american geriatrics society 2019 updated ags beers...
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CLINICAL INVESTIGATION
American Geriatrics Society 2019 Updated AGS Beers Criteria®
for Potentially Inappropriate Medication Use in Older AdultsBy 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, andregulators. Since 2011, the AGS has been the steward of thecriteria and has produced updates on a 3-year cycle. TheAGS Beers Criteria® is an explicit list of PIMs that are typi-cally best avoided by older adults in most circumstances orunder specific situations, such as in certain diseases or con-ditions. For the 2019 update, an interdisciplinary expertpanel reviewed the evidence published since the last update(2015) to determine if new criteria should be added or ifexisting criteria should be removed or undergo changes totheir recommendation, rationale, level of evidence, orstrength 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 InappropriateMedication (PIM) Use in Older Adults are widely used byclinicians, educators, researchers, healthcare administrators,and regulators. Since 2011, the AGS has been the stewardof the criteria and has produced updates on a 3-year cyclethat began in 2012.1,2 The AGS Beers Criteria® are anexplicit list of PIMs that are typically best avoided by olderadults in most circumstances or under specific situations,such as in certain diseases or conditions.
For the 2019 update, an interdisciplinary expert panelreviewed the evidence published since the last update(2015) to determine if new criteria should be added or ifexisting criteria should be removed or undergo changes totheir recommendation, rationale, level of evidence, orstrength 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 olderadults, those that should typically be avoided in olderadults with certain conditions, drugs to use with caution,drug-drug interactions, and drug dose adjustment based onkidney function.
OBJECTIVES
The specific aim was to update the 2015 AGS Beers Criteria®
using a comprehensive, systematic review and grading of theevidence on drug-related problems and adverse events inolder adults. The strategies to achieve this aim were to:
• Incorporate new evidence on PIMs included in the 2015 AGSBeers Criteria® and evidence regarding new criteria or modifi-cations of existing criteria being considered for the 2019update.
• Grade the strength and quality of each PIM statement based onthe level of evidence and strength of recommendation.
• Convene an interdisciplinary panel of 13 experts in geriatriccare and pharmacotherapy who would apply a modified Delphimethod, informed by the systematic review and grading, toreach consensus on the 2019 update.
• Incorporate exceptions in the AGS Beers Criteria® that thepanel deemed clinically appropriate. These exceptions wouldbe designed to make the criteria more individualized to clinicalpractice 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 inadults 65 years and older in all ambulatory, acute, andinstitutionalized settings of care, except for the hospiceand palliative care settings. Consumers, researchers, phar-macy benefits managers, regulators, and policymakers alsowidely use the AGS Beers Criteria®. The intention of theAGS Beers Criteria® is to improve medication selection;
From the *American Geriatrics Society, New York, New York.
Address correspondence to Mary Jordan Samuel, American GeriatricsSociety, 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, andpatterns of drug use of older adults.
As with previously published AGS Beers Criteria®, thegoal of the 2019 update continues to be improving thecare of older adults by reducing their exposure to PIMs thathave 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 aneducational tool and a quality measure—two uses that arenot always in agreement—and the panel considered andvigorously deliberated both. The AGS Beers Criteria® arenot meant to be applied in a punitive manner. Prescribingdecisions are not always clear-cut, and clinicians must con-sider multiple factors, including discontinuation of medica-tions no longer indicated. Quality measures must be clearlydefined, easily applied, and measured with limited informa-tion and, thus, although useful, cannot perfectly distinguishappropriate from inappropriate care. The panel’s review ofevidence at times identified subgroups of individuals whoshould 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 suchsubgroups cannot be easily identified through structuredand readily accessible electronic health data. As an exam-ple, the panel thought that a criterion should not beexpanded to include all adults 65 years and older whenonly certain subgroups have an adverse balance of benefitsvs harms for the medication, or conversely when a sizablesubgroup of older adults may be appropriate candidates fora medication that is otherwise problematic.
Despite past and current efforts to translate the cri-teria into practice, some controversy and myths abouttheir use in practice and policy continue to prevail. Thepanel addressed these concerns and myths by writing acompanion article to the 2015 update of the AGS BeersCriteria® and an updated 2019 short piece, which remainsthe best way to advise patients, providers, and health sys-tems on how to use (and not use) the 2019 AGS BeersCriteria®.3
METHODS
Methods used for the 2019 update of the AGS Beers Criteria®
were similar to those used in the 2015 update, with additionalemphasis on extending the rigor of the evidence review andsynthesis process.2 These methods were based on the Gradingof Recommendations Assessment, Development and Evalua-tion (GRADE) guidelines for clinical practice guideline devel-opment and are consistent with recommendations from theNational Academy of Medicine.4,5
Panel Composition
The AGS Beers Criteria® expert update panel comprised13 clinicians and included physicians, pharmacists, andnurses, 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 PharmacyQuality Alliance. Potential conflicts of interest were dis-closed at the beginning of the process and before each fullpanel call and are listed in the disclosures section of thisarticle. Panelists were recused from discussion in areas inwhich they had a potential conflict of interest.
Literature Review
Literature searches were conducted in PubMed and theCochrane Library from January 1, 2015, to September30, 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 havelow utilizations (eg, meprobamate and central α-agonistantihypertensives other than clonidine) or no longer avail-able in the United States were excluded from the literaturesearch. Searches targeted controlled clinical trials, observa-tional studies, and systematic reviews and meta-analyses,with filters for human participants, 65 years and older, andEnglish language. Clinical reviews and guidelines were alsoincluded to provide context. Case reports, case series, lettersto the editor, and editorials were excluded.
Searches identified 17,627 references; 5403 abstractswere sent to panelists for review, of which 1422 referenceswere selected for full-text review. Among these, 377 articleswere abstracted into evidence tables, including 67 systematicreviews 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 fourwork groups, each assigned a subset of the criteria. Eachwork group led the review and synthesis of evidence for itssubset of the criteria, convening via conference calls andelectronically via e-mail.
The development process began by soliciting ideas fromthe panelists about criteria that should be explored for addi-tion, modification, or removal. Suggestions from otherswere 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 mostrelevant when considering evidence for each criterion(ie, the “desired evidence” for reviewing each criterion).These discussions were not considered binding but providedguidance for keeping the evidence review and synthesisfocused on what was most clinically relevant.
Each work group reviewed abstracts from the literaturesearches for the criteria in its purview and collectivelyselected a subset for full-text review. This selection processconsidered the methodologic quality of each study, its rele-vance to older adults, and its concordance with the desiredevidence noted above. After reviewing the full text of eachselected article, the work group then decided by consensuswhich articles represented the best available evidence, basedon a balance of these same three key criteria (methodologicquality, 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 selectingsystematic reviews and meta-analyses when available,because resource constraints precluded the panel from con-ducting these types of comprehensive analyses. In general, astudy was considered relevant to older adults if the mean ormedian age of participants was older than 65 years, andespecially relevant if most or all participants were olderthan this age threshold.
Articles comprising the best available evidence wereabstracted by AGS staff into evidence tables. These tablessummarized the design, population, and findings of eachstudy, and identified markers of methodologic qualityhighlighted by the GRADE criteria for clinical trials andobservational studies and by A MeaSurement Tool toAssess Systematic Reviews (AMSTAR).6–8 Each work groupthen synthesized evidence for each criterion from the 2015to 2017 literature reviews based on GRADE guidelines andthe American College of Physicians’ evidence gradingframework (Table 1).6,9
Using evidence from the 2015 to 2017 literaturereview, evidence findings from previous updates in 2012and 2015, and clinical judgment, each work group pre-sented to the full panel its findings and suggestions forchanges (or no change) to the criteria, with ensuing discus-sion. For most criteria, a consensus emerged, to leave anexisting 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 thecriterion, the recommendation, the rationale, the quality ofevidence, and the strength of recommendation. As noted inthe GRADE guidelines, strength of recommendation ratingsincorporate a variety of considerations, including expertopinion and clinical judgment and context, and thus do notalways align with quality of evidence ratings.
After discussion of proposed changes, an anonymous Del-phi process was used to ascertain panel consensus, using afive-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 panelistswere included. The remainder were brought back for groupdiscussion, 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 includedremoving a number of medications that are used onlyrarely. 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 frominformation on more commonly used medications. Inselected cases, the panel changed the wording of certain cri-teria, recommendations, and rationale statements toimprove clarity and avoid potential misinterpretations.
The final set of criteria was reviewed by the AGS Exec-utive Committee and Clinical Practice and Models of CareCommittee and subsequently released for public comment.Comments were solicited from the general public and sentto 39 organizations. Comments were accepted over a3-week period from August 13, 2018, until September4, 2018. A total of 244 comments were received from47 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 thecriteria 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 liststhose drugs with strong anticholinergic properties that aresometimes referenced in Tables 2 through 6. Comparedwith the 2015 criteria, several drugs were removed fromTable 2 (medications that are potentially inappropriate inmost older adults), Table 3 (medications that are potentiallyinappropriate in older adults with certain conditions), andTable 4 (medications that should be used with caution).These removals are summarized in Table 8 and includeremoval of drugs no longer available in the United States(ticlopidine, oral pentazocine). In other cases, the recom-mendation was removed entirely because the panel decidedthe drug-related problem was not sufficiently unique toolder adults (eg, using stimulating medications in patientswith insomnia or avoiding medications that can lower theseizure threshold in patients with a seizure disorder). Theseremovals do not imply that these medications are now con-sidered safe for older adults; rather, they were made to helpkeep the AGS Beers Criteria® streamlined and focused onmedications 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 effectsin these conditions is weak, and because the panelexpressed concern that the intersection of this criterion withanother criterion that discourages chronic use of proton-pump inhibitors in the absence of strong indications wouldoverly restrict therapeutic options for older adults withdementia who have gastroesophageal reflux or similarissues. 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 oncardiovascular drugs include minor updates to the rationaleand a minor change to clarify the recommendation foravoiding digoxin as first-line therapy for atrial fibrillationand heart failure (Table 2). The rationale to avoid sliding-scale insulin has been revised to clarify its meaning andintent (Table 2). Glimepiride has been added to the list ofsulfonylureas with a greater risk of severe prolonged hypo-glycemia (Table 2). The duration of use of metoclopramidehas been added to be consistent with US Food and DrugAdministration labeling (Table 2).
The serotonin-norepinephrine reuptake inhibitors(SNRIs) have been added to the list of drugs to avoid inpatients 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, otherantidepressants, 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 ofavailability of safer alternatives. After reviewing and dis-cussing the evidence on antipsychotics to treat psychosis inpatients with Parkinson disease, the panel decided toremove aripiprazole as preferred and add pimavanserin.Thus, the 2019 AGS Beers Criteria® recognize quetiapine,clozapine, and pimavanserin as exceptions to the generalrecommendation to avoid all antipsychotics in older adultswith Parkinson disease (Table 3). However, none of thesethree excepted drugs is close to ideal in either efficacy orsafety, 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 whohave 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 areasymptomatic (ie, excellent control of heart failure signs andsymptoms, with or without use of medications) and avoided inolder adults who are symptomatic; and that cilostazol shouldcontinue to be avoided in older adults with heart failure ofany type.
Drugs To Be Used With Caution
Table 4 contains drugs to be used with caution in olderadults. The purpose of this table is to identify drugs forwhich there is some cause for concern, but for which theevidence and/or clinical context is as of yet insufficient tomerit inclusion in the main tables. Compared with the pre-vious update, the following changes and additionswere made:
• The age threshold beyond which extra caution is advised forusing aspirin for primary prevention of cardiovascular disease
Table 1. Designations of Quality of Evidence and Strength of Recommendationsa
Quality of EvidenceQuality of evidence ratings for each criterion are based on synthetic assessment of two complementary approaches to evaluating thequality 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 anddirectly applicable results. This also means thatfurther research is very unlikely to change ourconfidence in the estimate of effect.”
Consider the following five factors for the studiesthat comprise the best-available evidence for agiven criterion:1. Risk of bias: Severity of threats to studies’
internal validity (eg, randomized vsobservational design, potential forconfounding, bias in measurement)
2. Inconsistency: Do different studies providesimilar or different estimates of effect size
3. Indirectness: How relevant are the studies tothe clinical question at hand (eg, nature ofstudy of population, comparison group, typeof outcomes measured)
4. Imprecision: Precision of estimates of effect5. Publication bias: Risk of bias due to selective
publication of results
Moderate-quality evidence “Evidence…obtained from RCTs with importantlimitations…. In addition, evidence from well-designed controlled trials without randomization,well-designed cohort or case-control analyticstudies, and multiple time series with or withoutintervention are in this category. Moderate-quality evidence also means that furtherresearch will probably have an important effecton our confidence in the estimate of effect andmay change the estimate.”
Low-quality evidence “Evidence obtained from observational studieswould typically be rated as low quality becauseof the risk for bias. Low-quality evidence meansthat further research is very likely to have animportant effect on our confidence in theestimate of effect and will probably change theestimate. However, the quality of evidence maybe rated as moderate or even high, dependingon circumstances under which evidence isobtained from observational studies.”
# # # # #Overall quality of evidence that supports a given criterion: high, moderate, low
Strength of EvidenceStrength of evidence ratings for each criterion are based on synthetic integration of the quality of evidence, the frequency and severityof 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 ofPhysicians: summary of methods. Ann Intern Med. 2010;153:194-–199. Guyatt G, Oxman AD, Sultan S, et al. GRADE guidelines,: 11.: making an overallrating 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
Tab
le2.
2019
American
GeriatricsSo
cietyBeers
Criteria®
forPo
tentially
Inap
prop
riateM
edicationUse
inOlder
Adu
ltsa
OrganSystem
,TherapeuticCa
tegory,D
rug(s)
Ratio
nale
Recommendatio
nQu
ality
ofEvidence
Strength
ofRe
commendatio
n
Anticho
linergics
b
Firs
t-ge
neratio
nan
tihistamines
Bromph
enira
mine
Carbino
xamine
Chlorph
enira
mine
Clemas
tine
Cyp
rohe
ptad
ine
Dex
brom
phen
iramine
Dex
chlorphe
niramine
Dim
enhy
drinate
Diphe
nhyd
ramine(oral)
Dox
ylam
ine
Hyd
roxyzine
Mec
lizine
Prometha
zine
Pyrilamine
Trip
rolidine
Highlyan
ticho
linergic;
clea
ranc
eredu
cedwith
adva
nced
age,
andtoleranc
ede
velops
whe
nus
edas
hypn
otic;risk
ofco
nfus
ion,
drymou
th,c
onstipation,
andothe
ran
ticho
linergiceffectsor
toxicity
Use
ofdiph
enhy
dram
inein
situations
such
asac
ute
trea
tmen
tofs
evereallergic
reac
tionmay
beap
prop
riate.
Avo
idMod
erate
Stron
g
Antiparkins
onianag
ents
Ben
ztropine
(oral)
Trih
exyp
henidy
l
Not
reco
mmen
dedforprev
entio
nor
trea
tmen
tof
extrap
yram
idal
symptom
swith
antip
sych
otics;
more
effectiveag
ents
availablefortrea
tmen
tofP
arkins
ondise
ase
Avo
idMod
erate
Stron
g
Antispa
smod
ics
Atrop
ine(exclude
sop
htha
lmic)
Bellado
nnaalka
loids
Clidinium-chlordiaz
epox
ide
DicyclomineHom
atropine
(exclude
sop
thalmic)
Hyo
scya
mine
Meths
copo
lamine
Propa
nthe
line
Sco
polamine
Highlyan
ticho
linergic,
unce
rtaineffectiven
ess
Avo
idMod
erate
Stron
g
Antith
rombo
tics
Dipyridam
ole,
oral
shorta
cting(doe
sno
tapp
lyto
theex
tend
ed-relea
seco
mbina
tionwith
aspirin
)
May
caus
eorthos
tatic
hypo
tens
ion;
moreeffective
alternatives
available;
IVform
acce
ptab
leforus
ein
cardiacstress
testing
Avo
idMod
erate
Stron
g
Anti-infec
tive
Nitrofuran
toin
Poten
tialfor
pulm
onarytoxicity,h
epatox
icity,a
ndpe
riphe
raln
europa
thy,
espe
cially
with
long
-term
use;
saferalternatives
available
Avo
idin
individu
alswith
crea
tinine
clea
ranc
e<30
mL/min
orforlong
-term
supp
ression
Low
Stron
g
Cardiov
ascu
lar
Periphe
rala
lpha
-1bloc
kers
fortrea
tmen
tof
hype
rten
sion
Dox
azos
inPrazo
sin
Teraz
osin
Highris
kof
orthos
tatic
hypo
tens
ionan
das
sociated
harm
s,es
pecially
inolde
rad
ults;n
otreco
mmen
dedas
routinetrea
tmen
tfor
hype
rten
sion
;alte
rnativeag
ents
have
supe
riorris
k/be
nefitp
rofile
Avo
idus
eas
anan
tihyp
ertens
ive
Mod
erate
Stron
g
(Con
tinu
ed)
JAGS MONTH 2019–VOL. 00, NO. 00 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL 5
Tab
le2(C
ontd.)
OrganSystem
,TherapeuticCa
tegory,D
rug(s)
Ratio
nale
Recommendatio
nQu
ality
ofEvidence
Strength
ofRe
commendatio
n
Cen
tral
alph
a-ag
onists
Clonidine
forfirst-linetrea
tmen
tof
hype
rten
sion
Other
CNSalph
a-ag
onists
Gua
nabe
nzGua
nfac
ine
Methy
ldop
aRes
erpine
(>0.1mg/da
y)
Highris
kof
adve
rseCNSeffects;
may
caus
ebrad
ycardia
andorthos
tatic
hypo
tens
ion;
notrec
ommen
dedas
routine
trea
tmen
tfor
hype
rten
sion
Avo
idas
first-linean
tihyp
ertens
ive
Avo
idothe
rCNSalph
a-ag
onists
aslisted
Low
Low
Stron
g
Stron
g
Disop
yram
ide
May
indu
cehe
artfailure
inolde
rad
ults
beca
useof
potent
nega
tiveinotropicac
tion;
strong
lyan
ticho
linergic;
othe
ran
tiarrhy
thmic
drug
spreferred
Avo
idLo
wStron
g
Drone
darone
Worse
outcom
esha
vebe
enrepo
rted
inpa
tientstaking
dron
edaron
ewho
have
perm
anen
tatrialfi
brillationor
seve
reor
rece
ntly
deco
mpe
nsated
heartfailure.
Avo
idin
individu
alswith
perm
anen
tatria
lfibrillationor
seve
reor
rece
ntly
deco
mpe
nsated
heartfailure
High
Stron
g
Digox
inforfirst-linetrea
tmen
tofa
trial
fibrillationor
ofhe
artfailure
Use
inatria
lfibrillation:
shou
ldno
tbeus
edas
afirst-line
agen
tinatria
lfibrillation,
beca
usetherearesa
feran
dmoreeffectivealternatives
forrate
controls
uppo
rted
byhigh
-qua
lityev
iden
ce.
Use
inhe
artfailure:e
vide
nceforbe
nefits
andha
rmsof
digo
xinis
confl
ictin
gan
dof
lower
quality;m
ostb
utno
tall
oftheev
iden
ceco
ncerns
usein
HFrEF.T
here
isstrong
eviden
ceforothe
rag
ents
asfirst-linetherap
yto
redu
ceho
spita
lizations
andmortalityin
adults
with
HFrEF.In
heartfailure,h
ighe
rdo
sage
sareno
tassoc
iatedwith
additio
nalb
enefi
tand
may
increa
seris
kof
toxicity.
Dec
reas
edrena
lclearan
ceof
digo
xinmay
lead
toincrea
sedris
kof
toxiceffects;
furthe
rdo
seredu
ctionmay
bene
cessaryin
thos
ewith
stag
e4or
5ch
ronickidn
eydise
ase.
Avo
idthis
rate
controla
gent
asfirst-
linetherap
yforatria
lfibrillation
Avo
idas
first-linetherap
yforhe
art
failure
Ifus
edforatria
lfibrillationor
heart
failure,a
void
dosa
ges>0.12
5mg/da
y
Atrialfi
brillation:
low
Hea
rtfailure:
low
Dos
age
>0.12
5mg/da
y:mod
erate
Atrialfibrillation:
strong
Hea
rtfailure:
strong
Dos
age
>0.12
5mg/da
y:strong
Nife
dipine
,immed
iate
releas
ePoten
tialfor
hypo
tens
ion;
riskof
prec
ipita
tingmyo
cardial
isch
emia
Avo
idHigh
Stron
g
Amioda
rone
Effe
ctiveformaintaining
sinu
srhythm
buth
asgrea
ter
toxicitie
sthan
othe
ran
tiarrhy
thmicsus
edin
atria
lfibrillation;
may
bereas
onab
lefirst-linetherap
yin
patie
nts
with
conc
omita
nthe
artfailure
orsu
bstantialleft
ventric
ular
hype
rtroph
yifrhythm
controlispreferredov
errate
control
Avo
idas
first-linetherap
yforatria
lfibrillationun
less
patie
ntha
she
art
failure
orsu
bstantialleftv
entricular
hype
rtroph
y
High
Stron
g
Cen
tral
nervou
ssystem
Antidep
ressan
ts,a
lone
orin
combina
tion
Amitriptyline
Amox
apine
Clomipramine
Des
ipramine
Dox
epin
>6mg/da
yIm
ipramine
Highlyan
ticho
linergic,
seda
ting,
andca
useorthos
tatic
hypo
tens
ion;
safety
profi
leof
low-dos
edo
xepin
(≤6mg/da
y)co
mpa
rableto
that
ofplac
ebo
Avo
idHigh
Stron
g
6 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL MONTH 2019–VOL. 00, NO. 00 JAGS
Tab
le2(C
ontd.)
OrganSystem
,TherapeuticCa
tegory,D
rug(s)
Ratio
nale
Recommendatio
nQu
ality
ofEvidence
Strength
ofRe
commendatio
n
Nortriptyline
Parox
etine
Protriptyline
Trim
ipramine
Antipsych
otics,
first(co
nven
tiona
l)an
dse
cond
(atypica
l)ge
neratio
nIncrea
sedris
kof
cerebrov
ascu
larac
cide
nt(strok
e)an
dgrea
terrate
ofco
gnitive
declinean
dmortalityin
person
swith
demen
tiaAvo
idan
tipsych
oticsforb
ehav
ioralproblem
sof
demen
tiaor
delirium
unless
nonp
harm
acolog
icalop
tions
(eg,
beha
vioral
interven
tions
)hav
efailedor
areno
tpos
siblean
dtheolde
rad
ultisthreaten
ingsu
bstantialharm
tose
lfor
othe
rs
Avo
id,e
xcep
tinsc
hizo
phreniaor
bipo
lardiso
rder,o
rforsh
ort-term
use
asan
tiemetic
durin
gch
emothe
rapy
Mod
erate
Stron
g
Barbiturates
Amob
arbital
Butab
arbital
Butalbital
Mep
hoba
rbita
lPen
toba
rbita
lPhe
noba
rbita
lSec
obarbital
Highrate
ofph
ysical
depe
nden
ce,toleran
ceto
slee
pbe
nefits,g
reater
riskof
overdo
seat
low
dosa
ges
Avo
idHigh
Stron
g
Ben
zodiaz
epines
Sho
rtan
dinterm
ediate
actin
g:
Alprazo
lam
Estaz
olam
Loraze
pam
Oxa
zepa
mTem
azep
amTria
zolam
Long
actin
g:
Chlordiaz
epox
ide(alone
orin
combina
tion
with
amitriptylineor
clidinium)
Clona
zepa
mCloraze
pate
Diaze
pam
Fluraze
pam
Qua
zepa
m
Older
adults
have
increa
sedse
nsitivity
tobe
nzod
iaze
pine
san
dde
crea
sedmetab
olism
oflong
-ac
tingag
ents;inge
neral,allb
enzo
diaz
epines
increa
seris
kof
cogn
itive
impa
irmen
t,de
lirium,falls,fractures
,and
motor
vehiclecras
hesin
olde
rad
ults
May
beap
prop
riate
forse
izurediso
rders,
rapidey
emov
emen
tsleep
beha
vior
diso
rder,b
enzo
diaz
epine
with
draw
al,e
than
olwith
draw
al,s
everege
neralized
anxietydiso
rder,a
ndpe
riproce
durala
nesthe
sia
Avo
idMod
erate
Stron
g
Mep
roba
mate
Highrate
ofph
ysical
depe
nden
ce;s
edating
Avo
idMod
erate
Stron
gNon
benz
odiaze
pine
,ben
zodiaz
epine
rece
ptor
agon
isth
ypno
tics(ie
,“Z-drugs
”)Eszop
iclone
Zalep
lon
Zolpide
m
Non
benz
odiaze
pine
benz
odiaze
pine
rece
ptor
agon
ist
hypn
otics(ie
,Zdrug
s)ha
vead
verseev
ents
similarto
thos
eof
benz
odiaze
pine
sin
olde
rad
ults
(eg,
delirium,
falls,fractures
);increa
sedem
erge
ncyroom
visits/
hosp
italizations
;motor
vehiclecras
hes;
minim
alim
prov
emen
tinslee
platenc
yan
ddu
ratio
n
Avo
idMod
erate
Stron
g
Ergoloidmes
ylates
(deh
ydroge
natedergo
talkaloids
)Isox
suprine
Lack
ofeffica
cyAvo
idHigh
Stron
g
(Con
tinu
ed)
JAGS MONTH 2019–VOL. 00, NO. 00 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL 7
Tab
le2(C
ontd.)
OrganSystem
,TherapeuticCa
tegory,D
rug(s)
Ratio
nale
Recommendatio
nQu
ality
ofEvidence
Strength
ofRe
commendatio
n
End
ocrin
eAnd
roge
nsMethy
ltestos
terone
Tes
tosteron
e
Poten
tialfor
cardiacprob
lems;
contraindica
tedin
men
with
pros
tate
canc
erAvo
idun
less
indica
tedforco
nfirm
edhy
pogo
nadism
with
clinical
symptom
sMod
erate
Wea
k
Des
icca
tedthyroid
Con
cernsab
outc
ardiac
effects;
saferalternatives
available
Avo
idLo
wStron
g
Estroge
nswith
orwith
outp
roge
stins
Evide
nceof
carcinog
enic
potential(brea
stan
den
dometriu
m);lack
ofca
rdioprotec
tiveeffect
and
cogn
itive
protec
tionin
olde
rwom
enEvide
nceindica
testhat
vagina
lestroge
nsforthe
treatmen
tof
vagina
ldryne
ssaresa
fean
deffective;
wom
enwith
ahistoryof
brea
stca
ncer
who
dono
tres
pond
tono
nhormon
altherap
iesaread
vise
dto
discus
stheris
ksan
dbe
nefitsof
low-dos
eva
gina
lestroge
n(dos
ages
ofes
tradiol
<25μg
twicewee
kly)
with
theirh
ealth
care
prov
ider
Avo
idsystem
ices
trog
en(eg,
oral
and
topica
lpatch
)
Vag
inal
crea
mor
vagina
ltab
lets:
acce
ptab
leto
uselow-dos
eintrav
aginal
estrog
enforman
agem
ent
ofdy
spareu
nia,
recu
rren
tlow
erurinarytrac
tinfec
tions
,and
othe
rva
gina
lsym
ptom
s
Orala
ndpa
tch:
high
Vag
inal
crea
mor
vagina
ltablets:
mod
erate
Orala
ndpa
tch:
strong
Top
ical
vagina
lcrea
mor
tablets:
wea
k
Growth
horm
one
Impa
cton
body
compo
sitio
nis
smalla
ndas
sociated
with
edem
a,arthralgia,c
arpa
ltun
nels
yndrom
e,gy
neco
mas
tia,impa
iredfastinggluc
ose
Avo
id,e
xcep
tfor
patientsrig
orou
sly
diag
nose
dby
eviden
ce-bas
edcriteria
with
grow
thho
rmon
ede
ficien
cydu
eto
anes
tablishe
detiology
High
Stron
g
Insu
lin,s
lidingscale(in
sulin
regimen
sco
ntaining
only
short-or
rapid-ac
tinginsu
lindo
sedac
cordingto
curren
tblood
gluc
ose
leve
lswith
outc
oncu
rren
tuse
ofba
salo
rlong
-actinginsu
lin)
Highe
rris
kof
hypo
glycem
iawith
outimprov
emen
tin
hype
rglyce
mia
man
agem
entreg
ardles
sof
care
setting
.Avo
idinsu
linregimen
sthat
includ
eon
lysh
ort-or
rapid-
actin
ginsu
lindo
sedac
cordingto
curren
tblood
gluc
ose
leve
lswith
outc
oncu
rren
tuse
ofba
salo
rlong
-acting
insu
lin.T
hisreco
mmen
datio
ndo
esno
tapp
lyto
regimen
sthat
containba
salins
ulin
orlong
-actinginsu
lin.
Avo
idMod
erate
Stron
g
Meg
estrol
Minim
aleffect
onweigh
t;increa
sesris
kof
thrombo
ticev
ents
andpo
ssibly
deathin
olde
rad
ults
Avo
idMod
erate
Stron
g
Sulfony
lureas
,lon
gac
ting
Chlorprop
amide
Glim
epiride
Glybu
ride(alsokn
ownas
gliben
clam
ide)
Chlorprop
amide:
prolon
gedha
lf-lifein
olde
rad
ults;c
anca
useprolon
gedhy
poglycem
ia;c
ause
sSIADH
Glim
epiride
andglyb
uride:
high
erris
kof
seve
reprolon
gedhy
poglycem
iain
olde
rad
ults
Avo
idHigh
Stron
g
Gas
trointes
tinal
Metoc
lopram
ide
Can
caus
eex
trap
yram
idal
effects,
includ
ingtardive
dyskines
ia;riskmay
begrea
terin
frailo
lder
adults
and
with
prolon
gedex
posu
re
Avo
id,u
nles
sforg
astro
paresiswith
durationof
useno
ttoex
ceed
12wee
ksex
cept
inrare
case
s
Mod
erate
Stron
g
Mineral
oil,give
norally
Poten
tialfor
aspiratio
nan
dad
verseeffects;
safer
alternatives
available
Avo
idMod
erate
Stron
g
Proton-pu
mpinhibitors
Riskof
Clostrid
ium
difficile
infectionan
dbo
neloss
and
frac
tures
Avo
idsche
duledus
efor>
8wee
ksun
less
forh
igh-riskpa
tients(eg,
oral
cortico
steroids
orch
ronicNSAID
use),
eros
ivees
opha
gitis,B
arrettes
opha
gitis,
patholog
icalhy
persec
retoryco
ndition
,or
demon
stratedne
edform
ainten
ance
treatmen
t(eg
,bec
ause
offailure
ofdrug
discon
tinua
tiontrialor
H2-rece
ptor
antago
nists)
High
Stron
g
8 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL MONTH 2019–VOL. 00, NO. 00 JAGS
Tab
le2(C
ontd.)
OrganSystem
,TherapeuticCa
tegory,D
rug(s)
Ratio
nale
Recommendatio
nQu
ality
ofEvidence
Strength
ofRe
commendatio
n
Painmed
ications
Mep
eridine
Orala
nalges
icno
teffe
ctivein
dosa
gesco
mmon
lyus
ed;
may
have
high
erris
kof
neurotox
icity,inc
luding
delirium,
than
othe
rop
ioids;
saferalternatives
available
Avo
idMod
erate
Stron
g
Non
–cycloo
xyge
nase-selectiveNSAIDs,oral:
Asp
irin>32
5mg/da
yDiclofena
cDiflun
isal
Etodo
lac
Fen
oprofen
Ibup
rofen
Ketop
rofen
Mec
lofena
mate
Mefen
amic
acid
Melox
icam
Nab
umeton
eNap
roxe
nOxa
proz
inPiro
xica
mSulinda
cTolmetin
Increa
sedris
kof
gastrointestinal
blee
ding
orpe
ptic
ulce
rdise
asein
high
-riskgrou
ps,inc
luding
thos
e>75
yearsor
taking
oral
orpa
renteral
corticos
teroids,
anticoa
gulants,
oran
tiplateleta
gents;
useof
proton
-pum
pinhibitoror
misop
rostol
redu
cesbu
tdoe
sno
telim
inateris
k.Upp
erga
strointestinal
ulce
rs,g
ross
blee
ding
,orpe
rforation
caus
edby
NSAIDsoc
curin
~1%
ofpa
tientstrea
tedfor
3-6mon
thsan
din
~2%
-4%
ofpa
tientstrea
tedfor1ye
ar;
thes
etren
dsco
ntinue
with
long
erdu
ratio
nof
use.
Also
canincrea
sebloo
dpres
sure
andindu
cekidn
eyinjury.
Risks
aredo
serelated.
Avo
idch
ronicus
e,un
less
othe
ralternatives
areno
teffe
ctivean
dpa
tient
cantake
gastroprotec
tive
agen
t(proton
-pum
pinhibitoror
misop
rostol)
Mod
erate
Stron
g
Indo
metha
cin
Ketorolac
,inc
lude
spa
renteral
Increase
drisk
ofgastrointestinalbleed
ing/pep
ticulcer
diseas
eand
acute
kidney
injury
inolder
adu
ltsIndo
metha
cinis
morelikelythan
othe
rNSAID
sto
have
adve
rseCNSeffects.
Ofallthe
NSAID
s,indo
metha
cin
hasthemos
tad
verseeffects.
Avo
idMod
erate
Stron
g
Ske
letalm
usclerelaxa
nts
Carisop
rodo
lChlorzo
xazo
neCyc
lobe
nzap
rine
Metax
alon
eMetho
carbam
olOrphe
nadrine
Mos
tmus
clerelaxa
ntspo
orly
toleratedby
olde
rad
ults
beca
useso
meha
vean
ticho
linergicad
verseeffects,
seda
tion,
increa
sedris
kof
frac
tures;
effectiven
essat
dosa
gestoleratedby
olde
rad
ults
ques
tiona
ble
Avo
idMod
erate
Stron
g
Gen
itourinary
Des
mop
ressin
Highris
kof
hypo
natrem
ia;s
afer
alternativetrea
tmen
tsAvo
idfortrea
tmen
tofn
octuria
orno
cturna
lpolyu
riaMod
erate
Stron
g
Abb
reviations:C
NS,
centraln
ervo
ussystem
;HFrEF,
heartfailu
rewithredu
cedejection
fraction
;NSA
ID,n
onsteroida
lanti-inflam
matorydrug
;SIA
DH,syn
drom
eof
inap
prop
riatean
tidiuretic
horm
onesecretion.
a The
prim
arytarget
audience
isthepracticing
clinician.
The
intentions
ofthecriteria
includ
e(1)im
prov
ingtheselectionof
prescription
drug
sby
clinicians
andpa
tients;(2)evalua
ting
patterns
ofdrug
usewithin
popu
lation
s;(3)educatingclinicians
andpa
tients
onprop
erdrug
usage;an
d(4)evalua
ting
health-outcome,
quality-of-care,
cost,a
ndutilization
data.
bSeealso
criterionon
high
lyan
ticholinergican
tidepressants.
JAGS MONTH 2019–VOL. 00, NO. 00 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL 9
Tab
le3.
2019
American
GeriatricsSo
cietyBeers
Criteria®
forPo
tentially
Inap
prop
riateM
edicationUse
inOlder
Adu
ltsDue
toDrug-Disease
orDrug-Sy
ndrome
Interactions
Tha
tM
ayExa
cerbatetheDisease
orSy
ndromea
Diseaseor
Syndrome
Drug(s)
Ratio
nale
Recommendatio
nQu
ality
ofEvidence
Strength
ofRe
commendatio
n
Cardiov
ascu
lar
Hea
rtfailure
Avo
id:C
ilostaz
ol
Avo
idin
heartfailure
with
redu
ced
ejec
tionfrac
tion:
Non
dihy
drop
yridineCCBs(diltiaze
m,
verapa
mil)
Use
with
cautionin
patie
ntswith
heart
failure
who
areas
ymptom
atic;a
void
inpa
tientswith
symptom
atic
heartfailure:
NSAIDsan
dCOX-2
inhibitors
Thiaz
olidined
ione
s(pioglita
zone
,rosiglita
zone
)
Drone
darone
Poten
tialtoprom
otefluidretention
and/or
exac
erba
tehe
artfailure
(NSAIDs
andCOX-2
inhibitors,n
ondihy
drop
yridine
CCBs,thiazo
lidined
ione
s);p
oten
tialto
increa
semortalityinolde
radu
ltswith
heart
failure
(cilostaz
olan
ddron
edaron
e)
Asno
ted,
avoid
orus
ewith
caution
Cilostaz
ol:low
Non
dihy
drop
yridine
CCBs:
mod
erate
NSAIDs:
mod
erate
COX-2
inhibitors:low
Thiaz
olidined
ione
s:high
Drone
darone
:high
Cilostaz
ol:s
tron
g
Non
dihy
drop
yridine
CCBs:
strong
NSAIDs:
strong
COX-2
inhibitors:stro
ng
Thiaz
olidined
ione
s:strong
Drone
darone
:stron
g
Syn
cope
AChE
Is
Non
selectivepe
riphe
rala
lpha
-1bloc
kers
(ie,d
oxaz
osin,p
razo
sin,
terazo
sin)
Tertia
ryTCAs
Antipsych
otics:
Chlorprom
azine
Thioridaz
ine
Olanz
apine
AChE
Isca
usebrad
ycardiaan
dsh
ould
beav
oide
din
olde
rad
ults
who
sesync
ope
may
bedu
eto
brad
ycardia.
Non
selective
perip
herala
lpha
-1bloc
kers
caus
eorthos
tatic
bloo
dpres
sure
chan
gesan
dsh
ould
beav
oide
din
olde
rad
ults
who
sesync
opemay
bedu
eto
orthos
tatic
hypo
tens
ion.
Tertiary
TCAsan
dthe
antipsych
oticslistedincrea
setheriskof
orthos
tatic
hypo
tens
ionor
brad
ycardia.
Avo
idAChE
Is,T
CAs,
and
antip
sych
otics:
high
Non
selectivepe
riphe
ral
alph
a-1bloc
kers:h
igh
AChE
Isan
dTCAs:
strong
Non
selective
perip
herala
lpha
-1bloc
kers
and
antip
sych
otics:
wea
k
Cen
tral
nervou
ssystem
Delirium
Anticho
linergics
(see
Tab
le7an
dfull
crite
riaav
ailableon
www.
geria
tricscareo
nline.org.)
Antipsych
oticsb
Ben
zodiaz
epines
Corticos
teroids(orala
ndpa
renteral)c
H2-rece
ptor
antago
nists
Cim
etidine
Fam
otidine
Nizatidine
Ran
itidine
Mep
eridine
Non
benz
odiaze
pine
,ben
zodiaz
epine
rece
ptor
agon
isth
ypno
tics:
eszo
piclon
e,za
leplon
,zolpide
m
Avo
idin
olde
rad
ults
with
orat
high
risk
ofde
lirium
beca
useof
potentialo
findu
cing
orworse
ning
delirium
Avo
idan
tipsych
oticsforbe
havioral
prob
lemsof
demen
tiaan
d/or
delirium
unless
nonp
harm
acolog
ical
optio
ns(eg,
beha
vioral
interven
tions
)ha
vefailedor
areno
tpos
siblean
dtheolde
rad
ultis
threaten
ingsu
bstantialh
arm
tose
lfor
othe
rs.A
ntipsych
oticsareas
sociated
with
grea
terris
kof
cerebrov
ascu
lar
accide
nt(strok
e)an
dmortalityin
person
swith
demen
tia.
Avo
idH2-rece
ptor
antago
nists:
low
Allothe
rs:m
oderate
Stron
g
Dem
entia
orco
gnitive
impa
irmen
tAnticho
linergics
(see
Tab
le7an
dfull
crite
riaav
ailableon
www.
geria
tricscareo
nline.org)
Ben
zodiaz
epines
Non
benz
odiaze
pine
,ben
zodiaz
epine
rece
ptor
agon
isth
ypno
tics
Eszop
iclone
Avo
idbe
caus
eof
adve
rseCNSeffects
Avo
idan
tipsych
oticsforbe
havioral
prob
lemsof
demen
tiaan
d/or
delirium
unless
nonp
harm
acolog
ical
optio
ns(eg,
beha
vioral
interven
tions
)ha
vefailedor
areno
tpos
siblean
dtheolde
rad
ultis
threaten
ingsu
bstantialh
arm
tose
lfor
Avo
idMod
erate
Stron
g
10 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL MONTH 2019–VOL. 00, NO. 00 JAGS
Tab
le3(C
ontd.)
Diseaseor
Syndrome
Drug(s)
Ratio
nale
Recommendatio
nQu
ality
ofEvidence
Strength
ofRe
commendatio
n
Zalep
lon
Zolpide
mAntipsych
otics,
chronican
das
-nee
ded
useb
othe
rs.A
ntipsych
oticsareas
sociated
with
grea
terris
kof
cerebrov
ascu
lar
accide
nt(strok
e)an
dmortalityin
person
swith
demen
tia.
History
offalls
orfrac
tures
Antiepileptics
Antipsych
oticsb
Ben
zodiaz
epines
Non
benz
odiaze
pine
,ben
zodiaz
epine
rece
ptor
agon
isth
ypno
tics
Eszop
iclone
Zalep
lon
Zolpide
m
Antidep
ressan
tsTCAs
SSRIs
SNRIs
Opioids
May
caus
eatax
ia,impa
iredps
ycho
motor
func
tion,
sync
ope,
additiona
lfalls;sho
rter-
actingbe
nzod
iaze
pine
sareno
tsafer
than
long
-actingon
es.
Ifon
eofthedrug
smustbeused
,con
side
rredu
cing
useofothe
rCNS-active
med
ications
thatincrea
seriskoffalls
and
fractures
(ie,antiepileptics,op
ioid-re
ceptor
agon
ists,antipsychotics,an
tidep
ressan
ts,
nonb
enzodiazep
inean
dbe
nzod
iazepine
receptor
agon
isthypno
tics,othe
rseda
tives/hypno
tics)an
dimplem
entother
strategies
toredu
cefallrisk.Datafor
antidep
ressan
tsaremixed
butnocompe
lling
eviden
cethatcerta
inan
tidep
ressan
tsconfer
less
fallriskthan
othe
rs.
Avo
idun
less
safer
alternatives
areno
tav
ailable;
avoid
antie
pilepticsex
cept
for
seizurean
dmoo
ddiso
rders
Opioids
:avo
idex
cept
for
pain
man
agem
entinthe
setting
ofse
vere
acute
pain
(eg,
rece
ntfrac
tures
orjointrep
lace
men
t)
Opioids
:mod
erate
Allothe
rs:h
igh
Stron
g
Parkins
ondise
ase
Antiemetics
Metoc
lopram
ide
Proch
lorperaz
ine
Prometha
zine
Allan
tipsych
otics(excep
tque
tiapine
,cloz
apine,
pimav
anse
rin)
Dopam
ine-receptor
antagonistswith
potentialtoworsenparkinsonian
symptom
s
Excep
tions
:Pim
avan
serin
andcloz
apineap
pear
tobe
less
likelyto
prec
ipita
teworse
ning
ofParkins
ondise
ase.
Que
tiapine
has
only
been
stud
iedin
low-qua
lityclinical
trials
with
effica
cyco
mpa
rableto
that
ofplac
eboin
five
trials
andto
that
ofcloz
apinein
twoothe
rs.
Avo
idMod
erate
Stron
g
Gas
trointes
tinal
History
ofga
stric
ordu
oden
alulce
rsAsp
irin>32
5mg/da
yNon
–COX-2–se
lectiveNSAIDs
May
exac
erba
teex
istin
gulce
rsor
caus
ene
w/add
ition
alulce
rsAvo
idun
less
othe
ralternatives
areno
teffectivean
dpa
tient
can
take
gastroprotec
tive
agen
t(ie,p
roton-pu
mp
inhibitoror
misop
rostol)
Mod
erate
Stron
g
Kidne
y/urinarytrac
tChron
ickidn
eydise
asestag
e4or
high
er(creatinine
clea
ranc
e<30
mL/min)
NSAIDs(non
-COXan
dCOXse
lective,
oral
andpa
renteral,n
onac
etylated
salicylates
)
May
increa
seris
kof
acutekidn
eyinjury
andfurthe
rde
clineof
rena
lfun
ction
Avo
idMod
erate
Stron
g
(Con
tinu
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. Thiscriterion was also expanded to cover use of aspirin as primaryprevention of colorectal cancer. Note that this criterion doesnot apply to use of aspirin for secondary prevention of eitherdisease.
• In addition to the existing caution about dabigatran, theupdated criteria highlight caution about use of rivaroxaban fortreatment of venous thromboembolism or atrial fibrillation inadults 75 years or older.
• Tramadol was added to the list of drugs associated withhyponatremia or syndrome of inappropriate antidiuretic hor-mone secretion. The chemotherapeutic agents carboplatin, cyclo-phosphamide, cisplatin, and vincristine were removed from thislist 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 toolder adults.
• The combination dextromethorphan/quinidine was added tothe “use with caution” table on the basis of limited efficacy inpatients with behavioral symptoms of dementia without pseu-dobulbar affect while potentially increasing the risk of falls anddrug-drug interactions.
• The combination trimethoprim-sulfamethoxazole (TMP-SMX)should be used with caution by patients with reduced kidneyfunction and taking an angiotensin-converting enzyme inhibi-tor (ACEI) or angiotensin receptor blocker (ARB) because ofan increased risk of hyperkalemia.
Drug-Drug Interactions
Table 5 contains potentially clinically important drug-druginteractions to be avoided in older adults. New recommen-dations include avoiding use of opioids concurrently withbenzodiazepines and avoiding use of opioids concurrentlywith gabapentinoids (except when transitioning from theformer to the latter). Other additions to the table are inter-actions involving TMP-SMX, macrolide antibiotics, andciprofloxacin. TMP-SMX in combination with phenytoinor warfarin increases the risk of phenytoin toxicity andbleeding, respectively. Macrolides, excluding azithromycin,or ciprofloxacin in combination with warfarin increasesbleeding risk. Ciprofloxacin in combination with theophyl-line increases risk of theophylline toxicity. The concurrentuse of a combination of three or more central nervous sys-tem (CNS) agents (antidepressants, antipsychotics, benzodi-azepines, nonbenzodiazepine benzodiazepine receptoragonist hypnotics, antiepileptics, and opioids) and increasedfall risk have been collapsed into one recommendationinstead of separate recommendations for each drug class.The recommendation on avoiding concurrent use of medi-cations that increase serum potassium has been expandedto encompass a broader range of these medications.
PIMs Based on Kidney Function
Table 6 contains a list of medications that should beavoided or have their dosage reduced based on kidney func-tion. Two antibiotics have been added, ciprofloxacin andTMP-SMX, over concerns of increased CNS effects and ten-don rupture, and worsening renal function and hyperkale-mia, respectively. Dofetilide was also added because ofconcerns of corrected QT interval prolongation and torsadede pointes. The creatinine clearance lower limit at which toavoid edoxaban has been reduced to less than 15 mL/min.T
able
3(C
ontd.)
Diseaseor
Syndrome
Drug(s)
Ratio
nale
Recommendatio
nQu
ality
ofEvidence
Strength
ofRe
commendatio
n
Urin
aryinco
ntinen
ce(alltype
s)in
wom
enEstroge
noral
andtran
sdermal
(exclude
sintrav
aginal
estrog
en)
Periphe
rala
lpha
-1bloc
kers
Dox
azos
inPrazo
sin
Teraz
osin
Lack
ofeffica
cy(orale
stroge
n)an
dag
grav
ationof
inco
ntinen
ce(alpha
-1bloc
kers)
Avo
idin
wom
enEstroge
n:high
Periphe
rala
lpha
-1bloc
kers:m
oderate
Estroge
n:strong
Periphe
rala
lpha
-1bloc
kers:s
tron
g
Lower
urinarytrac
tsymptom
s,be
nign
pros
tatic
hype
rplasia
Stron
glyan
ticho
linergicdrug
s,ex
cept
antim
usca
rinicsforurinaryinco
ntinen
ce(see
Tab
le7an
dfullcrite
riaav
ailableon
www.geriatricscareo
nline.org)
May
decrea
seurinaryflow
andca
use
urinaryretention
Avo
idin
men
Mod
erate
Stron
g
Abb
reviations:AChE
I,acetylcholinesterase
inhibitor;
CCB,calcium
chan
nelblocker;
CNS,
centralnervou
ssystem
;COX,cycloo
xygena
se;NSA
ID,no
nsteroidal
anti-infl
ammatory
drug
;SN
RI,
serotonin-
norepineph
rine
reup
take
inhibitor;SSRI,selectiveserotoninreup
take
inhibitor;TCA,tricyclic
antidepressant.
a The
prim
arytarget
audience
isthepracticing
clinician.
The
intentions
ofthecriteria
includ
e(1)im
prov
ingtheselectionof
prescription
drug
sby
clinicians
andpa
tients;(2)evalua
ting
patterns
ofdrug
usewithin
popu
lation
s;(3)educatingclinicians
andpa
tients
onprop
erdrug
usage;an
d(4)evalua
ting
health-outcome,
quality-of-care,
cost,a
ndutilization
data.
bMay
berequ
ired
totreatconcurrent
schizoph
renia,
bipo
lardisorder,a
ndotherselected
mentalh
ealthcond
itions
butshou
ldbe
prescribed
inthelowesteffectivedo
sean
dshortest
possible
duration
.c Excludesinha
ledan
dtopicalforms.Orala
ndpa
renteral
corticosteroidsmay
berequ
ired
forcond
itions
such
asexacerba
tion
ofchronicob
structivepu
lmon
arydiseasebu
tshou
ldbe
prescribed
inthelowesteffective
dose
andfortheshortest
possible
duration
.
12 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL MONTH 2019–VOL. 00, NO. 00 JAGS
DISCUSSION
The 2019 AGS Beers Criteria® update contributes to thecritically 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 medicationclasses to be avoided in older adults (Table 2) and 16 cri-teria specific to more than 40 medications or medicationclasses 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 BeersCriteria®, 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 updateby the AGS and the fifth update of the AGS Beers Criteria®
since their original release.1,2,10–12 The criteria was firstpublished almost 30 years ago in 1991, making them thelongest running criteria for PIMs in older adults.
Table 4. 2019 American Geriatrics Society Beers Criteria® for Potentially Inappropriate Medications: Drugs To BeUsed With Caution in Older Adultsa
Drug(s) Rationale RecommendationQuality ofEvidence
Strength ofRecommendation
Aspirin for primary preventionof cardiovascular diseaseand colorectal cancer
Risk of major bleeding from aspirinincreases markedly in older age. Severalstudies suggest lack of net benefit whenused for primary prevention in older adultwith cardiovascular risk factors, but evidenceis not conclusive. Aspirin is generallyindicated for secondary prevention in olderadults with established cardiovasculardisease.
Use with caution inadults ≥70 years
Moderate Strong
DabigatranRivaroxaban
Increased risk of gastrointestinal bleedingcompared with warfarin and reported rateswith other direct oral anticoagulants whenused for long-term treatment of VTE or atrialfibrillation in adults ≥75 years.
Use with cautionfor treatment ofVTE or atrialfibrillation in adults≥75 years
Moderate Strong
Prasugrel Increased risk of bleeding in older adults;benefit in highest-risk older adults (eg, thosewith prior myocardial infarction or diabetesmellitus) may offset risk when used for itsapproved indication of acute coronarysyndrome to be managed with percutaneouscoronary intervention.
Use with caution inadults ≥75 years
Moderate Weak
AntipsychoticsCarbamazepineDiureticsMirtazapineOxcarbazepineSNRIsSSRIsTCAsTramadol
May exacerbate or cause SIADH orhyponatremia; monitor sodium level closelywhen starting or changing dosages in olderadults
Use with caution Moderate Strong
Dextromethorphan/quinidine
Limited efficacy in patients with behavioralsymptoms of dementia (does not apply totreatment of PBA). May increase risk of fallsand concerns with clinically significant druginteractions. Does not apply to treatment ofpseudobulbar affect.
Use with caution Moderate Strong
Trimethoprim-sulfamethoxazole
Increased risk of hyperkalemia when usedconcurrently with an ACEI or ARB inpresence of decreased creatinine clearance
Use with caution inpatients on ACEIor ARB anddecreasedcreatinineclearance
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 cliniciansand 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
Tab
le5.
2019
American
GeriatricsSo
cietyBeers
Criteria®
forPo
tentially
Clin
ically
Impo
rtan
tDrug-DrugInteractions
Tha
tSh
ould
BeAvo
ided
inOlder
Adu
lts
ObjectDrug
andClass
InteractingDrug
andClass
Risk
Ratio
nale
Recommendatio
nQu
ality
ofEvidence
Strength
ofRe
commendatio
n
RASinhibitor(ACEIs,A
RBs,
aliskiren)
orpo
tassium-spa
ring
diuretics(amilorid
e,triamterene
)
Ano
ther
RASinhibitor
(ACEIs,A
RBs,
aliskiren)
Increa
sedris
kof
hype
rkalem
iaAvo
idroutineus
ein
thos
ewith
chronickidn
eydise
asestag
e3a
orhigh
er
Mod
erate
Stron
g
Opioids
Ben
zodiaz
epines
Increa
sedris
kof
overdo
seAvo
idMod
erate
Stron
gOpioids
Gab
apen
tin,p
rega
balin
Increa
sedris
kof
seve
rese
datio
n-relatedad
verse
even
ts,inc
luding
resp
iratory
depres
sion
andde
ath
Avo
id;e
xcep
tions
arewhe
ntran
sitio
ning
from
opioid
therap
yto
gaba
pentin
orpreg
abalin,o
rwhe
nus
ingga
bape
ntinoids
toredu
ceop
ioid
dose
,alth
ough
cautionsh
ould
beus
edin
all
circum
stan
ces.
Mod
erate
Stron
g
Anticho
linergic
Anticho
linergic
Increa
sedris
kof
cogn
itive
decline
Avo
id;m
inim
izenu
mbe
rof
anticho
linergicdrug
s(Tab
le7)
Mod
erate
Stron
g
Antidepressants(TCAs,SSRIs,and
SNRIs)
Antipsy
chotics
Antiepileptics
Ben
zodiaz
epines
and
nonb
enzo
diaz
epine,
benz
odiaze
pine
rece
ptor
agon
isth
ypno
tics
(ie,“Z-drugs
”)Opioids
Any
combina
tionof
three
ormoreof
thes
eCNS-activedrug
sa
Increa
sedris
kof
falls
(all)
and
offrac
ture
(ben
zodiaz
epines
andno
nben
zodiaz
epine,
benz
odiaze
pine
rece
ptor
agon
isth
ypno
tics)
Avo
idtotalo
fthree
ormore
CNS-activedrug
sa;m
inim
ize
numbe
rof
CNS-activedrug
s
Com
bina
tions
includ
ing
benzod
iazepine
san
dno
nben
zodiazep
ine,
benzod
iazepine
receptor
agon
isthypno
ticsor
opioids:high
Allothe
rco
mbina
tions
:mod
erate
Stron
g
Corticos
teroids,
oral
orpa
renteral
NSAIDs
Increa
sedris
kof
peptic
ulce
rdise
aseor
gastrointestinal
blee
ding
Avo
id;ifn
otpo
ssible,p
rovide
gastrointestinal
protec
tion
Mod
erate
Stron
g
Lithium
ACEIs
Increa
sedris
kof
lithium
toxicity
Avo
id;m
onito
rlithium
conc
entrations
Mod
erate
Stron
g
Lithium
Loop
diuretics
Increa
sedris
kof
lithium
toxicity
Avo
id;m
onito
rlithium
conc
entrations
Mod
erate
Stron
g
Periphe
ralα
-1bloc
kers
Loop
diuretics
Increa
sedris
kof
urinary
inco
ntinen
cein
olde
rwom
enAvo
idin
olde
rwom
en,u
nles
sco
ndition
swarrant
both
drug
sMod
erate
Stron
g
Phe
nytoin
Trim
etho
prim
-sulfametho
xazo
leIncrea
sedris
kof
phen
ytoin
toxicity
Avo
idMod
erate
Stron
g
The
ophy
lline
Cim
etidine
Increa
sedris
kof
theo
phylline
toxicity
Avo
idMod
erate
Stron
g
The
ophy
lline
Ciproflox
acin
Increa
sedris
kof
theo
phylline
toxicity
Avo
idMod
erate
Stron
g
Warfarin
Amioda
rone
Increa
sedris
kof
blee
ding
Avo
idwhe
npo
ssible;ifu
sed
toge
ther,m
onito
rINR
clos
ely
Mod
erate
Stron
g
Warfarin
Ciproflox
acin
Increa
sedris
kof
blee
ding
Avo
idwhe
npo
ssible;ifu
sed
toge
ther,m
onito
rINR
clos
ely
Mod
erate
Stron
g
Warfarin
Mac
rolides
(excluding
azith
romycin)
Increa
sedris
kof
blee
ding
Avo
idwhe
npo
ssible;ifu
sed
toge
ther,m
onito
rINR
clos
ely
Mod
erate
Stron
g
14 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL MONTH 2019–VOL. 00, NO. 00 JAGS
The 2019 update has a similar number of changes tothe 2015 update but fewer changes than the 2012 update.This is likely because, with the support of the AGS and theexpert panel, the criteria have been regularly updated aboutevery 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 AGSBeers Criteria®, the panel had to have new evidence or astrong rationale, for reasons such as the literature showed achange in evidence that cast new doubt on their “avoid”status. Finally, some drugs or drug-disease combinationswere omitted because they are not disproportionately rele-vant to the older adult population; this included the criteriaon drugs to avoid in adults with chronic seizures or epilepsyand in adults with insomnia.
Four new medications or medication classes wereadded 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, andpotentially increased risk of falls in older adults. TMP-SMXwas placed in the “use with caution table” because ofincreased risk of hyperkalemia when used concurrently withan ACEI or ARB in the presence of decreased creatinineclearance.13,14 Rivaroxaban was also added to the use withcaution table for adults 75 years or older. Other importantchanges in the use with caution table included lowering theage 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 inthe 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, foundthat low-dose aspirin used for primary prevention in olderadults did not confer a reduction in mortality, disability-freesurvival, or cardiovascular events.16,17 In a few instances,the level of evidence was revised based on new literature andthe improved modified grading method. For instance,H2-receptor antagonists were removed from the list of drugsto avoid in dementia, and the evidence level for H2-receptorantagonists was decreased to low (from moderate in 2015)for drugs to avoid in delirium.18 Again in 2019, the panelclarified the language for sliding-scale insulin because thiscontinued 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 antidepressantdrug classes to avoid in persons with a history of falls orfractures.19,20 For this criterion, the level of evidence foropioids was changed to “moderate”; all other drugs remainat high. Two new drug-drug interactions involving opioidswere added, reflecting evidence of substantial harms thatcan occur when opioids are used concurrently with benzodi-azepines or gabapentinoids. Though these drug interactionsinvolving opioids are problematic in all persons, they aregrowing increasingly common and may lead to greater harmin vulnerable older adults. These concerns need to be balancedwith the need to treat chronic pain. A recent review of deathsfrom opioids concluded that the burden of opioid overdose inolder adults requires special attention, noting the largestT
able
5(C
ontd.)
ObjectDrug
andClass
InteractingDrug
andClass
Risk
Ratio
nale
Recommendatio
nQu
ality
ofEvidence
Strength
ofRe
commendatio
n
Warfarin
Trim
etho
prim
-sulfametho
xazo
leIncrea
sedris
kof
blee
ding
Avo
idwhe
npo
ssible;ifu
sed
toge
ther,m
onito
rINR
clos
ely
Mod
erate
Stron
g
Warfarin
NSAIDs
Increa
sedris
kof
blee
ding
Avo
idwhe
npo
ssible;ifu
sed
toge
ther,m
onito
rclos
elyfor
blee
ding
High
Stron
g
Abb
reviations:ACEI,an
giotensin-conv
erting
enzymeinhibitor;
ARB,an
giotensinreceptor
blocker;
CNS,
centralnervou
ssystem
;IN
R,internationa
lno
rmalized
ratio;
NSA
ID,no
nsteroidal
anti-infl
ammatorydrug
;RAS,
renin-an
giotensinsystem
;SNRI,serotonin-
norepineph
rine
reup
take
inhibitor;SSRI,selectiveserotoninreup
take
inhibitor;TCA,tricyclic
antidepressant.
a CNS-active
drug
s:an
tiepileptics;an
tipsycho
tics;b
enzodiazepines;n
onbenzod
iazepine,b
enzodiazepinereceptor
agon
isthy
pnotics;TCAs;SSRIs;S
NRIs;a
ndop
ioids.
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 TheirDosage Reduced With Varying Levels of Kidney Function in Older Adults
Medication Classand Medication
Creatinine Clearanceat Which ActionRequired, mL/min Rationale Recommendation
Quality ofEvidence
Strength ofRecommendation
Anti-infectiveCiprofloxacin <30 Increased risk of CNS effects
(eg, seizures, confusion) andtendon rupture
Doses used to treat commoninfections typically requirereduction when CrCl<30 mL/min
Moderate Strong
Trimethoprim-sulfamethoxazole
<30 Increased risk of worsening ofrenal function and hyperkalemia
Reduce dose if CrCl15-29 mL/minAvoid if CrCl <15 mL/min
Moderate Strong
Cardiovascularor hemostasis
Amiloride <30 Increased potassium anddecreased sodium
Avoid Moderate Strong
Apixaban <25 Lack of evidence for efficacyand safety in patients with aCrCl <25 mL/min
Avoid Moderate Strong
Dabigatran <30 Lack of evidence for efficacyand safety in individuals with aCrCl <30 mL/min. Label dosefor patients with a CrCl15-30 mL/min based onpharmacokinetic data.
Avoid; dose adjustment advisedwhen CrCl >30 mL/min in thepresence of drug-druginteractions
Moderate Strong
Dofetilide <60 QTc prolongation and torsadede pointes
Reduce dose if CrCl20-59 mL/minAvoid if CrCl <20 mL/min
Moderate Strong
Edoxaban 15-50<15 or >95
Lack of evidence of efficacy orsafety in patients with a CrCl<30 mL/min
Reduce dose if CrCl15-50 mL/minAvoid if CrCl <15or >95 mL/min
Moderate Strong
Enoxaparin <30 Increased risk of bleeding Reduce dose Moderate StrongFondaparinux <30 Increased risk of bleeding Avoid Moderate StrongRivaroxaban <50 Lack of efficacy or safety
evidence in patients with a CrCl<30 mL/min
Nonvalvular atrial fibrillation:reduce dose if CrCl15-50 mL/min; avoid if CrCl<15 mL/minVenous thromboembolismtreatment and for VTEprophylaxis with hip or kneereplacement: avoid if CrCl<30 mL/min
Moderate Strong
Spironolactone <30 Increased potassium Avoid Moderate StrongTriamterene <30 Increased potassium and
decreased sodiumAvoid Moderate Strong
Central nervous systemand analgesics
Duloxetine <30 Increased gastrointestinaladverse effects (nausea,diarrhea)
Avoid Moderate Weak
Gabapentin <60 CNS adverse effects Reduce dose Moderate StrongLevetiracetam ≤80 CNS adverse effects Reduce dose Moderate StrongPregabalin <60 CNS adverse effects Reduce dose Moderate StrongTramadol <30 CNS adverse effects Immediate release: reduce
doseExtended release: avoid
Low Weak
GastrointestinalCimetidine <50 Mental status changes Reduce dose Moderate StrongFamotidine <50 Mental status changes Reduce dose Moderate StrongNizatidine <50 Mental status changes Reduce dose Moderate StrongRanitidine <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 to64 (754% increase from 0.2% to 1.7%) and 65 years andolder and the absolute number of deaths in this group ismoderate.21,22
Several drug-drug interactions involving antimicrobialagents were also added to Table 5, and the recommendationto avoid concurrent use of three or more CNS-active
medications was reformatted to clarify and bring furtherattention to the increased risk of falls and other harms thatcan occur when multiple CNS-active medications arecombined.23
PIM use continues to be a serious problem in olderadults 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 aneducational tool at the bedside, and as a public health toolto improve medication safety in older adults. The AGSBeers Criteria® can increase awareness of polypharmacyand aid decision making when choosing drugs to avoid inolder adults. In a 2017 study using medical expendituredata (n = 16,588) in adults 65 years and older, poor healthstatus was associated with increased PIM use. In anotherstudy, the use of PIMs, as measured by the 2015 criteria, inpersons with dementia was 11% higher after diagnosis thanin the year of diagnosis.24,25 Benzodiazepine use remainscommon in older adults, especially in older women, despitethe fact that older adults are highly vulnerable to harmsassociated with use of these drugs.26 The challenge ofdecreasing PIM use and improving the overall quality ofmedication prescribing in older adults remains, and theAGS 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 avoidin older adults. However, they are not meant to supplantclinical 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. Thesecriteria were developed to be used in conjunction with aperson-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 BeersCriteria®, entitled “How to Use the Beers Criteria: A Guidefor Patients, Clinicians, Health Systems, and Payors,”remains an important guide for using the AGS BeersCriteria®. It reminds clinicians that medications listed in theCriteria are potentially inappropriate, rather than definitelyinappropriate for all older adults, and encourages users toread the rationale and recommendation statements for eachmedication to avoid because these statements provideimportant guidance.3 Moreover, the criteria should not beinterpreted as giving license to steer patients away fromPIMs to even worse choices. For example, the recommenda-tion to avoid chronic, regular use of NSAIDs should not be
Table 6 (Contd.)
Medication Classand Medication
Creatinine Clearanceat Which ActionRequired, mL/min Rationale Recommendation
Quality ofEvidence
Strength ofRecommendation
HyperuricemiaColchicine <30 Gastrointestinal,
neuromuscular, bone marrowtoxicity
Reduce dose; monitor foradverse 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 PropertiesAntiarrhythmic Promethazine
Disopyramide PyrilamineTriprolidine
AntidepressantsAmitriptylineAmoxapineClomipramine AntimuscarinicsDesipramine (urinary incontinence)Doxepin (>6 mg) DarifenacinImipramine FesoterodineNortriptyline FlavoxateParoxetine OxybutyninProtriptyline SolifenacinTrimipramine Tolterodine
TrospiumAntiemetics
Prochlorperazine Antiparkinsonian agentsPromethazine Benztropine
TrihexyphenidylAntihistamines (first generation)
Brompheniramine AntipsychoticsCarbinoxamine ChlorpromazineChlorpheniramine ClozapineClemastine LoxapineCyproheptadine OlanzapineDexbrompheniramine PerphenazineDexchlorpheniramine ThioridazineDimenhydrinate TrifluoperazineDiphenhydramine (oral)Doxylamine AntispasmodicsHydroxyzine Atropine (excludes
ophthalmic)Meclizine Belladonna alkaloidsClidinium-chlordiazepoxide Scopolamine (excludes
ophthalmic)DicyclomineHomatropine(excludes ophthalmic)
Skeletal muscle relaxants
Hyoscyamine CyclobenzaprineMethscopolamine OrphenadrinePropantheline
JAGS MONTH 2019–VOL. 00, NO. 00 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL 17
interpreted as an invitation to prescribe opioids in theirplace. For further reference, a 2012 article provides a caseexample on how nurses can use the criteria to improvemedication use in older adults.28
As in previous years, the panel recognizes the need tooffer older adults and their clinicians pharmacological andnonpharmacological alternatives to medications included inthe AGS Beers Criteria®. Alternatives to some of the mostcommonly implicated medications listed in the 2015 update
were published in a companion article that accompaniedthat update. Readers are encouraged to review these sugges-tions, although we acknowledge that further work needs tobe done to keep pace with updates to the criteria and thechanging landscape of drug and nondrug therapies. We alsoencourage readers to research the safety and effectiveness ofpotential 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 2015American Geriatrics Society Beers Criteria®
Medication/Criterion Reason for Removal
Independent of Diagnosis or Condition (Table 2)Ticlopidine No longer on US market; low
usePentazocine Oral no longer on US marketConsidering Disease and Syndrome Interactions (Table 3)Chronic seizures or epilepsy
BupropionChlorpromazineClozapineMaprotilineOlanzapineThioridazineThiothixeneTramadol
Not unique to older adults
DementiaH2-receptor antagonists
Weak evidence and to avoidoverly restricting therapeuticoptions for older adults withdementia who havegastroesophageal reflux orsimilar issues (given acoexisting criterion advisingagainst chronic use of PPIsexcept in specificcircumstances)
InsomniaOral decongestants
PhenylephrinePseudoephedrine
StimulantsAmphetamineArmodafinilMethylphenidateModafinil
TheobrominesTheophyllineCaffeine
Not unique to older adults
Parkinson diseaseAripiprazole
Removed as a preferredantipsychotic in older adultswith Parkinson diseasebecause of safety and efficacyconcerns
Use With Caution (Table 4)SIADH/hyponatremia
CarboplatinCyclophosphamideCisplatinVincristine
Highly specialized drugs thatfell outside the scope of thecriteria
SyncopeVasodilators
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 adultsMethscopolaminePyrilamine
Strong anticholinergic
Considering Disease and Syndrome Interactions (Table 3)History of falls or fracturesSNRI
Associated with increased riskin older adults
Parkinson diseasePimavanserin
Unlike most otherantipsychotics, the revisedcriteria consider pimavanserinacceptable for treatment ofpsychosis in Parkinson disease
Use With Caution (Table 4)Rivaroxaban Emerging evidence of
increased risk of seriousbleeding compared with otheranticoagulant options
Tramadol Risk of SIADH/hyponatremiaDextromethorphan/quinidine Limited efficacy in treating
patients with dementiasymptoms disorder in absenceof pseudobulbar affect whilepotentially increasing risk offalls and drug-drug interactions
TMP-SMX Increased risk of hyperkalemiain combination with ACEIs andARBs in patients with reducedkidney function
Clinically Important Drug-Drug Interactions (Table 5)Opioids + benzodiazepines Increased risk of overdoseOpioids +gabapentin/pregabalin
Increased risk of overdose
Phenytoin + TMP-SMX Increased risk of phenytointoxicity
Theophylline + ciprofloxacin Increased risk of theophyllinetoxicity
Warfarin + ciprofloxacin Increased risk of bleedingWarfarin + macrolides(excluding azithromycin)
Increased risk of bleeding
Warfarin + TMP-SMX Increased risk of bleedingMedications That Should Be Avoided or Have Their DosageReduced With Decreased Kidney Function (Table 6)Ciprofloxacin Increased risk of CNS effectsTMP-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 inthe 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 approacheswith a person-centered approach to care is small butgrowing.29–32 One example of the growing evidence for non-drug alternatives is in the area of care for persons with dementiaand delirium. Scales and colleagues published a 2019 compre-hensive review of evidence-based nonpharmacologicalapproaches for behavioral and psychological symptoms ofdementia. They evaluated 197 articles that included sensorypractices (eg, massage, light therapy), psychosocial practices (eg,music, pet therapy, reminiscence), and structured care protocols(eg, mouth care, bathing). Though they had recommendationsfor improving the evidence base, they concluded most practiceswere acceptable to patients, had no harmful effects, and requiredminimal 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 andstrategies for improving pharmacological care for olderadults. 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 inconjunction with other tools and management strategies forimproving medication safety and effectiveness. Moreover,other explicit criteria for evaluating PIMs in older adults,including the screening tool of older people’s prescriptionsand screening tool to alert to right treatment criteria(STOPP/START criteria) can also be valuable resources forimproving medication therapy.34
Finally, the 2019 AGS Beers Criteria® have several limi-tations. Evidence for the benefits and harms of medicationsin 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 hypertensionDigoxin for atrial fibrillation and heart failure Added wording to Drug column; modified rationale; QE
for atrial fibrillation changed to LowEstrogen with or without progestin Added “recurrent” urinary tract infectionsSliding-scale insulin Clarified definition of sliding-scale insulinMetoclopramide Added duration of use to recommendationMeperidine Removed caveat from recommendationConsidering Disease and Syndrome Interactions (Table 3)Heart failure Reorganized recommendations; separated COX-2
inhibitors from other NSAIDs; added QE and SR forCOX-2 inhibitors; changed recommendation for NSAIDs,COX-2 inhibitors, and thiazolidinediones to use withcaution in asymptomatic heart failure and to avoid insymptomatic heart failure; modified rationale
Syncope Specified “nonselective peripheral α-1 blockers”;separated rationales, QE, and SR for AChEIs andnonselective peripheral alpha-1 blockers; modified QE forACHEIs and antipsychotics
Delirium Changed “Sedative/hypnotics” to Nonbenzodiazepine,benzodiazepine receptor agonist hypnotics; changed QEof H2-receptor antagonists to low
History of fractures and falls Changed SR of opioids to strongParkinson disease Added rationale for quetiapine, clozapine, and
pimavanserinChronic kidney disease and NSAIDs Changed wording (minor) of criterion titleUse With Caution (Table 4)Aspirin as primary prevention Modified age, indication, rationale, and QEDabigatran Modified rationale and recommendationPrasugrel Modified rationaleClinically Important Drug-Drug Interactions (Table 5)The table title Dropped “Non–anti-infective”ACEIs/ARBs and hyperkalemia Changed to renin-angiotensin system inhibitorsCombination 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 CrClexclusion 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.
JAGS MONTH 2019–VOL. 00, NO. 00 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL 19
clinical trials, and so decisions on the composition of the cri-teria were often made in context of best-available, ratherthan definitive, evidence. Moreover, evidence assessmentframeworks are not perfectly tuned to drug safety evaluation,particularly for observational studies from which much ofthe relevant evidence derives.35,36 The criteria are unable toaccount for the complexity of all individuals and patient sub-populations, and thus should be taken as guidance to supportclinical decision making and not as “the final word” as towhether a specific drug is appropriate or inappropriate foran individual patient. In addition, the criteria are not meantto apply to patients at the end of life or receiving palliativecare, when risk-benefit considerations of drug therapy can bedifferent. Medications considered for inclusion in the criteriawere generally those available in the United States, and thepanel did not seek to include agents available in other coun-tries that may be equally problematic. Finally, the updatedliterature search was comprehensive but may have missedcertain 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 updateprocess had a number of important strengths. The expertpanel included members from multiple clinical disciplines,backgrounds, and types of clinical experience. The inclusionof ex-officio members from the Centers for Medicare andMedicaid Services, the Pharmacy Quality Alliance, and theNational Committee for Quality Assurance provided a wel-come level of expertise when the panel was considering theopportunities and pitfalls of translating recommendationsinto quality measures. In addition, the panel used a rigorousprocess for identifying, reviewing, and synthesizing theavailable evidence to inform the guideline update process,and benefited from the close support of the AGS.
In conclusion, the 2019 update has several importantrevisions. Important additions among the nearly 70 modifi-cations to the 2015 AGS Beer Criteria® were new medica-tions, clarifications of criteria language and rationale, andthe addition of selected drug-drug interactions.
We hope that the criteria will be used thoughtfully andwidely. To facilitate this process, we encourage healthcareprofessionals, patients, payors, and health systems to accessresources with information on the criteria, includingpatient-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 futureevidence-based updates, keeping the AGS Beers Criteria®
useful, relevant, and a valuable tool for improving thehealth and well-being of older adults.
ACKNOWLEDGMENTS
The decisions and content of the 2019 American GeriatricsSociety (AGS) Beers Criteria® are those of the AGS and thepanel 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. Wemust also acknowledge the work of the late Mark H. Beers,MD, whose vision for better quality of care for older adultsremains active through tools like the AGS Beers Criteria®.
The following organizations with special interest andexpertise in the appropriate use of medications in olderadults provided peer review of a preliminary draft of thisguideline: American Medical Directors Association—TheSociety for Post-Acute and Long-Term Care Medicine,American Academy of Home Care Medicine, AmericanAcademy of Neurology, American Academy of Nurse Prac-titioners, American Academy of Nursing, American Associ-ation of Geriatric Psychiatry, American College ofCardiology, American College of Clinical Pharmacy, Ameri-can College of Obstetrics and Gynecology, American Col-lege of Osteopathic Internists, American College ofPhysicians, American College of Surgeons, American Osteo-pathic Association, American Psychiatric Nurses Associa-tion, American Public Health Association, American Societyof Anesthesiologists, American Society of Consultant Phar-macists, American Society of Health-System Pharmacists,the Endocrine Society, Gerontological Advanced PracticeNurses Association, Gerontological Society of America, andSociety of General Internal Medicine.
Conflicts of Interest: Dr. Beizer is a consultant forWolters-Klewer. Dr. Brandt is a consultant for Institute forHealthCare Improvement (Faculty), is section editor forSLACK, Inc, and received a grant from IMPAQ on MTM;Enhanced MTM. Dr. Fick is a paid consultant for SLACKInc and Precision Health Economics. She receives fundingfrom the National Institute of Health for delirium studies.Dr. Hollmann is a paid reviewer for regulatory-requiredRhode Island physician review of Utilization Review (UR)criteria for CVS/Caremark. Dr. Linnebur is a consultant forthe Colorado Access Pharmacy and Therapeutics Commit-tee. Dr. Semla is an editor for Lexi-Comp, and Dr. Semla’swife holds commercial interest in AbbVie (at which she isalso an employee) and Abbott Labs. Dr. Semla receiveshonoraria from the American Geriatrics Society (AGS) forhis contribution as an author of Geriatrics at Your Finger-tips and for serving as a section editor for the Journal of theAmerican Geriatrics Society and is a past president andchair of the AGS Board of Directors.
Author Contributions: All panel members contributedto the concept, design, and preparation of the manuscript.
Sponsor’s Role: American Geriatrics Society staff par-ticipated in the final technical preparation and submissionof the manuscript.
Panel Members and Affiliations
The following individuals were members of the AmericanGeriatrics Society (AGS) Panel to update the 2019 AGSBeers Criteria®: Donna M. Fick, PhD, RN, FGSA, FAAN,College of Nursing and Medicine, The Pennsylvania StateUniversity, 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 Schoolof 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, StJohns University, Queens, NY; Nicole Brandt, PharmD,MBA, BCPP, BCGP, FASCP, University of Maryland, Balti-more, MD; Robert Dombrowski, PharmD, Centers forMedicare 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 ofMedicine, University of Pittsburgh and Geriatric Research,Education and Clinical Center, Veterans Affairs HealthcareSystem, 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 andPharmaceutical 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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