o ld e r a d u lts
(e g , d e lir iu m ,
fa lls , fr a ct u re s) ; in cr e a se
d e m e rg e n cy
ro o m
vi si ts /
h o sp
ita liz a tio
n s;
m o to r ve
h ic le
cr a sh
e s;
m in im
a l
im p ro ve
m e n t in
sl e e p la te n cy
a n d d u ra tio
n
A vo
id M o d e ra te
S tr o n g
E rg o lo id
m e sy la te s
(d e h yd
ro g e n a te d e rg o t a lk a lo id s)
Is o xs u p ri n e
L a ck
o f e ffi ca
cy A vo
id H ig h
S tr o n g
(C o n ti n u ed
)
JAGS MONTH 2019–VOL. 00, NO. 00 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL 7
T ab
le 2 (C
o n td .)
O rg an
Sy st em
, Th er ap eu tic
Ca te go ry , D ru g( s)
R at io na le
R ec om
m en da tio
n Q ua lit y of
Ev id en ce
St re ng th
of R ec om
m en da tio
n
E n d o cr in e
A n d ro g e n s
M e th yl te st o st e ro n e
T e st o st e ro n e
P o te n tia
lf o r ca
rd ia c p ro b le m s;
co n tr a in d ic a te d in
m e n
w ith
p ro st a te
ca n ce
r A vo
id u n le ss
in d ic a te d fo r co
n fi rm
e d
h yp
o g o n a d is m
w ith
cl in ic a ls
ym p to m s
M o d e ra te
W e a k
D e si cc a te d th yr o id
C o n ce
rn s a b o u t ca
rd ia c e ff e ct s;
sa fe r a lte
rn a tiv e s
a va
ila b le
A vo
id L o w
S tr o n g
E st ro g e n s w ith
o r w ith
o u t p ro g e st in s
E vi d e n ce
o f ca
rc in o g e n ic
p o te n tia
l( b re a st
a n d
e n d o m e tr iu m ); la ck
o f ca
rd io p ro te ct iv e e ff e ct
a n d
co g n iti ve
p ro te ct io n in
o ld e r w o m e n
E vi d e n ce
in d ic a te s th a tv
a g in a le
st ro g e n s fo r th e tr e a tm
e n t
o fv
a g in a ld
ry n e ss
a re
sa fe
a n d e ff e ct iv e ;w
o m e n w ith
a h is to ry
o fb
re a st
ca n ce
r w h o d o n o tr e sp
o n d to
n o n h o rm
o n a lt h e ra p ie s a re
a d vi se
d to
d is cu
ss th e ri sk s a n d
b e n e fi ts o fl o w -d o se
va g in a le
st ro g e n (d o sa
g e s o fe
st ra d io l
< 2 5 μg
tw ic e w e e kl y)
w ith
th e ir h e a lth
ca re
p ro vi d e r
A vo
id sy st e m ic
e st ro g e n (e g , o ra la
n d
to p ic a lp
a tc h )
V a g in a lc
re a m
o r va
g in a lt a b le ts :
a cc e p ta b le
to u se
lo w -d o se
in tr a va
g in a l e st ro g e n fo r m a n a g e m e n t
o f d ys p a re u n ia , re cu
rr e n t lo w e r
u ri n a ry
tr a ct
in fe ct io n s,
a n d o th e r
va g in a ls
ym p to m s
O ra la
n d p a tc h :
h ig h
V a g in a lc
re a m
o r va
g in a l
ta b le ts :
m o d e ra te
O ra la
n d p a tc h :
st ro n g
T o p ic a lv
a g in a l
cr e a m
o r ta b le ts :
w e a k
G ro w th
h o rm
o n e
Im p a ct
o n b o d y co
m p o si tio
n is
sm a ll a n d a ss o ci a te d w ith
e d e m a , a rt h ra lg ia , ca
rp a lt u n n e ls
yn d ro m e ,
g yn
e co
m a st ia , im
p a ir e d fa st in g g lu co
se
A vo
id , e xc e p t fo r p a tie n ts
rig o ro u sl y
d ia g n o se
d b y e vi d e n ce
-b a se
d cr ite ria
w ith
g ro w th
h o rm
o n e d e fi ci e n cy
d u e to
a n e st a b lis h e d e tio lo g y
H ig h
S tr o n g
In su
lin , sl id in g sc a le
(i n su
lin re g im
e n s
co n ta in in g o n ly
sh o rt - o r ra p id -a ct in g in su
lin d o se
d a cc o rd in g to
cu rr e n t b lo o d g lu co
se le ve
ls w ith
o u t co
n cu
rr e n t u se
o f b a sa
lo r
lo n g -a ct in g in su
lin )
H ig h e r ri sk
o f h yp
o g ly ce
m ia
w ith
o u t im
p ro ve
m e n t in
h yp
e rg ly ce
m ia
m a n a g e m e n t re g a rd le ss
o f ca
re se
tt in g .
A vo
id in su
lin re g im
e n s th a t in cl u d e o n ly
sh o rt - o r ra p id -
a ct in g in su
lin d o se
d a cc o rd in g to
cu rr e n t b lo o d g lu co
se le ve
ls w ith
o u t co
n cu
rr e n t u se
o f b a sa
lo r lo n g -a ct in g
in su
lin . T h is
re co
m m e n d a tio
n d o e s n o t a p p ly
to re g im
e n s
th a t co
n ta in
b a sa
li n su
lin o r lo n g -a ct in g in su
lin .
A vo
id M o d e ra te
S tr o n g
M e g e st ro l
M in im
a le
ff e ct
o n w e ig h t; in cr e a se
s ri sk
o f th ro m b o tic
e ve
n ts
a n d p o ss ib ly
d e a th
in o ld e r a d u lts
A vo
id M o d e ra te
S tr o n g
S u lfo
n yl u re a s,
lo n g a ct in g
C h lo rp ro p a m id e
G lim
e p ir id e
G ly b u ri d e (a ls o kn
o w n a s g lib e n cl a m id e )
C h lo rp ro p a m id e : p ro lo n g e d h a lf- lif e in
o ld e r a d u lts ; ca
n ca
u se
p ro lo n g e d h yp
o g ly ce
m ia ; ca
u se
s S IA D H
G lim
e p ir id e a n d g ly b u ri d e : h ig h e r ri sk
o f se
ve re
p ro lo n g e d h yp
o g ly ce
m ia
in o ld e r a d u lts
A vo
id H ig h
S tr o n g
G a st ro in te st in a l
M e to cl o p ra m id e
C a n ca
u se
e xt ra p yr a m id a le
ff e ct s,
in cl u d in g ta rd iv e
d ys ki n e si a ; ri sk
m a y b e g re a te r in
fr a il o ld e r a d u lts
a n d
w ith
p ro lo n g e d e xp
o su
re
A vo
id ,u
n le ss
fo r g a st ro p a re si s w ith
d u ra tio n o fu
se n o tt o e xc e e d 1 2 w e e ks
e xc e p ti n ra re
ca se
s
M o d e ra te
S tr o n g
M in e ra lo
il, g iv e n o ra lly
P o te n tia
lf o r a sp
ir a tio
n a n d a d ve
rs e e ff e ct s;
sa fe r
a lte
rn a tiv e s a va
ila b le
A vo
id M o d e ra te
S tr o n g
P ro to n -p u m p in h ib ito
rs R is k o f C lo st ri d iu m
d iffi c ile
in fe ct io n a n d b o n e lo ss
a n d
fr a ct u re s
A vo
id sc h e d u le d u se
fo r > 8 w e e ks
u n le ss
fo r h ig h -r is k p a tie n ts (e g ,o
ra l
co rt ic o st e ro id s o r ch
ro n ic N S A ID
u se
), e ro si ve
e so
p h a g iti s, B a rr e tt e so
p h a g iti s,
p a th o lo g ic a lh yp
e rs e cr e to ry co
n d iti o n ,o
r d e m o n st ra te d n e e d fo r m a in te n a n ce
tr e a tm
e n t( e g ,b
e ca
u se
o ff a ilu re
o fd
ru g
d is co
n tin u a tio n tr ia lo r H 2 -r e ce
p to r
a n ta g o n is ts )
H ig h
S tr o n g
8 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL MONTH 2019–VOL. 00, NO. 00 JAGS
T ab
le 2 (C
o n td .)
O rg an
Sy st em
, Th er ap eu tic
Ca te go ry , D ru g( s)
R at io na le
R ec om
m en da tio
n Q ua lit y of
Ev id en ce
St re ng th
of R ec om
m en da tio
n
P a in
m e d ic a tio
n s
M e p e ri d in e
O ra la
n a lg e si c n o t e ff e ct iv e in
d o sa
g e s co
m m o n ly
u se
d ;
m a y h a ve
h ig h e r ri sk
o f n e u ro to xi ci ty , in cl u d in g d e lir iu m ,
th a n o th e r o p io id s;
sa fe r a lte
rn a tiv e s a va
ila b le
A vo
id M o d e ra te
S tr o n g
N o n – cy cl o o xy g e n a se -s e le ct iv e N S A ID s, o ra l:
A sp
ir in
> 3 2 5 m g /d a y
D ic lo fe n a c
D ifl u n is a l
E to d o la c
F e n o p ro fe n
Ib u p ro fe n
K e to p ro fe n
M e cl o fe n a m a te
M e fe n a m ic
a ci d
M e lo xi ca
m N a b u m e to n e
N a p ro xe
n O xa
p ro zi n
P ir o xi ca
m S u lin d a c
T o lm
e tin
In cr e a se
d ri sk
o f g a st ro in te st in a lb
le e d in g o r p e p tic
u lc e r
d is e a se
in h ig h -r is k g ro u p s,
in cl u d in g th o se
> 7 5 ye
a rs
o r
ta ki n g o ra lo
r p a re n te ra lc
o rt ic o st e ro id s,
a n tic o a g u la n ts ,
o r a n tip
la te le t a g e n ts ; u se
o f p ro to n -p u m p in h ib ito
r o r
m is o p ro st o l re d u ce
s b u t d o e s n o t e lim
in a te
ri sk . U p p e r
g a st ro in te st in a lu
lc e rs , g ro ss
b le e d in g , o r p e rf o ra tio
n ca
u se
d b y N S A ID s o cc u r in
~ 1 %
o f p a tie
n ts
tr e a te d fo r
3 -6
m o n th s a n d in
~ 2 % -4 %
o f p a tie
n ts
tr e a te d fo r 1 ye
a r;
th e se
tr e n d s co
n tin
u e w ith
lo n g e r d u ra tio
n o f u se
. A ls o
ca n in cr e a se
b lo o d p re ss u re
a n d in d u ce
ki d n e y in ju ry .
R is ks
a re
d o se
re la te d .
A vo
id ch
ro n ic
u se
, u n le ss
o th e r
a lte
rn a tiv e s a re
n o t e ff e ct iv e a n d
p a tie
n t ca
n ta ke
g a st ro p ro te ct iv e
a g e n t (p ro to n -p u m p in h ib ito
r o r
m is o p ro st o l)
M o d e ra te
S tr o n g
In d o m e th a ci n
K e to ro la c,
in cl u d e s p a re n te ra l
In c re a se
d ri s k o f g a st ro in te s ti n a l b le e d in g /p e p ti c u lc e r
d is e a s e
a n d
a c u te
k id n e y in ju ry
in o ld e r a d u lt s
In d o m e th a ci n is
m o re
lik e ly
th a n o th e r N S A ID
s to
h a ve
a d ve
rs e C N S e ff e ct s . O f a ll th e N S A ID
s , in d o m e th a ci n
h a s th e m o st
a d ve
rs e e ff e ct s.
A vo
id M o d e ra te
S tr o n g
S ke
le ta lm
u sc le
re la xa
n ts
C a ri so
p ro d o l
C h lo rz o xa
zo n e
C yc
lo b e n za
p ri n e
M e ta xa
lo n e
M e th o ca
rb a m o l
O rp h e n a d ri n e
M o st
m u sc le
re la xa
n ts
p o o rl y to le ra te d b y o ld e r a d u lts
b e ca
u se
so m e h a ve
a n tic h o lin e rg ic
a d ve
rs e e ff e ct s,
se d a tio
n , in cr e a se
d ri sk
o f fr a ct u re s;
e ff e ct iv e n e ss
a t
d o sa
g e s to le ra te d b y o ld e r a d u lts
q u e st io n a b le
A vo
id M o d e ra te
S tr o n g
G e n ito
u ri n a ry
D e sm
o p re ss in
H ig h ri sk
o f h yp
o n a tr e m ia ; sa
fe r a lte
rn a tiv e tr e a tm
e n ts
A vo
id fo r tr e a tm
e n t o f n o ct u ri a o r
n o ct u rn a lp
o ly u ri a
M o d e ra te
S tr o n g
A b b re vi at io n s: C N S,
ce n tr al
n er vo
u s sy st em
; H F rE F , h ea rt
fa il u re
w it h re d u ce d ej ec ti o n fr ac ti o n ; N SA
ID , n o n st er o id al
an ti -i n fl am
m at o ry
d ru g;
SI A D H , sy n d ro m e o f in ap
p ro p ri at e an
ti d iu re ti c h o rm
o n e se cr et io n .
a T h e p ri m ar y ta rg et
au d ie n ce
is th e p ra ct ic in g cl in ic ia n . T h e in te n ti o n s o f th e cr it er ia
in cl u d e (1 ) im
p ro vi n g th e se le ct io n o f p re sc ri p ti o n d ru gs
b y cl in ic ia n s an
d p at ie n ts ; (2 ) ev al u at in g p at te rn s o f d ru g u se
w it h in
p o p u la ti o n s; (3 ) ed u ca ti n g cl in ic ia n s an
d p at ie n ts
o n p ro p er
d ru g u sa ge ; an
d (4 ) ev al u at in g h ea lt h -o u tc o m e,
q u al it y- o f- ca re , co st , an
d u ti li za ti o n d at a.
b Se e al so
cr it er io n o n h ig h ly
an ti ch o li n er gi c an
ti d ep re ss an
ts .
JAGS MONTH 2019–VOL. 00, NO. 00 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL 9
T ab
le 3 . 2 0 1 9 A m er ic an
G er ia tr ic s So
ci et y B ee rs
C ri te ri a®
fo r P o te n ti al ly
In ap
p ro p ri at e M
ed ic at io n U se
in O ld er
A d u lt s D u e to
D ru g- D is ea se
o r D ru g- Sy
n d ro m e
In te ra ct io n s T h at
M ay
E x ac er b at e th e D is ea se
o r Sy
n d ro m ea
D is ea se
or Sy nd ro m e
D ru g( s)
R at io na le
R ec om
m en da tio
n Q ua lit y of
Ev id en ce
St re ng th
of R ec om
m en da tio
n
C a rd io va
sc u la r
H e a rt fa ilu re
A vo
id : C ilo st a zo
l
A vo
id in
h e a rt fa ilu re
w ith
re d u ce
d e je ct io n fr a ct io n :
N o n d ih yd
ro p yr id in e C C B s (d ilt ia ze
m ,
ve ra p a m il)
U se
w ith
ca u tio
n in
p a tie
n ts
w ith
h e a rt
fa ilu re
w h o a re
a sy m p to m a tic ; a vo
id in
p a tie
n ts
w ith
sy m p to m a tic
h e a rt fa ilu re :
N S A ID s a n d C O X -2
in h ib ito
rs
T h ia zo
lid in e d io n e s (p io g lit a zo
n e ,
ro si g lit a zo
n e )
D ro n e d a ro n e
P o te n tia
l to
p ro m o te
fl u id
re te n tio
n a n d /o r e xa
ce rb a te
h e a rt fa ilu re
(N S A ID s
a n d C O X -2
in h ib ito rs ,n
o n d ih yd
ro p yr id in e
C C B s, th ia zo
lid in e d io n e s) ;p
o te n tia lt o
in cr e a se
m o rt a lit y in o ld e r a d u lts
w ith
h e a rt
fa ilu re
(c ilo st a zo
la n d
d ro n e d a ro n e )
A s n o te d , a vo
id o r u se
w ith
ca u tio
n C ilo st a zo
l: lo w
N o n d ih yd
ro p yr id in e
C C B s:
m o d e ra te
N S A ID s:
m o d e ra te
C O X -2
in h ib ito
rs : lo w
T h ia zo
lid in e d io n e s:
h ig h
D ro n e d a ro n e : h ig h
C ilo st a zo
l: st ro n g
N o n d ih yd
ro p yr id in e
C C B s:
st ro n g
N S A ID s:
st ro n g
C O X -2
in hi bi to rs :s tro
ng
T h ia zo
lid in e d io n e s:
st ro n g
D ro n e d a ro n e : st ro n g
S yn
co p e
A C h E Is
N o n se
le ct iv e p e ri p h e ra la
lp h a -1
b lo ck e rs
(i e , d o xa
zo si n , p ra zo
si n , te ra zo
si n )
T e rt ia ry
T C A s
A n tip
sy ch
o tic s:
C h lo rp ro m a zi n e
T h io ri d a zi n e
O la n za
p in e
A C h E Is
ca u se
b ra d yc a rd ia
a n d sh
o u ld
b e
a vo
id e d in
o ld e r a d u lts
w h o se
sy n co
p e
m a y b e d u e to
b ra d yc a rd ia . N o n se
le ct iv e
p e rip
h e ra la
lp h a -1
b lo ck e rs
ca u se
o rt h o st a tic
b lo o d p re ss u re
ch a n g e s a n d
sh o u ld
b e a vo
id e d in
o ld e r a d u lts
w h o se
sy n co
p e m a y b e d u e to
o rt h o st a tic
h yp
o te n si o n . T e rt ia ry
T C A s a n d th e
a n tip sy ch
o tic s lis te d in cr e a se
th e ris k o f
o rt h o st a tic
h yp
o te n si o n o r b ra d yc a rd ia .
A vo
id A C h E Is , T C A s,
a n d
a n tip
sy ch
o tic s:
h ig h
N o n se
le ct iv e p e ri p h e ra l
a lp h a -1
b lo ck e rs : h ig h
A C h E Is
a n d T C A s:
st ro n g
N o n se
le ct iv e
p e ri p h e ra la
lp h a -1
b lo ck e rs
a n d
a n tip
sy ch
o tic s:
w e a k
C e n tr a ln
e rv o u s sy st e m
D e lir iu m
A n tic h o lin e rg ic s (s e e T a b le
7 a n d fu ll
cr ite
ri a a va
ila b le
o n w w w .
g e ri a tr ic sc a re o n lin e .o rg .)
A n tip
sy ch
o tic sb
B e n zo
d ia ze
p in e s
C o rt ic o st e ro id s (o ra la
n d p a re n te ra l) c
H 2 -r e ce
p to r a n ta g o n is ts
C im
e tid
in e
F a m o tid
in e
N iz a tid
in e
R a n iti d in e
M e p e ri d in e
N o n b e n zo
d ia ze
p in e , b e n zo
d ia ze
p in e
re ce
p to r a g o n is t h yp
n o tic s:
e sz o p ic lo n e , za
le p lo n , zo
lp id e m
A vo
id in
o ld e r a d u lts
w ith
o r a t h ig h ri sk
o f d e lir iu m
b e ca
u se
o f p o te n tia
lo f
in d u ci n g o r w o rs e n in g d e lir iu m
A vo
id a n tip
sy ch
o tic s fo r b e h a vi o ra l
p ro b le m s o f d e m e n tia
a n d /o r d e lir iu m
u n le ss
n o n p h a rm
a co
lo g ic a lo
p tio
n s (e g ,
b e h a vi o ra li n te rv e n tio
n s)
h a ve
fa ile d o r
a re
n o t p o ss ib le
a n d th e o ld e r a d u lt is
th re a te n in g su
b st a n tia
lh a rm
to se
lf o r
o th e rs . A n tip
sy ch
o tic s a re
a ss o ci a te d
w ith
g re a te r ri sk
o f ce
re b ro va
sc u la r
a cc id e n t (s tr o ke
) a n d m o rt a lit y in
p e rs o n s w ith
d e m e n tia
.
A vo
id H 2 -r e ce
p to r a n ta g o n is ts :
lo w
A ll o th e rs : m o d e ra te
S tr o n g
D e m e n tia
o r co
g n iti ve
im p a ir m e n t
A n tic h o lin e rg ic s (s e e T a b le
7 a n d fu ll
cr ite
ri a a va
ila b le
o n w w w .
g e ri a tr ic sc a re o n lin e .o rg )
B e n zo
d ia ze
p in e s
N o n b e n zo
d ia ze
p in e , b e n zo
d ia ze
p in e
re ce
p to r a g o n is t h yp
n o tic s
E sz o p ic lo n e
A vo
id b e ca
u se
o f a d ve
rs e C N S e ff e ct s
A vo
id a n tip
sy ch
o tic s fo r b e h a vi o ra l
p ro b le m s o f d e m e n tia
a n d /o r d e lir iu m
u n le ss
n o n p h a rm
a co
lo g ic a lo
p tio
n s (e g ,
b e h a vi o ra li n te rv e n tio
n s)
h a ve
fa ile d o r
a re
n o t p o ss ib le
a n d th e o ld e r a d u lt is
th re a te n in g su
b st a n tia
lh a rm
to se
lf o r
A vo
id M o d e ra te
S tr o n g
10 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL MONTH 2019–VOL. 00, NO. 00 JAGS
T ab
le 3 (C
o n td .)
D is ea se
or Sy nd ro m e
D ru g( s)
R at io na le
R ec om
m en da tio
n Q ua lit y of
Ev id en ce
St re ng th
of R ec om
m en da tio
n
Z a le p lo n
Z o lp id e m
A n tip
sy ch
o tic s,
ch ro n ic
a n d a s- n e e d e d
u se
b
o th e rs . A n tip
sy ch
o tic s a re
a ss o ci a te d
w ith
g re a te r ri sk
o f ce
re b ro va
sc u la r
a cc id e n t (s tr o ke
) a n d m o rt a lit y in
p e rs o n s
w ith
d e m e n tia
. H is to ry
o f fa lls
o r
fr a ct u re s
A n tie
p ile p tic s
A n tip
sy ch
o tic sb
B e n zo
d ia ze
p in e s
N o n b e n zo
d ia ze
p in e , b e n zo
d ia ze
p in e
re ce
p to r a g o n is t h yp
n o tic s
E sz o p ic lo n e
Z a le p lo n
Z o lp id e m
A n tid
e p re ss a n ts
T C A s
S S R Is
S N R Is
O p io id s
M a y ca
u se
a ta xi a ,i m p a ire
d p sy ch
o m o to r
fu n ct io n ,s yn
co p e ,a
d d iti o n a lf a lls ;s h o rt e r-
a ct in g b e n zo
d ia ze
p in e s a re
n o ts a fe r th a n
lo n g -a ct in g o n e s.
If on
e of th e dr ug
s m us tb e us ed
,c on
si de
r re du
ci ng
us e of ot he
r C N S -a ct iv e
m ed
ic at io ns
th at in cr ea
se ris k of fa lls
an d
fra ct ur es
(ie ,a nt ie pi le pt ic s, op
io id -r ec ep
to r
ag on
is ts ,a nt ip sy ch ot ic s, an
tid ep
re ss an
ts ,
no nb
en zo di az ep
in e an
d be
nz od
ia ze pi ne
re ce pt or
ag on
is th yp no
tic s, ot he
r se da
tiv es /h yp no
tic s) an
d im pl em
en to th er
st ra te gi es
to re du
ce fa ll ris k. D at a fo r
an tid ep
re ss an
ts ar e m ix ed
bu tn o co m pe
lli ng
ev id en
ce th at ce rta
in an
tid ep
re ss an
ts co nf er
le ss
fa ll ris k th an
ot he
rs .
A vo
id u n le ss
sa fe r
a lte
rn a tiv e s a re
n o t
a va
ila b le ; a vo
id a n tie
p ile p tic s e xc e p t fo r
se iz u re
a n d m o o d
d is o rd e rs
O p io id s:
a vo
id e xc e p t fo r
p a in
m a n a g e m e n t in
th e
se tt in g o f se
ve re
a cu
te p a in
(e g , re ce
n t fr a ct u re s
o r jo in t re p la ce
m e n t)
O p io id s:
m o d e ra te
A ll o th e rs : h ig h
S tr o n g
P a rk in so
n d is e a se
A n tie
m e tic s
M e to cl o p ra m id e
P ro ch
lo rp e ra zi n e
P ro m e th a zi n e
A ll a n tip
sy ch
o tic s (e xc e p t q u e tia
p in e ,
cl o za
p in e , p im
a va
n se
ri n )
D op am
in e- re ce pt or
an ta go ni st s w ith
po te nt ia lt o w or se n pa rk in so ni an
sy m pt om
s
E xc e p tio
n s:
P im
a va
n se
ri n a n d cl o za
p in e a p p e a r to
b e le ss
lik e ly
to p re ci p ita
te w o rs e n in g
o f P a rk in so
n d is e a se
. Q u e tia
p in e h a s
o n ly
b e e n st u d ie d in
lo w -q u a lit y cl in ic a l
tr ia ls
w ith
e ffi ca
cy co
m p a ra b le
to th a t
o f p la ce
b o in
fi ve
tr ia ls
a n d to
th a t o f
cl o za
p in e in
tw o o th e rs .
A vo
id M o d e ra te
S tr o n g
G a st ro in te st in a l
H is to ry
o f g a st ri c o r
d u o d e n a lu
lc e rs
A sp
ir in
> 3 2 5 m g /d a y
N o n – C O X -2 – se
le ct iv e N S A ID s
M a y e xa
ce rb a te
e xi st in g u lc e rs
o r
ca u se
n e w /a d d iti o n a lu
lc e rs
A vo
id u n le ss
o th e r
a lte
rn a tiv e s a re
n o t
e ff e ct iv e a n d p a tie
n t ca
n ta ke
g a st ro p ro te ct iv e
a g e n t (i e , p ro to n -p u m p
in h ib ito
r o r m is o p ro st o l)
M o d e ra te
S tr o n g
K id n e y/ u ri n a ry
tr a ct
C h ro n ic
ki d n e y
d is e a se
st a g e 4 o r
h ig h e r (c re a tin
in e
cl e a ra n ce
< 3 0 m L /m
in )
N S A ID s (n o n -C
O X a n d C O X se
le ct iv e ,
o ra la
n d p a re n te ra l, n o n a ce
ty la te d
sa lic yl a te s)
M a y in cr e a se
ri sk
o f a cu
te ki d n e y
in ju ry
a n d fu rt h e r d e cl in e o f re n a lf u n ct io n
A vo
id M o d e ra te
S tr o n g
(C o n ti n u ed
)
JAGS MONTH 2019–VOL. 00, NO. 00 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL 11
was lowered to 70 years or older from 80 years or older. This criterion was also expanded to cover use of aspirin as primary prevention of colorectal cancer. Note that this criterion does not apply to use of aspirin for secondary prevention of either disease.
• In addition to the existing caution about dabigatran, the updated criteria highlight caution about use of rivaroxaban for treatment of venous thromboembolism or atrial fibrillation in adults 75 years or older.
• Tramadol was added to the list of drugs associated with hyponatremia or syndrome of inappropriate antidiuretic hor- mone secretion. The chemotherapeutic agents carboplatin, cyclo- phosphamide, cisplatin, and vincristine were removed from this list because the panel thought the prescribing of these highly spe- cialized drugs fell outside the scope of the criteria.
• Vasodilators were removed, because syncope is not unique to older adults.
• The combination dextromethorphan/quinidine was added to the “use with caution” table on the basis of limited efficacy in patients with behavioral symptoms of dementia without pseu- dobulbar affect while potentially increasing the risk of falls and drug-drug interactions.
• The combination trimethoprim-sulfamethoxazole (TMP-SMX) should be used with caution by patients with reduced kidney function and taking an angiotensin-converting enzyme inhibi- tor (ACEI) or angiotensin receptor blocker (ARB) because of an increased risk of hyperkalemia.
Drug-Drug Interactions
Table 5 contains potentially clinically important drug-drug interactions to be avoided in older adults. New recommen- dations include avoiding use of opioids concurrently with benzodiazepines and avoiding use of opioids concurrently with gabapentinoids (except when transitioning from the former to the latter). Other additions to the table are inter- actions involving TMP-SMX, macrolide antibiotics, and ciprofloxacin. TMP-SMX in combination with phenytoin or warfarin increases the risk of phenytoin toxicity and bleeding, respectively. Macrolides, excluding azithromycin, or ciprofloxacin in combination with warfarin increases bleeding risk. Ciprofloxacin in combination with theophyl- line increases risk of theophylline toxicity. The concurrent use of a combination of three or more central nervous sys- tem (CNS) agents (antidepressants, antipsychotics, benzodi- azepines, nonbenzodiazepine benzodiazepine receptor agonist hypnotics, antiepileptics, and opioids) and increased fall risk have been collapsed into one recommendation instead of separate recommendations for each drug class. The recommendation on avoiding concurrent use of medi- cations that increase serum potassium has been expanded to encompass a broader range of these medications.
PIMs Based on Kidney Function
Table 6 contains a list of medications that should be avoided or have their dosage reduced based on kidney func- tion. Two antibiotics have been added, ciprofloxacin and TMP-SMX, over concerns of increased CNS effects and ten- don rupture, and worsening renal function and hyperkale- mia, respectively. Dofetilide was also added because of concerns of corrected QT interval prolongation and torsade de pointes. The creatinine clearance lower limit at which to avoid edoxaban has been reduced to less than 15 mL/min.T
ab le
3 (C
o n td .)
D is ea se
or Sy nd ro m e
D ru g( s)
R at io na le
R ec om
m en da tio
n Q ua lit y of
Ev id en ce
St re ng th
of R ec om
m en da tio
n
U ri n a ry
in co
n tin
e n ce
(a ll ty p e s)
in w o m e n
E st ro g e n o ra la
n d tr a n sd
e rm
a l
(e xc lu d e s in tr a va
g in a le
st ro g e n )
P e ri p h e ra la
lp h a -1
b lo ck e rs
D o xa
zo si n
P ra zo
si n
T e ra zo
si n
L a ck
o f e ffi ca
cy (o ra le
st ro g e n ) a n d
a g g ra va
tio n o f in co
n tin
e n ce
(a lp h a -1
b lo ck e rs )
A vo
id in
w o m e n
E st ro g e n : h ig h
P e ri p h e ra la
lp h a -1
b lo ck e rs : m o d e ra te
E st ro g e n : st ro n g
P e ri p h e ra la
lp h a -1
b lo ck e rs : st ro n g
L o w e r u ri n a ry
tr a ct
sy m p to m s,
b e n ig n
p ro st a tic
h yp
e rp la si a
S tr o n g ly
a n tic h o lin e rg ic
d ru g s,
e xc e p t
a n tim
u sc a ri n ic s fo r u ri n a ry
in co
n tin
e n ce
(s e e T a b le
7 a n d fu ll cr ite
ri a a va
ila b le
o n
w w w .g e ri a tr ic sc a re o n lin e .o rg )
M a y d e cr e a se
u ri n a ry
fl o w
a n d ca
u se
u ri n a ry
re te n tio
n A vo
id in
m e n
M o d e ra te
S tr o n g
A b b re vi at io n s:
A C h E I,
ac et yl ch o li n es te ra se
in h ib it o r;
C C B , ca lc iu m
ch an
n el
b lo ck er ; C N S,
ce n tr al
n er vo
u s sy st em
; C O X , cy cl o o x yg en as e;
N SA
ID , n o n st er o id al
an ti -i n fl am
m at o ry
d ru g;
SN R I,
se ro to n in -
n o re p in ep h ri n e re u p ta k e in h ib it o r; SS R I, se le ct iv e se ro to n in
re u p ta k e in h ib it o r; T C A , tr ic yc li c an
ti d ep re ss an
t. a T h e p ri m ar y ta rg et
au d ie n ce
is th e p ra ct ic in g cl in ic ia n . T h e in te n ti o n s o f th e cr it er ia
in cl u d e (1 ) im
p ro vi n g th e se le ct io n o f p re sc ri p ti o n d ru gs
b y cl in ic ia n s an
d p at ie n ts ; (2 ) ev al u at in g p at te rn s o f d ru g u se
w it h in
p o p u la ti o n s; (3 ) ed u ca ti n g cl in ic ia n s an
d p at ie n ts
o n p ro p er
d ru g u sa ge ; an
d (4 ) ev al u at in g h ea lt h -o u tc o m e,
q u al it y- o f- ca re , co st , an
d u ti li za ti o n d at a.
b M ay
b e re q u ir ed
to tr ea t co n cu rr en t sc h iz o p h re n ia , b ip o la r d is o rd er , an
d o th er
se le ct ed
m en ta l h ea lt h co n d it io n s b u t sh o u ld
b e p re sc ri b ed
in th e lo w es t ef fe ct iv e d o se
an d sh o rt es t p o ss ib le
d u ra ti o n .
c E x cl u d es
in h al ed
an d to p ic al
fo rm
s. O ra l an
d p ar en te ra l co rt ic o st er o id s m ay
b e re q u ir ed
fo r co n d it io n s su ch
as ex ac er b at io n o f ch ro n ic
o b st ru ct iv e p u lm
o n ar y d is ea se
b u t sh o u ld
b e p re sc ri b ed
in th e lo w es t ef fe ct iv e
d o se
an d fo r th e sh o rt es t p o ss ib le
d u ra ti o n .
12 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL MONTH 2019–VOL. 00, NO. 00 JAGS
DISCUSSION
The 2019 AGS Beers Criteria® update contributes to the critically important evidence base and discussion of medica- tions to avoid in older adults and the need to improve medi- cation use in older adults. The 2019 AGS Beers Criteria®
include 30 individual criteria of medications or medication classes to be avoided in older adults (Table 2) and 16 cri- teria specific to more than 40 medications or medication classes that should be used with caution or avoided in cer- tain diseases or conditions (Tables 3 and 4). As in past
updates, there were several changes to the 2019 AGS Beers Criteria®, including criteria that were modified or dropped, a few new criteria, and some changes in the level of evi- dence grading and clarifications in language and rationale (Tables 8–10).
The 2019 AGS Beers Criteria® is the third such update by the AGS and the fifth update of the AGS Beers Criteria®
since their original release.1,2,10–12 The criteria was first published almost 30 years ago in 1991, making them the longest running criteria for PIMs in older adults.
Table 4. 2019 American Geriatrics Society Beers Criteria® for Potentially Inappropriate Medications: Drugs To Be Used With Caution in Older Adultsa
Drug(s) Rationale Recommendation Quality of Evidence
Strength of Recommendation
Aspirin for primary prevention of cardiovascular disease and colorectal cancer
Risk of major bleeding from aspirin increases markedly in older age. Several studies suggest lack of net benefit when used for primary prevention in older adult with cardiovascular risk factors, but evidence is not conclusive. Aspirin is generally indicated for secondary prevention in older adults with established cardiovascular disease.
Use with caution in adults ≥70 years
Moderate Strong
Dabigatran Rivaroxaban
Increased risk of gastrointestinal bleeding compared with warfarin and reported rates with other direct oral anticoagulants when used for long-term treatment of VTE or atrial fibrillation in adults ≥75 years.
Use with caution for treatment of VTE or atrial fibrillation in adults ≥75 years
Moderate Strong
Prasugrel Increased risk of bleeding in older adults; benefit in highest-risk older adults (eg, those with prior myocardial infarction or diabetes mellitus) may offset risk when used for its approved indication of acute coronary syndrome to be managed with percutaneous coronary intervention.
Use with caution in adults ≥75 years
Moderate Weak
Antipsychotics Carbamazepine Diuretics Mirtazapine Oxcarbazepine SNRIs SSRIs TCAs Tramadol
May exacerbate or cause SIADH or hyponatremia; monitor sodium level closely when starting or changing dosages in older adults
Use with caution Moderate Strong
Dextromethorphan/ quinidine
Limited efficacy in patients with behavioral symptoms of dementia (does not apply to treatment of PBA). May increase risk of falls and concerns with clinically significant drug interactions. Does not apply to treatment of pseudobulbar affect.
Use with caution Moderate Strong
Trimethoprim- sulfamethoxazole
Increased risk of hyperkalemia when used concurrently with an ACEI or ARB in presence of decreased creatinine clearance
Use with caution in patients on ACEI or ARB and decreased creatinine clearance
Low Strong
Abbreviations: ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; PBA, pseudobulbar affect; SIADH, syndrome of inappro- priate antidiuretic hormone secretion; SNRI, serotonin-norepinephrine reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor; TCA, tricyclic antide- pressant; VTE, venous thromboembolism. aThe primary target audience is the practicing clinician. The intentions of the criteria include (1) improving 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, quality-of-care, cost, and utilization data.
JAGS MONTH 2019–VOL. 00, NO. 00 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL 13
T ab
le 5 . 2 0 1 9 A m er ic an
G er ia tr ic s So
ci et y B ee rs
C ri te ri a®
fo r P o te n ti al ly
C li n ic al ly
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t D ru g- D ru g In te ra ct io n s T h at
Sh o u ld
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id ed
in O ld er
A d u lt s
O bj ec t D ru g an d Cl as s
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a ll
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A n tic h o lin e rg ic
In cr e a se
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7 )
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A nt id ep re ss an ts (T C A s, S S R Is ,a nd
S N R Is )
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14 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL MONTH 2019–VOL. 00, NO. 00 JAGS
The 2019 update has a similar number of changes to the 2015 update but fewer changes than the 2012 update. This is likely because, with the support of the AGS and the expert panel, the criteria have been regularly updated about every 3 years since 2012. In 2019, 25 medications or medi- cation classes to be avoided outright or in a disease condi- tion were dropped from the AGS Beers Criteria® (Table 8). A few were also moved to a new table category or modified (Table 10). For medications to be removed from the AGS Beers Criteria®, the panel had to have new evidence or a strong rationale, for reasons such as the literature showed a change in evidence that cast new doubt on their “avoid” status. Finally, some drugs or drug-disease combinations were omitted because they are not disproportionately rele- vant to the older adult population; this included the criteria on drugs to avoid in adults with chronic seizures or epilepsy and in adults with insomnia.
Four new medications or medication classes were added to the list of drugs to be used with caution (Table 4; additions are also summarized in Table 9). Dextromethor- phan/quinidine was added because of its limited efficacy, concerns for clinically significant drug interactions, and potentially increased risk of falls in older adults. TMP-SMX was placed in the “use with caution table” because of increased risk of hyperkalemia when used concurrently with an ACEI or ARB in the presence of decreased creatinine clearance.13,14 Rivaroxaban was also added to the use with caution table for adults 75 years or older. Other important changes in the use with caution table included lowering the age threshold in the aspirin for primary prevention recom- mendation from 80 years or younger to 70 years or youn- ger on the basis of emerging evidence of a major increase in the risk of bleeding at a lower age.15 The Aspirin in Reduc- ing Events in the Elderly (ASPREE) trial, which was pub- lished outside the window of our literature search, found that low-dose aspirin used for primary prevention in older adults did not confer a reduction in mortality, disability-free survival, or cardiovascular events.16,17 In a few instances, the level of evidence was revised based on new literature and the improved modified grading method. For instance, H2-receptor antagonists were removed from the list of drugs to avoid in dementia, and the evidence level for H2-receptor antagonists was decreased to low (from moderate in 2015) for drugs to avoid in delirium.18 Again in 2019, the panel clarified the language for sliding-scale insulin because this continued to be an area of confusion for clinicians.
Importantly, several drugs were added to the drug- disease and drug-drug interactions tables (Tables 3 and 5). Notably, SNRIs were added to the list of antidepressant drug classes to avoid in persons with a history of falls or fractures.19,20 For this criterion, the level of evidence for opioids was changed to “moderate”; all other drugs remain at high. Two new drug-drug interactions involving opioids were added, reflecting evidence of substantial harms that can occur when opioids are used concurrently with benzodi- azepines or gabapentinoids. Though these drug interactions involving opioids are problematic in all persons, they are growing increasingly common and may lead to greater harm in vulnerable older adults. These concerns need to be balanced with the need to treat chronic pain. A recent review of deaths from opioids concluded that the burden of opioid overdose in older adults requires special attention, noting the largestT
ab le
5 (C
o n td .)
O bj ec t D ru g an d Cl as s
In te ra ct in g D ru g an d Cl as s
R is k R at io na le
R ec om
m en da tio
n Q ua lit y of
Ev id en ce
St re ng th
of R ec om
m en da tio
n
W a rf a ri n
T ri m e th o p ri m -s u lfa
m e th o xa
zo le
In cr e a se
d ri sk
o f b le e d in g
A vo
id w h e n p o ss ib le ; if u se
d to g e th e r, m o n ito
r IN R
cl o se
ly M o d e ra te
S tr o n g
W a rf a ri n
N S A ID s
In cr e a se
d ri sk
o f b le e d in g
A vo
id w h e n p o ss ib le ; if u se
d to g e th e r, m o n ito
r cl o se
ly fo r
b le e d in g
H ig h
S tr o n g
A b b re vi at io n s:
A C E I, an
gi o te n si n -c o n ve rt in g en zy m e in h ib it o r;
A R B , an
gi o te n si n re ce p to r b lo ck er ; C N S,
ce n tr al
n er vo
u s sy st em
; IN
R , in te rn at io n al
n o rm
al iz ed
ra ti o ; N SA
ID , n o n st er o id al
an ti -i n fl am
m at o ry
d ru g;
R A S,
re n in -a n gi o te n si n sy st em
; SN
R I, se ro to n in - n o re p in ep h ri n e re u p ta k e in h ib it o r; SS R I, se le ct iv e se ro to n in
re u p ta k e in h ib it o r; T C A , tr ic yc li c an
ti d ep re ss an
t. a C N S- ac ti ve
d ru gs : an
ti ep il ep ti cs ; an
ti p sy ch o ti cs ; b en zo d ia ze p in es ; n o n b en zo d ia ze p in e,
b en zo d ia ze p in e re ce p to r ag o n is t h yp
n o ti cs ; T C A s; SS R Is ; SN
R Is ; an
d o p io id s.
JAGS MONTH 2019–VOL. 00, NO. 00 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL 15
Table 6. 2019 American Geriatrics Society Beers Criteria® for Medications That Should Be Avoided or Have Their Dosage Reduced With Varying Levels of Kidney Function in Older Adults
Medication Class and Medication
Creatinine Clearance at Which Action Required, mL/min Rationale Recommendation
Quality of Evidence
Strength of Recommendation
Anti-infective Ciprofloxacin <30 Increased risk of CNS effects
(eg, seizures, confusion) and tendon rupture
Doses used to treat common infections typically require reduction when CrCl <30 mL/min
Moderate Strong
Trimethoprim- sulfamethoxazole
<30 Increased risk of worsening of renal function and hyperkalemia
Reduce dose if CrCl 15-29 mL/min Avoid if CrCl <15 mL/min
Moderate Strong
Cardiovascular or hemostasis
Amiloride <30 Increased potassium and decreased sodium
Avoid Moderate Strong
Apixaban <25 Lack of evidence for efficacy and safety in patients with a CrCl <25 mL/min
Avoid Moderate Strong
Dabigatran <30 Lack of evidence for efficacy and safety in individuals with a CrCl <30 mL/min. Label dose for patients with a CrCl 15-30 mL/min based on pharmacokinetic data.
Avoid; dose adjustment advised when CrCl >30 mL/min in the presence of drug-drug interactions
Moderate Strong
Dofetilide <60 QTc prolongation and torsade de pointes
Reduce dose if CrCl 20-59 mL/min Avoid if CrCl <20 mL/min
Moderate Strong
Edoxaban 15-50 <15 or >95
Lack of evidence of efficacy or safety in patients with a CrCl <30 mL/min
Reduce dose if CrCl 15-50 mL/min Avoid if CrCl <15 or >95 mL/min
Moderate Strong
Enoxaparin <30 Increased risk of bleeding Reduce dose Moderate Strong Fondaparinux <30 Increased risk of bleeding Avoid Moderate Strong Rivaroxaban <50 Lack of efficacy or safety
evidence in patients with a CrCl <30 mL/min
Nonvalvular atrial fibrillation: reduce dose if CrCl 15-50 mL/min; avoid if CrCl <15 mL/min Venous thromboembolism treatment and for VTE prophylaxis with hip or knee replacement: avoid if CrCl <30 mL/min
Moderate Strong
Spironolactone <30 Increased potassium Avoid Moderate Strong Triamterene <30 Increased potassium and
decreased sodium Avoid Moderate Strong
Central nervous system and analgesics
Duloxetine <30 Increased gastrointestinal adverse effects (nausea, diarrhea)
Avoid Moderate Weak
Gabapentin <60 CNS adverse effects Reduce dose Moderate Strong Levetiracetam ≤80 CNS adverse effects Reduce dose Moderate Strong Pregabalin <60 CNS adverse effects Reduce dose Moderate Strong Tramadol <30 CNS adverse effects Immediate release: reduce
dose Extended release: avoid
Low Weak
Gastrointestinal Cimetidine <50 Mental status changes Reduce dose Moderate Strong Famotidine <50 Mental status changes Reduce dose Moderate Strong Nizatidine <50 Mental status changes Reduce dose Moderate Strong Ranitidine <50 Mental status changes Reduce dose Moderate Strong
16 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL MONTH 2019–VOL. 00, NO. 00 JAGS
relative increase in opioids occurred in persons 55 to 64 (754% increase from 0.2% to 1.7%) and 65 years and older and the absolute number of deaths in this group is moderate.21,22
Several drug-drug interactions involving antimicrobial agents were also added to Table 5, and the recommendation to avoid concurrent use of three or more CNS-active
medications was reformatted to clarify and bring further attention to the increased risk of falls and other harms that can occur when multiple CNS-active medications are combined.23
PIM use continues to be a serious problem in older adults and especially in vulnerable older adults with multi- ple chronic conditions. Thus, the AGS Beers Criteria® con- tinue to be useful and necessary as a clinical tool, as an educational tool at the bedside, and as a public health tool to improve medication safety in older adults. The AGS Beers Criteria® can increase awareness of polypharmacy and aid decision making when choosing drugs to avoid in older adults. In a 2017 study using medical expenditure data (n = 16,588) in adults 65 years and older, poor health status was associated with increased PIM use. In another study, the use of PIMs, as measured by the 2015 criteria, in persons with dementia was 11% higher after diagnosis than in the year of diagnosis.24,25 Benzodiazepine use remains common in older adults, especially in older women, despite the fact that older adults are highly vulnerable to harms associated with use of these drugs.26 The challenge of decreasing PIM use and improving the overall quality of medication prescribing in older adults remains, and the AGS Beers Criteria® are one part of the solution.
The AGS Beers Criteria® are an essential evidence- based tool that should be used as a guide for drugs to avoid in older adults. However, they are not meant to supplant clinical judgment or an individual patient’s preferences, values, care goals, and needs, nor should they be used puni- tively or to excessively restrict access to medications. These criteria were developed to be used in conjunction with a person-centered team approach (physicians, nurses, phar- macists, other clinicians, the older adult, family, and others) to prescribing and monitoring adverse effects.27 A compan- ion article published to the 2015 updated AGS Beers Criteria®, entitled “How to Use the Beers Criteria: A Guide for Patients, Clinicians, Health Systems, and Payors,” remains an important guide for using the AGS Beers Criteria®. It reminds clinicians that medications listed in the Criteria are potentially inappropriate, rather than definitely inappropriate for all older adults, and encourages users to read the rationale and recommendation statements for each medication to avoid because these statements provide important guidance.3 Moreover, the criteria should not be interpreted as giving license to steer patients away from PIMs to even worse choices. For example, the recommenda- tion to avoid chronic, regular use of NSAIDs should not be
Table 6 (Contd.)
Medication Class and Medication
Creatinine Clearance at Which Action Required, mL/min Rationale Recommendation
Quality of Evidence
Strength of Recommendation
Hyperuricemia Colchicine <30 Gastrointestinal,
neuromuscular, bone marrow toxicity
Reduce dose; monitor for adverse effects
Moderate Strong
Probenecid <30 Loss of effectiveness Avoid Moderate Strong
Abbreviations: CNS, central nervous system; CrCl, creatinine clearance; QTc, corrected QT interval; VTE, venous thromboembolism.
Table 7. Drugs With Strong Anticholinergic Properties Antiarrhythmic Promethazine
Disopyramide Pyrilamine Triprolidine
Antidepressants Amitriptyline Amoxapine Clomipramine Antimuscarinics Desipramine (urinary incontinence) Doxepin (>6 mg) Darifenacin Imipramine Fesoterodine Nortriptyline Flavoxate Paroxetine Oxybutynin Protriptyline Solifenacin Trimipramine Tolterodine
Trospium Antiemetics
Prochlorperazine Antiparkinsonian agents Promethazine Benztropine
Trihexyphenidyl Antihistamines (first generation)
Brompheniramine Antipsychotics Carbinoxamine Chlorpromazine Chlorpheniramine Clozapine Clemastine Loxapine Cyproheptadine Olanzapine Dexbrompheniramine Perphenazine Dexchlorpheniramine Thioridazine Dimenhydrinate Trifluoperazine Diphenhydramine (oral) Doxylamine Antispasmodics Hydroxyzine Atropine (excludes
ophthalmic) Meclizine Belladonna alkaloids Clidinium-chlordiazepoxide Scopolamine (excludes
ophthalmic) Dicyclomine Homatropine (excludes ophthalmic)
Skeletal muscle relaxants
Hyoscyamine Cyclobenzaprine Methscopolamine Orphenadrine Propantheline
JAGS MONTH 2019–VOL. 00, NO. 00 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL 17
interpreted as an invitation to prescribe opioids in their place. For further reference, a 2012 article provides a case example on how nurses can use the criteria to improve medication use in older adults.28
As in previous years, the panel recognizes the need to offer older adults and their clinicians pharmacological and nonpharmacological alternatives to medications included in the AGS Beers Criteria®. Alternatives to some of the most commonly implicated medications listed in the 2015 update
were published in a companion article that accompanied that update. Readers are encouraged to review these sugges- tions, although we acknowledge that further work needs to be done to keep pace with updates to the criteria and the changing landscape of drug and nondrug therapies. We also encourage readers to research the safety and effectiveness of potential alternatives to drugs included in this document. Deprescribing is a concept to eliminate unsafe or unneces- sary drugs from a patient’s regimen. One source for online
Table 8. Medications/Criteria Removed Since 2015 American Geriatrics Society Beers Criteria®
Medication/Criterion Reason for Removal
Independent of Diagnosis or Condition (Table 2) Ticlopidine No longer on US market; low
use Pentazocine Oral no longer on US market Considering Disease and Syndrome Interactions (Table 3) Chronic seizures or epilepsy
Bupropion Chlorpromazine Clozapine Maprotiline Olanzapine Thioridazine Thiothixene Tramadol
Not unique to older adults
Dementia H2-receptor antagonists
Weak evidence and to avoid overly restricting therapeutic options for older adults with dementia who have gastroesophageal reflux or similar issues (given a coexisting criterion advising against chronic use of PPIs except in specific circumstances)
Insomnia Oral decongestants
Phenylephrine Pseudoephedrine
Stimulants Amphetamine Armodafinil Methylphenidate Modafinil
Theobromines Theophylline Caffeine
Not unique to older adults
Parkinson disease Aripiprazole
Removed as a preferred antipsychotic in older adults with Parkinson disease because of safety and efficacy concerns
Use With Caution (Table 4) SIADH/hyponatremia
Carboplatin Cyclophosphamide Cisplatin Vincristine
Highly specialized drugs that fell outside the scope of the criteria
Syncope Vasodilators
Not unique to older adults
Abbreviations: PPI, proton-pump inhibitor; SIADH, syndrome of inappro- priate antidiuretic hormone secretion.
Table 9. Medications/Criteria Added Since 2015 Ameri- can Geriatrics Society Beers Criteria®
Medication/Criterion Reason for Addition
Independent of Diagnosis or Condition (Table 2) Glimepiride Severe, prolonged
hypoglycemia in older adults Methscopolamine Pyrilamine
Strong anticholinergic
Considering Disease and Syndrome Interactions (Table 3) History of falls or fractures SNRI
Associated with increased risk in older adults
Parkinson disease Pimavanserin
Unlike most other antipsychotics, the revised criteria consider pimavanserin acceptable for treatment of psychosis in Parkinson disease
Use With Caution (Table 4) Rivaroxaban Emerging evidence of
increased risk of serious bleeding compared with other anticoagulant options
Tramadol Risk of SIADH/hyponatremia Dextromethorphan/quinidine Limited efficacy in treating
patients with dementia symptoms disorder in absence of pseudobulbar affect while potentially increasing risk of falls and drug-drug interactions
TMP-SMX Increased risk of hyperkalemia in combination with ACEIs and ARBs in patients with reduced kidney function
Clinically Important Drug-Drug Interactions (Table 5) Opioids + benzodiazepines Increased risk of overdose Opioids + gabapentin/pregabalin
Increased risk of overdose
Phenytoin + TMP-SMX Increased risk of phenytoin toxicity
Theophylline + ciprofloxacin Increased risk of theophylline toxicity
Warfarin + ciprofloxacin Increased risk of bleeding Warfarin + macrolides (excluding azithromycin)
Increased risk of bleeding
Warfarin + TMP-SMX Increased risk of bleeding Medications That Should Be Avoided or Have Their Dosage Reduced With Decreased Kidney Function (Table 6) Ciprofloxacin Increased risk of CNS effects TMP-SMX Increased risk of worsening of
renal function and hyperkalemia
Abbreviations: ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; CNS, central nervous system; SIADH, syndrome of inappropriate antidiuretic hormone secretion; SNRI, serotonin-norepinephrine reuptake inhibitor; TMP-SMX, trimethoprim-sulfamethoxazole.
18 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL MONTH 2019–VOL. 00, NO. 00 JAGS
deprescribing resources for many medications included in the 2019 AGS Beers Criteria® is https://deprescribing.org.
Of particular note is the potential role for nonpharmacolo- gical approaches to manage common conditions in older adults. The evidence base for specific nonpharmacological approaches with a person-centered approach to care is small but growing.29–32 One example of the growing evidence for non- drug alternatives is in the area of care for persons with dementia and delirium. Scales and colleagues published a 2019 compre- hensive review of evidence-based nonpharmacological approaches for behavioral and psychological symptoms of dementia. They evaluated 197 articles that included sensory practices (eg, massage, light therapy), psychosocial practices (eg, music, pet therapy, reminiscence), and structured care protocols (eg, mouth care, bathing). Though they had recommendations for improving the evidence base, they concluded most practices were acceptable to patients, had no harmful effects, and required minimal to moderate investment.33 Online resources for some of
these approaches can be found at www.nursinghometoolkit. com and www.hospitalelderlifeprogram.org.
While the AGS Beers Criteria® can be a valuable tool, it should be viewed within the larger context of tools and strategies for improving pharmacological care for older adults. Specifically, the AGS Beers Criteria® is one compo- nent of what should be a comprehensive approach to medi- cation use in older adults, and it should be used in conjunction with other tools and management strategies for improving medication safety and effectiveness. Moreover, other explicit criteria for evaluating PIMs in older adults, including the screening tool of older people’s prescriptions and screening tool to alert to right treatment criteria (STOPP/START criteria) can also be valuable resources for improving medication therapy.34
Finally, the 2019 AGS Beers Criteria® have several limi- tations. Evidence for the benefits and harms of medications in older adults is often limited, particularly from randomized
Table 10. Medications/Criterion Modified Since 2015 American Geriatrics Society Beers Criteria®
Medication/Criterion Modification
Independent of Diagnosis or Condition (Table 2) Peripheral α-1 blockers For treatment of hypertension Digoxin for atrial fibrillation and heart failure Added wording to Drug column; modified rationale; QE
for atrial fibrillation changed to Low Estrogen with or without progestin Added “recurrent” urinary tract infections Sliding-scale insulin Clarified definition of sliding-scale insulin Metoclopramide Added duration of use to recommendation Meperidine Removed caveat from recommendation Considering Disease and Syndrome Interactions (Table 3) Heart failure Reorganized recommendations; separated COX-2
inhibitors from other NSAIDs; added QE and SR for COX-2 inhibitors; changed recommendation for NSAIDs, COX-2 inhibitors, and thiazolidinediones to use with caution in asymptomatic heart failure and to avoid in symptomatic heart failure; modified rationale
Syncope Specified “nonselective peripheral α-1 blockers”; separated rationales, QE, and SR for AChEIs and nonselective peripheral alpha-1 blockers; modified QE for ACHEIs and antipsychotics
Delirium Changed “Sedative/hypnotics” to Nonbenzodiazepine, benzodiazepine receptor agonist hypnotics; changed QE of H2-receptor antagonists to low
History of fractures and falls Changed SR of opioids to strong Parkinson disease Added rationale for quetiapine, clozapine, and
pimavanserin Chronic kidney disease and NSAIDs Changed wording (minor) of criterion title Use With Caution (Table 4) Aspirin as primary prevention Modified age, indication, rationale, and QE Dabigatran Modified rationale and recommendation Prasugrel Modified rationale Clinically Important Drug-Drug Interactions (Table 5) The table title Dropped “Non–anti-infective” ACEIs/ARBs and hyperkalemia Changed to renin-angiotensin system inhibitors Combination of three or more CNS agents (antidepressants, antiepileptics, antipsychotics, benzodiazepines, and opioids)
Replaced individual criteria with a single criterion
Medications That Should Be Avoided or Have Their Dosage Reduced With Decreased Kidney Function (Table 6) Apixaban, dabigatran, edoxaban, and rivaroxaban Revised CrCl at which action is required, rationale and
recommendations to reflect current labeling, and CrCl exclusion parameters in clinical trials
Abbreviations: ACEI, angiotensin-converting enzyme inhibitor; AChEI, acetylcholinesterase inhibitor; ARB, angiotensin receptor blocker; CNS, central nervous sys- tem; COX, cyclooxygenase; CrCl, creatinine clearance; NSAID, nonsteroidal anti-inflammatory drug; QE, quality of evidence; SR, strength of recommendation.
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clinical trials, and so decisions on the composition of the cri- teria were often made in context of best-available, rather than definitive, evidence. Moreover, evidence assessment frameworks are not perfectly tuned to drug safety evaluation, particularly for observational studies from which much of the relevant evidence derives.35,36 The criteria are unable to account for the complexity of all individuals and patient sub- populations, and thus should be taken as guidance to support clinical decision making and not as “the final word” as to whether a specific drug is appropriate or inappropriate for an individual patient. In addition, the criteria are not meant to apply to patients at the end of life or receiving palliative care, when risk-benefit considerations of drug therapy can be different. Medications considered for inclusion in the criteria were generally those available in the United States, and the panel did not seek to include agents available in other coun- tries that may be equally problematic. Finally, the updated literature search was comprehensive but may have missed certain sources of evidence, such as articles written in lan- guages other than English, white papers, technical reports, and other evidence published in the “gray literature.”
Notwithstanding these limitations, the guideline update process had a number of important strengths. The expert panel included members from multiple clinical disciplines, backgrounds, and types of clinical experience. The inclusion of ex-officio members from the Centers for Medicare and Medicaid Services, the Pharmacy Quality Alliance, and the National Committee for Quality Assurance provided a wel- come level of expertise when the panel was considering the opportunities and pitfalls of translating recommendations into quality measures. In addition, the panel used a rigorous process for identifying, reviewing, and synthesizing the available evidence to inform the guideline update process, and benefited from the close support of the AGS.
In conclusion, the 2019 update has several important revisions. Important additions among the nearly 70 modifi- cations to the 2015 AGS Beer Criteria® were new medica- tions, clarifications of criteria language and rationale, and the addition of selected drug-drug interactions.
We hope that the criteria will be used thoughtfully and widely. To facilitate this process, we encourage healthcare professionals, patients, payors, and health systems to access resources with information on the criteria, including patient-oriented information on the Health in Aging Foun- dation website (www.healthinaging.org/medications-older- adults/) and guidance for all on the proper use of the cri- teria.3 Ongoing support from AGS will facilitate future evidence-based updates, keeping the AGS Beers Criteria®
useful, relevant, and a valuable tool for improving the health and well-being of older adults.
ACKNOWLEDGMENTS
The decisions and content of the 2019 American Geriatrics Society (AGS) Beers Criteria® are those of the AGS and the panel members and are not necessarily those of the US gov- ernment or US Department of Veterans Affairs.
Sue Radcliff, Independent Researcher, Denver, CO, provided research services. Jirong Yue and Gina Rocco pro- vided additional research services. Susan E. Aiello, DVM, ELS, provided editorial services. Elvy Ickowicz, MPH,
Elisha Medina-Gallagher, and Mary Jordan Samuel pro- vided additional research and administrative support. We must also acknowledge the work of the late Mark H. Beers, MD, whose vision for better quality of care for older adults remains active through tools like the AGS Beers Criteria®.
The following organizations with special interest and expertise in the appropriate use of medications in older adults provided peer review of a preliminary draft of this guideline: American Medical Directors Association—The Society for Post-Acute and Long-Term Care Medicine, American Academy of Home Care Medicine, American Academy of Neurology, American Academy of Nurse Prac- titioners, American Academy of Nursing, American Associ- ation of Geriatric Psychiatry, American College of Cardiology, American College of Clinical Pharmacy, Ameri- can College of Obstetrics and Gynecology, American Col- lege of Osteopathic Internists, American College of Physicians, American College of Surgeons, American Osteo- pathic Association, American Psychiatric Nurses Associa- tion, American Public Health Association, American Society of Anesthesiologists, American Society of Consultant Phar- macists, American Society of Health-System Pharmacists, the Endocrine Society, Gerontological Advanced Practice Nurses Association, Gerontological Society of America, and Society of General Internal Medicine.
Conflicts of Interest: Dr. Beizer is a consultant for Wolters-Klewer. Dr. Brandt is a consultant for Institute for HealthCare Improvement (Faculty), is section editor for SLACK, Inc, and received a grant from IMPAQ on MTM; Enhanced MTM. Dr. Fick is a paid consultant for SLACK Inc and Precision Health Economics. She receives funding from the National Institute of Health for delirium studies. Dr. Hollmann is a paid reviewer for regulatory-required Rhode Island physician review of Utilization Review (UR) criteria for CVS/Caremark. Dr. Linnebur is a consultant for the Colorado Access Pharmacy and Therapeutics Commit- tee. Dr. Semla is an editor for Lexi-Comp, and Dr. Semla’s wife holds commercial interest in AbbVie (at which she is also an employee) and Abbott Labs. Dr. Semla receives honoraria from the American Geriatrics Society (AGS) for his contribution as an author of Geriatrics at Your Finger- tips and for serving as a section editor for the Journal of the American Geriatrics Society and is a past president and chair of the AGS Board of Directors.
Author Contributions: All panel members contributed to the concept, design, and preparation of the manuscript.
Sponsor’s Role: American Geriatrics Society staff par- ticipated in the final technical preparation and submission of the manuscript.
Panel Members and Affiliations
The following individuals were members of the American Geriatrics Society (AGS) Panel to update the 2019 AGS Beers Criteria®: Donna M. Fick, PhD, RN, FGSA, FAAN, College of Nursing and Medicine, The Pennsylvania State University, University Park, PA (cochair); Todd P. Semla, PharmD, MS, BCPG, FCCP, AGSF, US Department of Vet- erans Affairs National Pharmacy Benefits Management Ser- vices (retired) and Northwestern University Feinberg School of Medicine, Chicago, IL (cochair); Michael Steinman, MD, University of California San Francisco and San Francisco
20 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL MONTH 2019–VOL. 00, NO. 00 JAGS
Veterans Affairs Medical Center, San Francisco, CA (cochair); Judith Beizer, PharmD, BCGP, FASCP, AGSF, St Johns University, Queens, NY; Nicole Brandt, PharmD, MBA, BCPP, BCGP, FASCP, University of Maryland, Balti- more, MD; Robert Dombrowski, PharmD, Centers for Medicare and Medicaid Services, Baltimore, MD (nonvot- ing member); Catherine E. DuBeau, MD, Dartmouth- Hitchcock Medical Center, Lebanon, NH; Lynn Pezzullo, RPh, CPEHR, Pharmacy Quality Alliance, Alexandria, VA (nonvoting member); Jerome J. Epplin, MD, AGSF, Litch- field Family Practice Center, Litchfield, IL; Nina Flanagan, PhD, GNP-BC, APHM-BC, Decker School of Nursing, Binghamton University, Dunmore, PA; Emily Morden, MSW, National Committee for Quality Assurance, Washington, DC (nonvoting member); Joseph Hanlon, PharmD, MS, BCPS, FASHP, FASCP, FGSA, AGSF, Department of Medicine (Geriatric Medicine) School of Medicine, University of Pittsburgh and Geriatric Research, Education and Clinical Center, Veterans Affairs Healthcare System, Pittsburgh, PA; Peter Hollmann, MD, AGSF, Brown Medicine, Providence, RI; Rosemary Laird, MD, MHSA, AGSF, Geriatric Medical Leader for Florida Hospi- tal, Winter Park, FL; Sunny Linnebur, PharmD, FCCP, BCPS, BCGP, FASCP, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO; Satinderpal Sandhu, MD, SUNY Upstate Medical Uni- versity and Syracuse Veterans Affairs Medical Center, Syracuse, NY.
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