Updated Beers Criteria Guide Drug Use in Elders

Ricki Lewis, PhD

February 01, 2019

The American Geriatrics Society (AGS) has released the 2019 update to the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. The update was published online January 29 in the Journal of the American Geriatrics Society.

"Medications play an important role in health and well-being for many older people," Donna M. Fick, PhD, RN, FGSA, FAAN, a co-chair of the expert panel responsible for the 2019 AGS Beers Criteria, said in a news release. "With this new update, we hope the latest information on what makes medications appropriate for older people can play an equally important role in decisions about treatment options that meet the needs of older adults while also keeping them as safe as possible."

The Beers Criteria are intended to improve medication selection, reduce adverse drug events, and provide a tool to assess cost, patterns, and quality of care of drugs used for people aged 65 years or older. It lists drugs that should be avoided in the treatment of older adults, either generally or in patients with specific diseases or conditions. Clinicians, researchers, educators, healthcare administrators, and regulators use the criteria, which were first published in 1991 and have been updated every 3 years since 2011.

The 2019 criteria include 30 medications or medication classes to be avoided in older adults in general and 40 medications or medication classes that should be used with caution or avoided in certain patients with certain diseases or conditions. Two criteria were added in response to the worsening opioid crisis — not prescribing opioids with benzodiazepines or gabapentinoids.

The criteria dropped eight seizure medications, eight drugs for insomnia, and vasodilators for syncope. Some of these drugs were dropped because the problems associated with their use are not unique to older patients. Two — ticlopidine and pentazocine — were dropped because they are no longer available in the United States.

Removed From the Criteria

H2-receptor antagonists were removed from the criteria because the evidence that they harm people with dementia is weak. The drugs, which relieve gastric reflux, can continue to be used in patients with delirium.

The chemotherapeutic drugs carboplatin, cisplatin, vincristine, and cyclophosphamide were removed from the criteria because the panel considered them to be "highly specialized" and outside the scope of the criteria.

"Use With Caution"

Dextromethorphan/quinidine should be used with caution because it has limited efficacy in alleviating behavioral symptoms of dementia in patients without pseudobulbar affect and because it potentially increases the risk for falls and drug-drug interactions.

Rivaroxaban is to be used with caution for venous thromboembolism or atrial fibrillation in patients older than 75 years because of the risk for gastrointestinal bleeding.

Trimethoprim and sulfamethoxazole can elevate risk for hyperkalemia in patients with decreased kidney function who are taking angiotensin-converting enzyme inhibitors or angiotensin receptor blockers.

Carbamazepine, mirtazapine, oxcarbazepine, serotonin, norepinephrine reuptake inhibitors, selective serotonin reuptake inhibitors, tricyclic antidepressants, and tramadol should be used with caution because they may exacerbate or cause SIADH (syndrome of inappropriate antidiuretic hormone secretion). Sodium levels should be monitored closely when using these drugs.

Aspirin should be used with caution for primary protection against cardiovascular disease or colorectal cancer in patients older than 70 years, not 80 years, because new data show that the age at which the risk for bleeding is elevated has fallen.

Serotonin and norepinephrine reuptake inhibitors should be prescribed with caution for patients at risk of falling or sustaining fractures.

Also New

For Parkinson's disease, the general advice to avoid all antipsychotics has been revised to accept quetiapine, clozapine, and pimavanserin.

For heart failure, nondihydropyridine and calcium channel blockers should not be prescribed for patients with low ejection fractions, and nonsteroidal anti-inflammatory drugs, COX-2 inhibitors, thiazolidinediones, and dronedarone should be prescribed with caution in patients who have no symptoms of heart failure.

Macrolides (except azithromycin) or ciprofloxacin should not be prescribed with warfarin owing to bleeding risk.

Ciprofloxacin and theophylline should not be prescribed owing to increased theophylline toxicity.

For patients with reduced kidney function, use of ciprofloxacin is associated with increased risk for tendon rupture and increased central nervous system effects. Use of trimethoprim-sulfamethoxazole is associated with worsening renal failure and hyperkalemia.

"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 punitively or to excessively restrict access to medications," the authors conclude.

Limitations of the criteria are that consideration was given only to studies published in English, including observational studies, and consideration was not given to subpopulations of patients.

In an accompanying editorial, panel members Michael A. Steinman, MD, Division of Geriatrics, the University of California, San Francisco, and Donna Fick, PhD, RN, the College of Nursing and the College of Medicine, Pennsylvania State University, Hershey, remind readers that the drugs that were deemed unsafe for older patients in the 2019 criteria are potentially inappropriate, not definitely inappropriate, and advise close reading of the details.

"Optimal application of the AGS Beers Criteria involves identifying potentially inappropriate medications and where appropriate offering safer nonpharmacologic and pharmacologic therapies," they write. Clinicians should view the criteria as a starting point for individual prescribing.

"Assuring the safe and effective use of medications by older adults is a cornerstone of high-quality medical care and a superb arena for interprofessional practice. Use the AGS Beers Criteria well, and use them wisely," Steinman and Fick conclude.

For the 2019 update, an expert panel reviewed evidence published since the last update to evaluate whether to add, remove, or change specific criteria. The 13 members of the panel were physicians, pharmacists, or nurses who had participated in the 2015 update.

The panel fully reviewed 1422 articles. Of those, 377 were abstracted into evidence tables; these articles included 29 controlled clinical trials, 281 observational studies, and 67 systematic meta-analyses and/or reviews. Comments were collected from August 13, 2018, to September 4, 2018, and included 79 comments from 47 individuals, 10 comments from six pharmaceutical companies, and 155 comments from 22 peer organizations.

Beizer consults for Wolters-Klewer. Brandt consults for Institute for HealthCare Improvement, is section editor for SLACK, Inc, and received a grant from IMPAQ on MTM. Fick consults for SLACK Inc and Precision Health Economics. Hollmann reviews physicians for CVS/Caremark. Linnebur consults for the Colorado Access Pharmacy and Therapeutics Committee. Semla is an editor for Lexi-Comp. Steinman consulted for iodine.com. The remaining authors have disclosed no relevant financial relationships.

J Am Geriatr Soc. Published online January 29, 2019. Abstract, Editorial

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