American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults

By the American Geriatrics Society 2015 Beers Criteria Update Expert Panel

J Am Geriatr Soc. 2015;63(11):2227-2246.

Abstract and Introduction

Abstract

The 2015 American Geriatrics Society (AGS) Beers Criteria are presented. Like the 2012 AGS Beers Criteria, they include lists of potentially inappropriate medications to be avoided in older adults. New to the criteria are lists of select drugs that should be avoided or have their dose adjusted based on the individual's kidney function and select drug–drug interactions documented to be associated with harms in older adults. The specific aim was to have a 13-member interdisciplinary panel of experts in geriatric care and pharmacotherapy update the 2012 AGS Beers Criteria using a modified Delphi method to systematically review and grade the evidence and reach a consensus on each existing and new criterion. The process followed an evidence-based approach using Institute of Medicine standards. The 2015 AGS Beers Criteria are applicable to all older adults with the exclusion of those in palliative and hospice care. Careful application of the criteria by health professionals, consumers, payors, and health systems should lead to closer monitoring of drug use in older adults.

Introduction

The American Geriatrics Society (AGS) Beers Criteria for Potentially Inappropriate Medication (PIM) Use in Older Adults is an explicit list of PIMs best avoided in older adults in general and in those with certain diseases or syndromes, prescribed at reduced dosage or with caution or carefully monitored. Beers Criteria PIMs have been found to be associated with poor health outcomes, including confusion, falls, and mortality.^[1,2] Avoiding PIMs in older adults is one strategy to decrease the risk of adverse events. Interventions using explicit criteria have been found to be an important component of strategies for reducing inappropriate medication usage.^[3–5]

The AGS Beers Criteria for PIM Use in Older Adults are one of the most frequently consulted sources about the safety of prescribing medications for older adults. The AGS Beers Criteria are used widely in geriatric clinical care, education, and research and in development of quality indicators. In 2011, the AGS assumed the responsibility of updating and maintaining the Beers Criteria and, in 2012, released the first update of the criteria since 2003. The AGS has made a commitment to update the criteria regularly. The changes in the 2015 update are not as extensive as those of the previous update, but in addition to updating existing criteria, two major components have been added: 1) drugs for which dose adjustment is required based on kidney function and 2) drug–drug interactions. Neither of these new additions is intended to be comprehensive, because such lists would be too extensive. An interdisciplinary expert panel focused on those drugs and drug–drug interactions for which there is evidence in older adults that they are at risk of serious harm if the dose is not adjusted or the drug interaction is overlooked.

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Table 1. Designations of Quality of Evidence and Strength of Recommendations
Quality of Evidence
High	Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes (≥2 consistent, higher-quality randomized controlled trials or multiple, consistent observational studies with no significant methodological flaws showing large effects)
Moderate	Evidence is sufficient to determine risks of adverse outcomes, but the number, quality, size, or consistency of included studies; generalizability to routine practice; or indirect nature of the evidence on health outcomes (≥1 higher-quality trial with >100 participants; ≥2 higher-quality trials with some inconsistency; ≥2 consistent, lower-quality trials; or multiple, consistent observational studies with no significant methodological flaws showing at least moderate effects) limits the strength of the evidence
Low	Evidence is insufficient to assess harms or risks in health outcomes because of limited number or power of studies, large and unexplained inconsistency between higher-quality studies, important flaws in study design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes
Strength of Recommendation
Strong	Benefits clearly outweigh harms, adverse events, and risks, or harms, adverse events, and risks clearly outweigh benefits
Weak	Benefits may not outweigh harms, adverse events, and risks
Insufficient	Evidence inadequate to determine net harms, adverse events, and risks

Adapted from¹¹.

Table 2. 2015 American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults
Organ System, Therapeutic Category, Drugs	Rationale	Recommendation	Quality of Evidence	Strength of Recommendation
Anticholinergics
First-generation antihistamines Brompheniramine Carbinoxamine Chlorpheniramine Clemastine Cyproheptadine Dexbrompheniramine DexchlorpheniramineDimenhydrinate Diphenhydramine (oral) Doxylamine Hydroxyzine Meclizine Promethazine Triprolidine	Highly anticholinergic; clearance reduced with advanced age, and tolerance develops when used as hypnotic; risk of confusion, dry mouth, constipation, and other anticholinergic effects or toxicity Use of diphenhydramine in situations such as acute treatment of severe allergic reaction may be appropriate	Avoid	Moderate	Strong
Antiparkinsonian agents Benztropine (oral) Trihexyphenidyl	Not recommended for prevention of extrapyramidal symptoms with antipsychotics; more-effective agents available for treatment of Parkinson disease	Avoid	Moderate	Strong
Antispasmodics Atropine (excludes ophthalmic) Belladonna alkaloids Clidinium-Chlordiazepoxide Dicyclomine Hyoscyamine Propantheline Scopolamine	Highly anticholinergic, uncertain effectiveness	Avoid	Moderate	Strong
Antithrombotics
Dipyridamole, oral short-acting (does not apply to the extended-release combination with aspirin)	May cause orthostatic hypotension; more effective alternatives available; intravenous form acceptable for use in cardiac stress testing	Avoid	Moderate	Strong
Ticlopidine	Safer, effective alternatives available	Avoid	Moderate	Strong
Anti-infective
Nitrofurantoin	Potential for pulmonary toxicity, hepatoxicity, and peripheral neuropathy, especially with long-term use; safer alternatives available	Avoid in individuals with creatinine clearance <30 mL/min or for long-term suppression of bacteria	Low	Strong
Cardiovascular
Peripheral alpha-1 blockers Doxazosin Prazosin Terazosin	High risk of orthostatic hypotension; not recommended as routine treatment for hypertension; alternative agents have superior risk–benefit profile	Avoid use as an antihypertensive	Moderate	Strong
Central alpha blockers Clonidine Guanabenz Guanfacine Methyldopa Reserpine (>0.1 mg/d)	High risk of adverse CNS effects; may cause bradycardia and orthostatic hypotension; not recommended as routine treatment for hypertension	Avoid clonidine as first-line antihypertensive Avoid others as listed	Low	Strong
Disopyramide	Disopyramide is a potent negative inotrope and therefore may induce heart failure in older adults; strongly anticholinergic; other antiarrhythmic drugs preferred	Avoid	Low	Strong
Dronedarone	Worse outcomes have been reported in patients taking dronedarone who have permanent atrial fibrillation or severe or recently decompensated heart failure	Avoid in individuals with permanent atrial fibrillation or severe or recently decompensated heart failure	High	Strong
Digoxin	Use in atrial fibrillation: should not be used as a first-line agent in atrial fibrillation, because more-effective alternatives exist and it may be associated with increased mortality	Avoid as first-line therapy for atrial fibrillation	Atrial fibrillation: moderate	Atrial fibrillation: strong
	Use in heart failure: questionable effects on risk of hospitalization and may be associated with increased mortality in older adults with heart failure; in heart failure, higher dosages not associated with additional benefit and may increase risk of toxicity	Avoid as first-line therapy for heart failure	Heart failure: low	Heart failure: strong
	Decreased renal clearance of digoxin may lead to increased risk of toxic effects; further dose reduction may be necessary in patients with Stage 4 or 5 chronic kidney disease	If used for atrial fibrillation or heart failure, avoid dosages >0.125 mg/d	Dosage >0.125 mg/d: moderate	Dosage >0.125 mg/d: strong
Nifedipine, immediate release	Potential for hypotension; risk of precipitating myocardial ischemia	Avoid	High	Strong
Amiodarone	Amiodarone is effective for maintaining sinus rhythm but has greater toxicities than other antiarrhythmics used in atrial fibrillation; it may be reasonable first-line therapy in patients with concomitant heart failure or substantial left ventricular hypertrophy if rhythm control is preferred over rate control	Avoid amiodarone as first-line therapy for atrial fibrillation unless patient has heart failure or substantial left ventricular hypertrophy	High	Strong
Central nervous system
Antidepressants, alone or in combination Amitriptyline Amoxapine Clomipramine Desipramine Doxepin >6 mg/d Imipramine Nortriptyline Paroxetine Protriptyline Trimipramine	Highly anticholinergic, sedating, and cause orthostatic hypotension; safety profile of low-dose doxepin (≤6 mg/d) comparable with that of placebo	Avoid	High	Strong
Antipsychotics, first- (conventional) and second- (atypical) generation	Increased risk of cerebrovascular accident (stroke) and greater rate of cognitive decline and mortality in persons with dementia Avoid antipsychotics for behavioral problems of dementia or delirium unless nonpharmacological options (e.g., behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others	Avoid, except for schizophrenia, bipolar disorder, or short-term use as antiemetic during chemotherapy	Moderate	Strong
Barbiturates Amobarbital Butabarbital Butalbital Mephobarbital Pentobarbital Phenobarbital Secobarbital	High rate of physical dependence, tolerance to sleep benefits, greater risk of overdose at low dosages	Avoid	High	Strong
Benzodiazepines Short- and intermediate- acting Alprazolam Estazolam Lorazepam Oxazepam Temazepam Triazolam	Older adults have increased sensitivity to benzodiazepines and decreased metabolism of long-acting agents; in general, all benzodiazepines increase risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes in older adults	Avoid	Moderate	Strong
Long-acting Clorazepate Chlordiazepoxide (alone or in combination with amitriptyline or clidinium) Clonazepam Diazepam Flurazepam Quazepam	May be appropriate for seizure disorders, rapid eye movement sleep disorders, benzodiazepine withdrawal, ethanol withdrawal, severe generalized anxiety disorder, and periprocedural anesthesia
Meprobamate	High rate of physical dependence; very sedating	Avoid	Moderate	Strong
Nonbenzodiazepine, benzodiazepine receptor agonist hypnotics Eszopiclone Zolpidem Zaleplon	Benzodiazepine-receptor agonists have adverse events similar to those of benzodiazepines in older adults (e.g., delirium, falls, fractures);increased emergency department visits and hospitalizations; motor vehicle crashes; minimal improvement in sleep latency and duration	Avoid	Moderate	Strong
Ergoloid mesylates (dehydrogenated ergot alkaloids) Isoxsuprine	Lack of efficacy	Avoid	High	Strong
Endocrine
Androgens Methyltestosterone Testosterone	Potential for cardiac problems; contraindicated in men with prostate cancer	Avoid unless indicated for confirmed hypogonadism with clinical symptoms	Moderate	Weak
Desiccated thyroid	Concerns about cardiac effects; safer alternatives available	Avoid	Low	Strong
Estrogens with or without progestins	Evidence of carcinogenic potential (breast and endometrium); lack of cardioprotective effect and cognitive protection in older women Evidence indicates that vaginal estrogens for the treatment of vaginal dryness are safe and effective; women with a history of breast cancer who do not respond to nonhormonal therapies are advised to discuss the risk and benefits of low-dose vaginal estrogen (dosages of estradiol <25 μg twice weekly) with their healthcare provider	Avoid oral and topical patch Vaginal cream or tablets: acceptable to use low-dose intravaginal estrogen for management of dyspareunia, lower urinary tract infections, and other vaginal symptoms	Oral and patch: high Vaginal cream or tablets: moderate	Oral and patch: strong Topical vaginal cream or tablets: weak
Growth hormone	Impact on body composition is small and associated with edema, arthralgia, carpal tunnel syndrome, gynecomastia, impaired fasting glucose	Avoid, except as hormone replacement after pituitary gland removal	High	Strong
Insulin, sliding scale	Higher risk of hypoglycemia without improvement in hyperglycemia management regardless of care setting; refers to sole use of short- or rapid-acting insulins to manage or avoid hyperglycemia in absence of basal or long-acting insulin; does not apply to titration of basal insulin or use of additional short- or rapid-acting insulin in conjunction with scheduled insulin (i.e., correction insulin)	Avoid	Moderate	Strong
Megestrol	Minimal effect on weight; increases risk of thrombotic events and possibly death in older adults	Avoid	Moderate	Strong
Sulfonylureas, long-duration Chlorpropamide	Chlorpropamide: prolonged half-life in older adults; can cause prolonged hypoglycemia; causes syndrome of inappropriate antidiuretic hormone secretion	Avoid	High	Strong
Glyburide	Glyburide: higher risk of severe prolonged hypoglycemia in older adults
Gastrointestinal
Metoclopramide	Can cause extrapyramidal effects, including tardive dyskinesia; risk may be greater in frail older adults	Avoid, unless for gastroparesis	Moderate	Strong
Mineral oil, given orally	Potential for aspiration and adverse effects; safer alternatives available	Avoid	Moderate	Strong
Proton-pump inhibitors	Risk of Clostridium difficile infection and bone loss and fractures	Avoid scheduled use for >8 weeks unless for high-risk patients (e.g., oral corticosteroids or chronic NSAID use), erosive esophagitis, Barrett's esophagitis, pathological hypersecretory condition, or demonstrated need for maintenance treatment (e.g., due to failure of drug discontinuation trial or H₂ blockers)	High	Strong
Pain medications
Meperidine	Not effective oral analgesic in dosages commonly used; may have higher risk of neurotoxicity, including delirium, than other opioids; safer alternatives available	Avoid, especially in individuals with chronic kidney disease	Moderate	Strong
Non-cyclooxygenase-selective NSAIDs, oral: Aspirin >325 mg/d Diclofenac Diflunisal Etodolac Fenoprofen Ibuprofen Ketoprofen Meclofenamate Mefenamic acid Meloxicam Nabumetone Naproxen Oxaprozin Piroxicam Sulindac Tolmetin	Increased risk of gastrointestinal bleeding or peptic ulcer disease in high-risk groups, including those aged >75 or taking oral or parenteral corticosteroids, anticoagulants, or antiplatelet agents; use of proton-pump inhibitor or misoprostol reduces but does not eliminate risk. Upper gastrointestinal ulcers, gross bleeding, or perforation caused by NSAIDs occur in approximately 1% of patients treated for 3–6 months and in ~2–4% of patients treated for 1 year; these trends continue with longer duration of use	Avoid chronic use, unless other alternatives are not effective and patient can take gastroprotective agent (proton-pump inhibitor or misoprostol)	Moderate	Strong
Indomethacin	Indomethacin is more likely than other NSAIDs to have adverse CNS effects. Of all the NSAIDs, indomethacin has the most adverse effects.	Avoid	Moderate	Strong
Ketorolac, includes parenteral	Increased risk of gastrointestinal bleeding, peptic ulcer disease, and acute kidney injury in older adults
Pentazocine	Opioid analgesic that causes CNS adverse effects, including confusion and hallucinations, more commonly than other opioid analgesic drugs; is also a mixed agonist and antagonist; safer alternatives available	Avoid	Low	Strong
Skeletal muscle relaxants Carisoprodol Chlorzoxazone Cyclobenzaprine Metaxalone Methocarbamol Orphenadrine	Most muscle relaxants poorly tolerated by older adults because some have anticholinergic adverse effects, sedation, increased risk of fractures; effectiveness at dosages tolerated by older adults questionable	Avoid	Moderate	Strong
Genitourinary
Desmopressin	High risk of hyponatremia; safer alternative treatments	Avoid for treatment of nocturia or nocturnal polyuria	Moderate	Strong

The primary target audience is practicing clinicians. The intentions of the criteria are to improve the selection of prescription drugs by clinicians and patients; evaluate patterns of drug use within populations; educate clinicians and patients on proper drug usage; and evaluate health-outcome, quality-of-care, cost, and utilization data.
CNS = central nervous system; NSAIDs = nonsteroidal anti-inflammatory drugs.

Table 3. 2015 American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Due to Drug–Disease or Drug–Syndrome Interactions That May Exacerbate the Disease or Syndrome
Disease or Syndrome	Drug(s)	Rationale	Recommendation	Quality of Evidence	Strength of Recommendation
Cardiovascular
Heart failure	NSAIDs and COX-2 inhibitors Nondihydropyridine CCBs (diltiazem, verapamil)—avoid only for heart failure with reduced ejection fraction Thiazolidinediones (pioglitazone, rosiglitazone) Cilostazol Dronedarone (severe or recently decompensated heart failure)	Potential to promote fluid retention and exacerbate heart failure	Avoid	NSAIDs: moderate CCBs: moderate Thiazolidinediones: high Cilostazol: low Dronedarone: high	Strong
Syncope	AChEIs Peripheral alpha-1 blockers Doxazosin Prazosin Terazosin Tertiary TCAs Chlorpromazinem Thioridazine Olanzapine	Increases risk of orthostatic hypotension or bradycardia	Avoid	Peripheral alpha-1 blockers: high TCAs, AChEIs, antipsychotics: moderate	AChEIs, TCAs: strong Peripheral alpha-1 blockers, antipsychotics: weak
Central nervous system
Chronic seizures or epilepsy	Bupropion Chlorpromazine Clozapine Maprotiline Olanzapine Thioridazine Thiothixene Tramadol	Lowers seizure threshold; may be acceptable in individuals with well-controlled seizures in whom alternative agents have not been effective	Avoid	Low	Strong
Delirium	Anticholinergics (see Table 7 for full list) Antipsychotics Benzodiazepines Chlorpromazine Corticosteroids^a H₂-receptor antagonists Cimetidine Famotidine Nizatidine Ranitidine Meperidine Sedative hypnotics	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening deliriumm Avoid antipsychotics for behavioral problems of dementia or delirium unless nonpharmacological options (e.g., behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others Antipsychotics are associated with greater risk of cerebrovascular accident (stroke) and mortality in persons with dementia	Avoid	Moderate	Strong
Dementia or cognitive impairment	Anticholinergics (see Table 7 for full list) Benzodiazepines H₂-receptor antagonists Nonbenzodiazepine, benzodiazepine receptor agonist hypnotics Eszopiclone Zolpidem Zaleplon Antipsychotics, chronic and as-needed use	Avoid because of adverse CNS effects Avoid antipsychotics for behavioral problems of dementia or delirium unless nonpharmacological options (e.g., behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. Antipsychotics are associated with greater risk of cerebrovascular accident (stroke) and mortality in persons with dementia	Avoid	Moderate	Strong
History of falls or fractures	Anticonvulsants Antipsychotics Benzodiazepines Nonbenzodiazepine, benzodiazepine receptor agonist hypnotics Eszopiclone Zaleplon Zolpidem TCAs SSRIs Opioids	May cause ataxia, impaired psychomotor function, syncope, additional falls; shorter-acting benzodiazepines are not safer than long-acting ones If one of the drugs must be used, consider reducing use of other CNS-active medications that increase risk of falls and fractures (i.e., anticonvulsants, opioid-receptor agonists, antipsychotics, antidepressants, benzodiazepine-receptor agonists, other sedatives and hypnotics) and implement other strategies to reduce fall risk	Avoid unless safer alternatives are not available; avoid anticonvulsants except for seizure and mood disorders Opioids: avoid, excludes pain management due to recent fractures or joint replacement	High Opioids: moderate	Strong Opioids: strong
Insomnia	Oral decongestants Pseudoephedrine Phenylephrine Stimulants Amphetamine Armodafinil Methylphenidate Modafinil Theobromines Theophylline Caffeine	CNS stimulant effects	Avoid	Moderate	Strong
Parkinson disease	All antipsychotics (except aripiprazole, quetiapine, clozapine) Antiemetics Metoclopramide Prochlorperazine Promethazine	Dopamine-receptor antagonists with potential to worsen parkinsonian symptoms Quetiapine, aripiprazole, clozapine appear to be less likely to precipitate worsening of Parkinson disease	Avoid	Moderate	Strong
Gastrointestinal
History of gastric or duodenal ulcers	Aspirin (>325 mg/d) Non-COX-2 selective NSAIDs	May exacerbate existing ulcers or cause new or additional ulcers	Avoid unless other alternatives are not effective and patient can take gastroprotective agent (i.e., proton-pump inhibitor or misoprostol)	Moderate	Strong
Kidney and urinary tract
Chronic kidney disease Stages IV or less (creatinine clearance <30 mL/min)	NSAIDs (non-COX and COX-selective, oral and parenteral)	May increase risk of acute kidney injury and further decline of renal function	Avoid	Moderate	Strong
Urinary incontinence (all types) in women	Estrogen oral and transdermal (excludes intravaginal estrogen) Peripheral alpha-1 blockers Doxazosin Prazosin Terazosin	Aggravation of incontinence	Avoid in women	Estrogen: high Peripheral alpha-1 blockers: moderate	Estrogen: strong Peripheral alpha-1 blockers: strong
Lower urinary tract symptoms, benign prostatic hyperplasia	Strongly anticholinergic drugs, except antimuscarinics for urinary incontinence (see Table 7 for complete list)	May decrease urinary flow and cause urinary retention	Avoid in men	Moderate	Strong

The primary target audience is the practicing clinician. The intentions of the criteria are to improve selection of prescription drugs by clinicians and patients; evaluate patterns of drug use within populations; educate clinicians and patients on proper drug usage; and evaluate health-outcome, quality-of-care, cost, and utilization data.
^aExcludes inhaled and topical forms. Oral and parenteral corticosteroids may be required for conditions such as exacerbations of chronic obstructive pulmonary disease but should be prescribed in the lowest effective dose and for the shortest possible duration.
CCB = calcium channel blocker; AChEI = acetylcholinesterase inhibitor; CNS = central nervous system; COX = cyclooxygenase; NSAID = nonsteroidal anti-inflammatory drug; SSRIs = selective serotonin reuptake inhibitors; TCA = tricyclic antidepressant.

Table 4. 2015 American Geriatrics Society Beers Criteria for Potentially Inappropriate Medications to Be Used with Caution in Older Adults
Drug(s)	Rationale	Recommendation	Quality of Evidence	Strength of Recommendation
Aspirin for primary prevention of cardiac events	Lack of evidence of benefit versus risk in adults aged ≥80	Use with caution in adults aged ≥80	Low	Strong
Dabigatran	Increased risk of gastrointestinal bleeding compared with warfarin and reported rates with other target-specific oral anticoagulants in adults aged ≥75; lack of evidence of efficacy and safety in individuals with CrCl <30 mL/min	Use with caution in in adults aged ≥75 and in patients with CrCl <30 mL/min	Moderate	Strong
Prasugrel	Increased risk of bleeding in older adults; benefit in highest-risk older adults (e.g., those with prior myocardial infarction or diabetes mellitus) may offset risk	Use with caution in adults aged ≥75	Moderate	Weak
Antipsychotics Diuretics Carbamazepine Carboplatin Cyclophosphamide Cisplatin Mirtazapine Oxcarbazepine SNRIs SSRIs TCAs Vincristine	May exacerbate or cause syndrome of inappropriate antidiuretic hormone secretion or hyponatremia; monitor sodium level closely when starting or changing dosages in older adults	Use with caution	Moderate	Strong
Vasodilators	May exacerbate episodes of syncope in individuals with history of syncope	Use with caution	Moderate	Weak

Table 5. 2015 American Geriatrics Society Beers Criteria for Potentially Clinically Important Non-Anti-infective Drug–Drug Interactions That Should Be Avoided in Older Adults
Object Drug and Class	Interacting Drug and Class	Risk Rationale	Recommendation	Quality of Evidence	Strength of Recommendation
ACEIs	Amiloride or triamterene	Increased risk of Hyperkalemia	Avoid routine use; reserve for patients with demonstrated hypokalemia while taking an ACEI	Moderate	Strong
Anticholinergic	Anticholinergic	Increased risk of Cognitive decline	Avoid, minimize number of anticholinergic drugs (Table 7)	Moderate	Strong
Antidepressants (i.e., TCAs and SSRIs)	≥2 other CNS-active drugs^a	Increased risk of Falls	Avoid total of ≥3 CNS-active drugs^a; minimize number of CNS-active drugs	Moderate	Strong
Antipsychotics	≥2 other CNS-active drugs^a	Increased risk of Falls	Avoid total of ≥3 CNS-active drugs^a; minimize number of CNS-active drugs	Moderate	Strong
Benzodiazepines and nonbenzodiazepine, benzodiazepine receptor agonist hypnotics	≥2 other CNS-active drugs^a	Increased risk of Falls and fractures	Avoid total of ≥3 CNS-active drugs^a; minimize number of CNS-active drugs	High	Strong
Corticosteroids, oral or parenteral	NSAIDs	Increased risk of Peptic ulcer disease or gastrointestinal bleeding	Avoid; if not possible, provide gastrointestinal protection	Moderate	Strong
Lithium	ACEIs	Increased risk of Lithium toxicity	Avoid, monitor lithium concentrations	Moderate	Strong
Lithium	Loop diuretics	Increased risk of Lithium toxicity	Avoid, monitor lithium concentrations	Moderate	Strong
Opioid receptor agonist analgesics	≥2 other CNS-active drugs^a	Increased risk of Falls	Avoid total of ≥3 CNS-active drugs^a; minimize number of CNS drugs	High	Strong
Peripheral Alpha-1 blockers	Loop diuretics	Increased risk of Urinary incontinence in older women	Avoid in older women, unless conditions warrant both drugs	Moderate	Strong
Theophylline	Cimetidine	Increased risk of Theophylline toxicity	Avoid	Moderate	Strong
Warfarin	Amiodarone	Increased risk of Bleeding	Avoid when possible; monitor international normalized ratio closely	Moderate	Strong
Warfarin	NSAIDs	Increased risk of Bleeding	Avoid when possible; if used together, monitor for bleeding closely	High	Strong

^aCentral nervous system (CNS)-active drugs: antipsychotics; benzodiazepines; nonbenzodiazepine, benzodiazepine receptor agonist hypnotics; tricyclic antidepressants (TCAs); selective serotonin reuptake inhibitors (SSRIs); and opioids.
ACEI = angiotensin-converting enzyme inhibitor; NSAID = nonsteroidal anti-inflammatory drug.

Table 6. 2015 American Geriatrics Society Beers Criteria for Non-Anti-Infective 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, mL/min, at Which Action Required	Rationale	Recommendation	Quality of Evidence	Strength of Recommendation
Cardiovascular or hemostasis
Amiloride	<30	Increased potassium, and decreased sodium	Avoid	Moderate	Strong
Apixaban	<25	Increased risk of bleeding	Avoid	Moderate	Strong
Dabigatran	<30	Increased risk of bleeding	Avoid	Moderate	Strong
Edoxaban	30–50	Increased risk of bleeding	Reduce dose	Moderate	Strong
	<30 or >95		Avoid
Enoxaparin	<30	Increased risk of bleeding	Reduce dose	Moderate	Strong
Fondaparinux	<30	Increased risk of bleeding	Avoid	Moderate	Strong
Rivaroxaban	30–50	Increased risk of bleeding	Reduce dose	Moderate	Strong
	<30		Avoid
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
Hyperuricemia
Colchicine	<30	Gastrointestinal, neuromuscular, bone marrow toxicity	Reduce dose; monitor for adverse effects	Moderate	Strong
Probenecid	<30	Loss of effectiveness	Avoid	Moderate	Strong

CNS = central nervous system.

Table 7. Drugs with Strong Anticholinergic Properties
Antihistamines Brompheniramine Carbinoxamine Chlorpheniramine Clemastine Cyproheptadine DexbrompheniramineDexchlorpheniramine Dimenhydrinate Diphenhydramine (oral) Doxylamine Hydroxyzine Meclizine Triprolidine	Antiparkinsonian agents Benztropine Trihexyphenidyl	Skeletal muscle relaxants Cyclobenzaprine Orphenadrine
Antidepressants Amitriptyline Amoxapine Clomipramine Desipramine Doxepin (>6 mg) Imipramine Nortriptyline Paroxetine Protriptyline Trimipramine	Antipsychotics Chlorpromazine Clozapine Loxapine Olanzapine Perphenazine Thioridazine Trifluoperazine	Antiarrhythmic Disopyramide
Antimuscarinics (urinary incontinence) Darifenacin Fesoterodine Flavoxate Oxybutynin Solifenacin Tolterodine Trospium	Antispasmodics Atropine (excludes ophthalmic) Belladonna alkaloids Clidinium-chlordiazepoxide Dicyclomine Homatropine (excludes ophthalmic) Hyoscyamine Propantheline Scopolamine (excludes ophthalmic)	Antiemetic Prochlorperazine Promethazine

Table 8. Medications Moved to Another Category or Modified Since 2012 Beers Criteria
Independent of Diagnoses or Condition (Table 2)	Considering Disease or Syndrome Interactions (Table 3)
Nitrofurantoin—recommendation and rationale modified	Heart failure—rationale and quality of evidence modified
Dronedarone—recommendation and rationale modified	Chronic seizures or epilepsy—quality of evidence modified
Digoxin—recommendation and rationale modified	Delirium—recommendation and rationale modified
Benzodiazepines—recommendation modified	Dementia or cognitive impairment—recommendation and rationale modified; new drugs added
Nonbenzodiazepine, benzodiazepine receptor agonist hypnotics—recommendation modified	History of falls or fractures—recommendation and rationale modified; new drugs added
Meperidine—recommendation modified	Parkinson disease—recommendation and rationale modified
Indomethacin and ketorolac, includes parenteral—rationale modified	Chronic kidney disease Stage IV or less (creatinine clearance <30 mL/min)—triamterene moved to Tables 5 and 6
Antipsychotics—recommendation and rationale modified	Insomnia—new drugs added
Estrogen—recommendation modified
Insulin, sliding scale—rationale modified

Table 9. Medications Removed Since 2012 Beers Criteria
Independent of Diagnoses or Condition (Table 2)	Considering Disease and Syndrome Interactions (Table 3)
Antiarrhythmic drugs (Class 1a, 1c, III except amiodarone) as first-line treatment for atrial fibrillation	Chronic constipation—entire criterion
Trimethobenzamide	Lower urinary tract—inhaled anticholinergic drugs
Mesoridazine—no longer marketed in United States
Chloral hydrate—no longer marketed in United States

Table 10. Medications Added Since 2012 Beers Criteria
Independent of Diagnoses or Condition (Table 2)	Considering Disease and Syndrome Interactions (Table 3)
Proton-pump inhibitors	Falls and fractures—opioids
Desmopressin	Insomnia—armodafinil and modafinil
Anticholinergics, first-generation antihistamines—meclizine	Dementia or cognitive impairment—eszopiclone and zaleplon
	Delirium—antipsychotics

Authors and Disclosures

American Geriatrics Society 2015 Beers Criteria Update Expert Panel

Special Projects & Governance, American Geriatrics Society, New York, New York

Address correspondence to
Mary Jordan Samuel, Manager, Special Projects & Governance, American Geriatrics Society, 40 Fulton Street, 18th Floor, New York, NY 10038. E-mail: msamuel@americangeriatrics.org

Panel Members and Affiliations
The following individuals were members of the AGS Panel to update the 2015 AGS Beers Criteria: Donna M. Fick, PhD, RN, FGSA, FAAN, College of Nursing and Medicine, The Pennsylvania State University, University Park, PA (co-chair); Todd P. Semla, PharmD, MS, BCPS, FCCP, AGSF, U.S. Department of Veterans Affairs National Pharmacy Benefits Management Services and Northwestern University Feinberg School of Medicine, Chicago, IL (co-chair); Judith Beizer, PharmD, CGP, FASCP, AGSF, St. Johns University, New York, NY; Nicole Brandt, PharmD, BCPP, CGP, University of Maryland, Baltimore, MD; Robert Dombrowski, PharmD, Centers for Medicare and Medicaid Services, Baltimore, MD (nonvoting member); Catherine E. DuBeau, MD, University of Massachusetts Medical School, Worcester, MA; Woody Eisenberg, MD, Pharmacy Quality Alliance, Inc., Baltimore, MD (nonvoting member); Jerome J. Epplin, MD, AGSF, Litchfield Family Practice Center, Litchfield, IL; Nina Flanagan, PhD, GNP-BC, APHM-BC, Decker School of Nursing, Binghamton University, Dunmore, PA; Erin Giovannetti, 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 (GRECC) System, Pittsburgh, PA; Peter Hollmann, MD, AGSF, Alpert Medical School, Brown University, Providence, RI; Rosemary Laird, MD, MHSA, AGSF, Geriatric Medical Leader for Florida Hospital, Winter Park, FL; Sunny Linnebur, PharmD, FCCP, BCPS, CGP, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO; Satinderpal Sandhu, MD, Summa Health Care System and Northeast Ohio Medical University, Akron, OH; Michael Steinman, MD, University of California at San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, CA.

Conflict of Interest
Dr. Beizer is an author and editor for LexiComp, Inc. Dr. Brandt is a consultant for Omnicare, Centers for Medicare and Medicaid Services, and University of Pittsburgh and a Section Editor for the Journal of Gerontological Nursing and received a grant from Econometrica. Dr. Fick is a paid consultant for SLACK Inc., is an editor for the Journal of Gerontological Nursing, and has current R01 funding from the National Institutes of Health and the National Institute of Nursing Research. Dr. Linnebur is a consultant for Colorado Access and Kindred Healthcare. Dr. Semla serves on the AARP Caregiver Advisory Panel, is an editor for LexiComp, and is a consultant for Omnicare. Dr. Semla's wife holds commercial interest in AbbVie (at which she is also an employee), Abbott, and Hospira. Dr. Semla receives honoraria from the AGS for his contribution as an author of Geriatrics at Your Fingertips 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. Dr. Steinman is a consult for Iodine.com, a web start-up company.

Author Contributions
All panel members contributed to the concept, design, and preparation of the manuscript.

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American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults

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