Kathleen Louden

June 09, 2015

NATIONAL HARBOR, Maryland — The American Geriatrics Society (AGS) is updating its Beers Criteria, which help prevent adverse drug events in older adults. A preview was shared during a well-attended plenary symposium here at the AGS 2015 Annual Scientific Meeting, and the final version is scheduled to be published in July.

The society is removing its recommendation to avoid nitrofurantoin in patients with a creatinine clearance level under 60 mL/min.

This is one of the most controversial changes, said Judith Beizer, PharmD, from St. John's University College of Pharmacy and Health Sciences in Queens, New York, who is a member of the expert panel updating the criteria.

However, she said, "we have new evidence that nitrofurantoin can be used safely and effectively" in these patients.

The panel retained the recommendation to avoid long-term use of nitrofurantoin because of the potential for pulmonary toxicity.

A table of drug–drug interactions and a list of medicines that need dose adjustments in patients with renal impairment will be added to the criteria, which were last updated in 2012 (J Am Geriatr Soc. 2012;60:616-631).

Drug–Drug Interactions

The expert panel reviewed more than 25,000 new literature citations and included 335 studies as supporting evidence in the tables.

"Inappropriate medication use in older adults increases the risk of mortality, morbidity, and adverse drug events, yet remains common," said session moderator Donna Fick, PhD, from Pennsylvania State University College of Nursing in University Park, who is cochair of the task force that updated the criteria.

Previous studies have shown that the rate of preventable use of inappropriate medications in older adults ranges from 28% in ambulatory settings (JAMA. 2003;289:1107-1116) to 42% in long-term-care settings (Am J Med. 2005;118:251-258).

A goal of the Beers Criteria is to improve geriatric care by reducing exposure to potentially inappropriate medications and the frequency of adverse drug events, Dr Fick explained.

There is a strong recommendation against combining multiple anticholinergic medications because they reportedly increase the risk for cognitive decline, said Nicole Brandt, PharmD, from the University of Maryland School of Pharmacy in Baltimore, who is also a member of the panel.

And there is a recommendation against the three or more medications that are active on the central nervous system, such as antidepressants, antipsychotics, benzodiazepines, and benzodiazepine-receptor agonists, because they can increase the risk for falls and, in the case of benzodiazepines, can increase fracture risk.

Bleeding, Hyperkalemia, Kidney Injury

Drugs that should not be prescribed, or that should be prescribed at lower doses, for older adults with impaired kidney function are listed in a table on renal dosing. Dr Brandt explained that although the list is not comprehensive, it was important to add to the criteria. Some of the listed drugs are associated, in elderly patients, with adverse effects such as bleeding, hyperkalemia, and kidney injury.

The recommendation to avoid the use of proton pump inhibitors (PPIs) for more than 8 weeks in older adults is new. An exception is made for patients at high risk, such as long-term users of nonsteroidal anti-inflammatory drugs and patients with erosive esophagitis, Barrett's esophagitis, pathologic hypersecretory condition, or a demonstrated need for maintenance therapy.

Dr Brandt pointed out that there are many references demonstrating, in elderly patients, an increased risk for Clostridium difficile infection and bone loss and fractures with the long-term use of PPIs.

Some key principles to consider when using the Beers Criteria were outlined by Michael Steinman, MD, from the University of California at San Francisco.

Beers Criteria Key Principles
Medications listed are potentially, not definitely, inappropriate in older adults
The rationale and recommendation statements in the tables provide guidance and exceptions to the recommendations
Prescribing should be adjusted to take into account why a drug is listed
Safer pharmacologic and nonpharmacologic alternatives to the listed drugs are available; a list of alternative medications is being developed by the AGS
The criteria should be a starting point from which to develop a comprehensive process to improve medication appropriateness and safety
The criteria do not apply in all countries


Dr Steinman explained that health insurance plans should not excessively restrict access to listed drugs through either prior authorization requirements or coverage policies, which drew applause from the audience.

"We had not envisioned that the Beers Criteria would be used by insurance companies to require physician preauthorization for listed drugs. The criteria are intended to supplement or support your clinical judgment," he explained.

To avoid oversimplification of the recommendations, the expert panel added caveats and exceptions to this revision, he said.

For instance, he pointed out, the recommendation to avoid opiates in seniors only applies if patients are at high risk for falls.

Dr Steinman advised clinicians using the Beers Criteria to ask themselves why the patient is taking a drug and whether it is truly needed, whether there are safer alternatives, and whether the patient has characteristics that would increase or mitigate the potential risks of the drug.

We had not envisioned that the Beers Criteria would be used by insurance companies to require physician preauthorization for listed drugs.

"I'm excited about the update," said Michael Koronkowski, PharmD, from the University of Illinois at Chicago College of Pharmacy. "The criteria need to be updated regularly, maybe more often than 3 years."

He added that he would like to see the Beers Criteria compared with usual care in a randomized clinical trial. "These criteria need to go through the rigor of scientific study to determine if they improve outcomes," he told Medscape Medical News.

As in past revisions, most of the 2015 criteria are based on evidence of moderate strength or quality, Dr Fick said, but she noted that older adults are often excluded from randomized clinical trials, which produce high-quality evidence.

There was concern from some audience members about the lack of awareness of the Beers Criteria.

"Emergency department visits are growing, yet doctors in my emergency department are not aware of the Beers Criteria," said one physician.

"All of you can take this information back to your practice and colleagues to help disseminate it," Dr Beizer suggested.

Dr Fick is a paid consultant for SLACK Inc. Dr Beizer is an editor for LexiComp Online, which is owned by Wolters Kluwer Health. Dr Brandt is a paid consultant for the Centers for Medicare and Medicaid Services. Dr Steinman is a paid consultant for Iodine Inc., a healthcare technology startup. Dr Koronkowski is a consultant for Catamaran, a pharmacy benefit manager.

American Geriatrics Society (AGS) 2015 Annual Scientific Meeting. Presented May 16, 2015.


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