updated beers criteria nov 12015

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CLINICAL INVESTIGATIONS

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

By the American Geriatrics Society 2015 Beers Criteria Update Expert Panel

The 2015 American Geriatrics Society (AGS) Beers Criteriaare presented. Like the 2012 AGS Beers Criteria, theyinclude lists of potentially inappropriate medications to beavoided in older adults. New to the criteria are lists of select drugs that should be avoided or have their doseadjusted based on the individual’s kidney function andselect drug – drug interactions documented to be associatedwith harms in older adults. The specific aim was to have a

13-member interdisciplinary panel of experts in geriatriccare and pharmacotherapy update the 2012 AGS BeersCriteria using a modified Delphi method to systematicallyreview and grade the evidence and reach a consensus oneach existing and new criterion. The process followed anevidence-based approach using Institute of Medicine stan-dards. The 2015 AGS Beers Criteria are applicable to allolder adults with the exclusion of those in palliative andhospice care. Careful application of the criteria by healthprofessionals, consumers, payors, and health systemsshould lead to closer monitoring of drug use in olderadults. J Am Geriatr Soc 63:2227–2246, 2015.

Key words: Beers List; medications; Beers Criteria;drugs; older adults; polypharmacy

The American Geriatrics Society (AGS) Beers Criteriafor Potentially Inappropriate Medication (PIM) Use inOlder Adults is an explicit list of PIMs best avoided inolder adults in general and in those with certain diseasesor syndromes, prescribed at reduced dosage or with cau-tion or carefully monitored. Beers Criteria PIMs have been

found to be associated with poor health outcomes, includ-ing confusion, falls, and mortality.1,2 Avoiding PIMs in

older adults is one strategy to decrease the risk of adverseevents. Interventions using explicit criteria have beenfound to be an important component of strategies forreducing inappropriate medication usage.3 – 5

The AGS Beers Criteria for PIM Use in Older Adultsare one of the most frequently consulted sources about thesafety of prescribing medications for older adults. TheAGS Beers Criteria are used widely in geriatric clinicalcare, education, and research and in development of qual-

ity indicators. In 2011, the AGS assumed the responsibilityof updating and maintaining the Beers Criteria and, in2012, released the first update of the criteria since 2003.The AGS has made a commitment to update the criteriaregularly. The changes in the 2015 update are not asextensive as those of the previous update, but in additionto updating existing criteria, two major components havebeen added: 1) drugs for which dose adjustment isrequired based on kidney function and 2) drug – drug inter-actions. Neither of these new additions is intended to becomprehensive, because such lists would be too extensive.An interdisciplinary expert panel focused on those drugsand drug – drug interactions for which there is evidence in

older adults that they are at risk of serious harm if thedose is not adjusted or the drug interaction is overlooked.

OBJECTIVES

The specific aim was to update the 2012 AGS Beers Crite-ria using a comprehensive, systematic review and gradingof the evidence on drug-related problems and adverse drugevents in older adults. The strategies to achieve this aimwere to:

• Incorporate new evidence on currently listed PIMs andevidence from new medications or conditions notaddressed in the 2012 update.

• Incorporate two new areas of evidence on drug –

druginteractions and dose adjustments based on kidney func-tion for select medications.

• Grade the strength and quality of each PIM statementbased on the level of evidence and strength of recom-mendation.

• Convene an interdisciplinary panel of 13 experts in geri-atric care and pharmacotherapy who would apply amodified Delphi method to the systematic review and

From the Special Projects & Governance, American Geriatrics Society,New York, New York.

Address correspondence to Mary Jordan Samuel, Manager, Special Projects& Governance, American Geriatrics Society, 40 Fulton Street, 18th Floor,New York, NY 10038. E-mail: [email protected]

DOI: 10.1111/jgs.13702

JAGS 63:2227–2246, 2015

©

2015, Copyright the Authors Journal compilation © 2015, The American Geriatrics Society 0002-8614/15/$15.00


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grading to reach consensus on the updated 2015 AGSBeers Criteria.

• Incorporate needed exceptions in the criteria as thepanel deemed clinically appropriate. These exceptionswould be designed to make the criteria more individual-ized to clinical practice and be more relevant across set-tings of care.

INTENT OF CRITERIA

The primary target audience for the AGS Beers Criteria ispracticing clinicians. The criteria are intended for use in allambulatory, acute, and institutionalized settings of care forpopulations aged 65 and older in the United States, with theexception of hospice and palliative care. Consumers,researchers, pharmacy benefits managers, regulators, andpolicymakers also widely use the AGS Beers Criteria. Theintentions of the criteria are to: improve medication selec-tion; educate clinicians and patients; reduce adverse drugevents; and serve as a tool for evaluating quality of care,cost, and patterns of drug use of older adults.

The goal of the 2015 AGS Beers Criteria continues tobe improving the care of older adults by reducing theirexposure to PIMs. This is accomplished by using the criteriaas an educational tool and quality measure — two uses thatare not always in agreement. These criteria are not meant tobe applied in a punitive manner. Prescribing decisions arenot always clear-cut, and clinicians must consider multiplefactors, including discontinuation of medications no longerindicated. Quality measures must be clearly defined, easilyapplied, and measured with limited information and thus,although useful, cannot perfectly distinguish appropriatefrom inappropriate care. The panel considered and vigor-ously discussed both roles during deliberations. The panel’sreview of evidence at times identified subgroups of individu-als who should be exempt from a given criterion or towhom a specific criterion should apply. Such a criterionmay not be easily applied as a quality measure, particularlywhen such subgroups cannot be easily identified throughstructured and readily accessible electronic health data. Inthese cases, the panel felt that a criterion should not beexpanded to include all adults aged 65 and older when onlycertain subgroups have an adverse balance of benefits versusharms for the medication or conversely may be appropriatecandidates for a medication that is otherwise problematic.

Despite past and current efforts to translate the crite-ria into practice, some controversy and myths about theiruse in practice and policy continue to prevail. The panel

addressed these concerns and myths by writing a compan-ion piece to the updated criteria to address the best wayfor patients, providers, and health systems to use (and notuse) the 2015 AGS Beers Criteria. Alternative suggestionsto medications included in the current Use of High-RiskMedications in the Elderly and Potentially Harmful Drug-Disease Interactions in the Elderly quality measures arepresented in another companion paper. Both papers willbe published online in this journal.

METHODS

For this new update, the AGS employed a well-testedframework that has long been used for development of

clinical practice guidelines.6,7 Specifically, the frameworkinvolved the appointment of a 13-member interdisciplinaryexpert panel with relevant clinical expertise and experienceand an understanding of how the criteria have been previ-ously used. This framework also involved a developmentprocess that included a systematic literature review andevaluation of the evidence base by the expert panel.Finally, the Institute of Medicine’s 2011 report on devel-

oping practice guidelines, which included a period for pub-lic comments, guided the framework. These threeframework principles are described in greater detail below.

PANEL SELECTION

A panel with expertise in geriatric medicine, nursing, phar-macy practice, research, and quality measures was con-vened comprising members of the previous panel and newmembers. Other factors that influenced selection of panelmembers were the desire to have interdisciplinary represen-tation, a range of medical expertise, and representationfrom different practice settings (e.g., long-term care, ambu-latory care, geriatric mental health, palliative care and hos-pice). In addition to the 13-member panel, representativesfrom the Centers for Medicare and Medicaid Services,National Committee for Quality Assurance, and PharmacyQuality Alliance were invited to serve as ex-officio mem-bers.

Each expert panel member completed a disclosureform at the beginning of the guideline process that wasshared with the entire panel at the start of each panelmeeting and call. Panel members who disclosed affiliationsor financial interests with commercial entities are listed inthe disclosures section of this article. Panel members wereasked to recuse themselves from discussions if they had apotential conflict of interest.

LITERATURE SEARCH

The literature from August 1, 2011 (the end of the previ-ous panel’s search) to July 1, 2014, was searched to iden-tify published systematic reviews, meta-analyses,randomized controlled trials, and observational studiesthat were relevant to the project. The initial literaturesearch was conducted on PubMed and the CochraneLibrary. The drugs, drug classes, and conditions includedin the 2012 criteria were used as initial search terms andwere generally focused on “adverse drug events” and “ad-verse drug reactions.” Individual drugs, drug classes, and

conditions were searched individually and in combination.Search filters included human subjects, English language,and aged 65 and older. Case reports, case series, editorials,and letters were excluded. Clinical reviews were includedfor initial screening as potential background informationand for reference list review. The initial searches identified20,748 citations, of which 6,719 were selected for prelimi-nary abstract review. The panel co-chairs reviewed 3,387citations and abstracts, of which 2,199 were excluded fornot meeting the study purpose or not containing primarydata. At the time of the panel’s face-to-face meeting, theco-chairs had selected 1,188 unduplicated citations for thefull panel review. Subsequent searches (defined by panel

workgroups) were conducted until December 15, 2014;

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some of these searches included studies published in theprior 10 years. The AGS also gave its members and mem-bers of the public a chance to submit evidence they felt thepanel should consider. Any evidence submitted had to beevidence based and published in a peer-reviewed journal.Panel members reviewed abstracts, and evidence tableswere developed for 342 studies, including 60 systematicreviews and meta-analyses, 49 randomized controlled tri-

als, and 233 observational and other types of publications.

DEVELOPMENT PROCESS

Since the previous update, the AGS had created a groupto monitor the literature and to advise the 2015 expertpanel of any articles relevant to the 2012 criteria andrespond accordingly. Two members of the expert panel(MS, SL) led this group, which was composed of mem-bers of the AGS Clinical Practice Committee and otherexpert members of AGS. The 2015 expert panel convenedfor a 2-day in-person meeting on July 28 – 29, 2014, toreview the groups’ findings and the results of the litera-ture search. Panel discussions were used to define termsand to address questions of consistency, inclusion of infre-quently used drugs, strategies for evaluating the evidence,consolidation or expansion of individual criterion, anddevelopment of renal dosage and drug – drug interactiontables. The panel then split into four groups, with eachassigned a specific set of criteria for evaluation. Groupswere assigned as closely as possible according to specificarea of clinical expertise (e.g., cardiovascular, central ner-vous system). Groups reviewed the literature search,selected citations relevant to their assigned criteria, anddetermined which citations they wanted to see the full-text article for and which should be abstracted into anevidence table. The groups then presented their findings

to the full panel for comment and consensus. After themeeting, each group participated in a series of conferencecalls to continue the literature selection process andresolve any questions.

An independent researcher led the effort to prepareevidence tables and relied on the assistance of one otherresearcher for the initial drafts of evidence tables. The evi-dence tables included a summary of the study, as well as aquality rating and rating of the risk of bias for selectedarticles. The quality rating system was based on theCochrane Risk of Bias8 and Jadad scoring system.9 Theratings were based on six critical elements: evidence of bal-anced allocation, allocation concealment, blinded outcome

assessment, completeness of outcome data, selective out-come reporting, and other sources of bias. Following theCochrane approach, each article was assigned a qualityscore (1 – 6 points) and a risk-of-bias rating. Low risk of bias was indicated by a low risk of bias in all six domains,unclear risk of bias was indicated by an unclear rating onone or more domains (others low) or a high risk of biason one domain (others low or unclear), and high risk of bias was indicated by a high risk of bias on two or moredomains. The independent researcher reviewed all evidencetables and proposed quality and risk-of-bias ratings beforethey were distributed to the expert panel to use for theGrades of Recommendation Assessment, Development,

and Evaluation

10

(GRADE) rating process.

Each panelist independently rated the quality of evi-dence and strength of recommendation for each criterionusing the American College of Physicians’ Guideline Grad-ing System11 (Table 1), which is based on the GRADEscheme developed previously. AGS staff compiled the pan-elist ratings for each group and returned them to thatgroup, which then reached consensus in a conference call.Additional literature was obtained and included as needed.

When group consensus could not be reached, the full panelreviewed the ratings and worked through any differencesuntil consensus was reached. The panel judged each crite-rion as being a strong or weak recommendation on thebasis of the quality of supporting evidence, the frequencyand severity of harms, and the availability of better treat-ment alternatives. For some criteria, the panel provided a“strong” recommendation, even though the quality of evi-dence was low or moderate, when the potential for harmwas substantial and safer or more-effective alternativeswere available.

After consensus was reached within the expert panel,the updated guidelines were circulated for peer review torelevant organizations and societies and posted to the AGSwebsite for public comment. Organizations that partici-pated in peer review are listed in the Acknowledgmentssection of this article. The panel reviewed and addressedall comments.

Table 1. Designations of Quality of Evidence andStrength of Recommendations

Quality of EvidenceHigh Evidence includes consistent results from well-

designed, well-conducted studies in representativepopulations that directly assess effects on healthoutcomes (≥2 consistent, higher-quality randomizedcontrolled trials or multiple, consistent observationalstudies with no significant methodological flawsshowing large effects)

Moderate Evidence is sufficient to determine risks of adverseoutcomes, but the number, quality, size, or consistencyof included studies; generalizability to routine practice;or indirect nature of the evidence on health outcomes(≥1 higher-quality trial with >100 participants; ≥2higher-quality trials with some inconsistency; ≥2consistent, lower-quality trials; or multiple, consistentobservational studies with no significantmethodological flaws showing at least moderateeffects) limits the strength of the evidence

Low Evidence is insufficient to assess harms or risks inhealth outcomes because of limited number or powerof studies, large and unexplained inconsistencybetween higher-quality studies, important flaws instudy design or conduct, gaps in the chain of evidence,or lack of information on important health outcomes

Strength of RecommendationStrong Benefits clearly outweigh harms, adverse events, and

risks, or harms, adverse events, and risks clearlyoutweigh benefits

Weak Benefits may not outweigh harms, adverse events,and risks

Insufficient Evidence inadequate to determine net harms, adverseevents, and risks

Adapted from

11

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RESULTS

The panel’s recommendations are presented in Tables 2 – 7. References, as evidence tables, supporting the recom-mendations appear in the online appendix posted on theAGS website (www.americangeriatrics.org). Consistentwith the 2012 AGS Beers Criteria, Tables 2 – 4 list PIMSfor older adults outside the palliative care and hospice

setting, including medications to avoid for many or mostolder adults (Table 2); medications for older adults withspecific diseases or syndromes to avoid (Table 3); andmedications to be used with caution (Table 4). New tothe AGS Beers Criteria are potentially clinically impor-tant non-anti-infective drug – drug interactions (Table 5)and non-anti-infective medications to avoid or thedosage of which should be adjusted based on the indi-vidual’s kidney function (Table 6). Tables 8-10 documentthe differences between the 2012 and 2015 AGS BeersCriteria.

Noteworthy Changes to PIMs and Older Adults

Based on two retrospective studies, the recommendation toavoid the anti-infective nitrofurantoin in individuals with acreatinine clearance of less than 60 mL/min has beenrevised, given evidence that it can be used with relativesafety and efficacy in individuals with a creatinine clear-ance of 30 mL/min or greater. The long-term use of nitro-furantoin for suppression should still be avoided becauseof concerns of irreversible pulmonary fibrosis, liver toxic-ity, and peripheral neuropathy (Table 2).

The recommendation to avoid antiarrhythmic drugs(Classes 1a, 1c, III) as first-line treatment for atrial fibrilla-tion has been removed in light of new evidence and guide-lines that suggest that rhythm control can have outcomes

as good as or better than those with rate control. Never-theless, certain antiarrhythmics remain in the criteria.Amiodarone is still to be avoided as first-line therapy foratrial fibrillation unless the individual has heart failure orsubstantial left ventricular hypertrophy. Dronedarone is tobe avoided in individuals with permanent atrial fibrillationor with severe or recently decompensated heart failure.Disopyramide, a Class 1a antiarrhythmic drug, should alsobe avoided because it is highly anticholinergic. Digoxinshould be avoided as first-line therapy for atrial fibrillationor heart failure and should not be prescribed in daily dosesgreater than 0.125 mg for any indication.

The nonbenzodiazepine, benzodiazepine receptor ago-

nist hypnotics (eszopiclone, zaleplon, zolpidem) are to beavoided without consideration of duration of use becauseof their association with harms balanced with their mini-mal efficacy in treating insomnia. The recommendation toavoid sliding-scale insulin is retained, and further clarifica-tion of what constitutes a sliding-scale regimen is pro-vided. An addition to Table 2 is the avoidance of the useof proton-pump inhibitors beyond 8 weeks without justifi-cation. Multiple studies and five systematic reviews andmeta-analyses support an association between proton-pump inhibitor exposure and Clostridium difficile infec-tion, bone loss, and fractures. Desmopressin for the treat-ment of nocturia or nocturnal polyuria is another addition

because of the high risk of hyponatremia.

Noteworthy Changes to Drug – Disease and Drug – Syndrome PIMS

The nonbenzodiazepine, benzodiazepine receptor agonisthypnotics have been added to the list of drugs to avoid inindividuals with dementia or cognitive impairment. Opi-oids have been added to the list of central nervous system(CNS) medications that should be avoided in individuals

with a history of falls or fractures. Antipsychotics are tobe avoided as first-line treatment of delirium because of conflicting evidence on their effectiveness and the potentialfor adverse drug effects (Table 3).

Drugs to Be Used with Caution

Table 4, medications to be used with caution in olderadults, has not been changed. The panel determined thatthe medications listed in this table did not rise to the levelof meriting inclusion in Tables 2 and 3 and should not beconsidered key elements of the criteria. Nevertheless, thepanel believed that there was sufficient uncertainty or con-cern about the balance of benefits and harms for the listedmedications that clinicians should be aware of potentialproblems and exercise caution when considering their use.

Drug – Drug Interactions

New to the AGS Beers Criteria are drug – drug interactions(excluding anti-infectives) that are highly associated withharmful outcomes in older adults.12 The list is selective,and not comprehensive, and is not intended to diminishthe clinical importance of known drug – drug interactionsnot listed. Examples of drug – drug interactions included inthis new section include peripheral alpha-1 blockers usedin combination with loop diuretics, which increases the

risk of urinary incontinence in women, and taking three ormore CNS-active drugs concomitantly, which increases therisk of falls. Other interactions manifest as extensions of both drugs’ known pharmacological effects (e.g., angioten-sin-converting enzyme inhibitors (ACEIs) and potassium-sparing diuretics without indications for use in systolicheart failure (amiloride and triamterene), which togetherincrease risk of hyperkalemia). Other interactions increasethe risk of a drug’s toxicity (e.g., lithium in combinationwith an ACEI or loop diuretics) (Table 5).

PIMs Based on Kidney Function

Also new for 2015 are drugs that should be avoided or forwhich the dose should be adjusted in individuals with aspecific degree of kidney impairment to avoid harm. Thislist was adapted from published consensus guidelines thatan expert group including two AGS Beers Criteria pan-elists developed.13 The AGS Beers panel reviewed the evi-dence and selected medications from these earlierconsensus guidelines for inclusion; added additional medi-cations, including several anticoagulants; and includedspironolactone and triamterene, which in the 2012 criteriahad been listed in Tables 2 and 3, respectively. The crea-tinine clearance thresholds below which use of apixaban,edoxaban, and rivaroxaban are to be avoided are based onclinical trial exclusion criteria and may not be the same as


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T a b l e 2

. 2 0 1 5 A m e r i c a n G e r i a t r i c s S o c i e t y B e e r s C r i t e r i a f o r P o t e n t i a l l y I n a p p r o p r i a t e M e d i c a t i o n U s e i n O l d e r A d u l t s

O r g a n

S y s

t e m

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t i c

C a

t e g o r y

, D r u g s

R a

t i o n a

l e

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d a

t i o n

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l i t y o

f

E v

i d e n c e

S t r e n g

t h o

f

R e c o m m e n

d a

t i o n

A n t i c h o l i n e r g i c s

F i r s t - g e n e r a t i o n a n t i h i s t a m i n e s

B r o m p h e n i r a m i n e

C a r b i n o x a m i n e

C h l o r p h e n i r a m i n e

C l e m a s t i n e

C y p r o h e p t a d i n e

D e x b r o m p h e n i r a m i n e

D e x c h l o r p h e n i r a m i n e

D i m e n h y d r i n a t e

D i p h e n h y d r a m i n e ( o r a l )

D o x y l a m i n e

H y d r o x y z i n e

M e c l i z i n e

P r o m e t h a z i n e

T r i p r o l i d i n e

H i g

h l y a n t i c h o l i n e r g i c ; c l e a r a n c e r e d u c e d w i t h

a d v a n c e d a g e , a n d t o l e r a n c e d e v e l o p s w h e n

u s e d a s h y p n o t i c ; r i s k o f c o n f u s i o n ,

d r y m o u t h ,

c o n s t i p a t i o n , a n d o t h e r a n t i c h o l i n e r g i c e f f e c t s

o r

t o x

i c i t y

U s e o f d i p h e n h y d r a m i n e i n s i t u a t i o n s s u c h a s

a c u

t e t r e a t m e n t o f s e v e r e a l l e r g i c r e a c t i o n m a y

b e

a p p r o p r i a t e

A v o i d

M o d e r a t e

S t r o n g

A n t i p a r k i n s o n i a n a g e n t s

B e n z t r o p i n e ( o r a l )

T r i h e x y p h e n i d y l

N o t r e c o m m e n d e d f o r p r e v e n t i o n o f

e x t

r a p y r a m i d a l s y m p t o m s w i t h a n t i p s y c h o t i c s ;

m o

r e - e f f e c t i v e a g e n t s a v a i l a b l e f o r t r e a t m e n t o

f

P a r k i n s o n d i s e a s e

A v o i d

M o d e r a t e

S t r o n g

A n t i s p a s m o d i c s

A t r o p i n e ( e x c l u d e s o p h t h a l m i c )

B e l l a d o n n a a l k a l o i d s

C l i d i n i u m - C h l o r d i a z e p o x i d e

D i c y c l o m i n e

H y o s c y a m i n e

P r o p a n t h e l i n e

S c o p o l a m i n e

H i g

h l y a n t i c h o l i n e r g i c , u n c e r t a i n e f f e c t i v e n e s s

A v o i d

M o d e r a t e

S t r o n g

A n t i t h r o m b o t i c s

D i p y r i d a m o l e , o r a l s h o r t - a c t i n g

( d o e s n o t a p p l y t o t h e e x t e n d e d -

r e l e a s e c o m b i n a t i o n w i t h a s p i r i n )

M a

y c a u s e o r t h o s t a t i c h y p o t e n s i o n ; m o r e

e f f e c t i v e a l t e r n a t i v e s a v a i l a b l e ; i n t r a v e n o u s f o r m

a c c

e p t a b l e f o r u s e i n c a r d i a c s t r e s s t e s t i n g

A v o i d

M o d e r a t e

S t r o n g

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S a f e r , e f f e c t i v e a l t e r n a t i v e s a v a i l a b l e

A v o i d

M o d e r a t e

S t r o n g

A n t i - i n f e c t i v e

N i t r o f u r a n t o i n

P o t e n t i a l f o r p u l m o n a r y t o x i c i t y ,

h e p a t o x i c i t y ,

a n d p e r i p h e r a l n e u r o p a t h y , e s p e c i a l l y w i t h l o n g -

t e r m

u s e ; s a f e r a l t e r n a t i v e s a v a i l a b l e

A v o i d i n i n d i v i d u a l s w i t h c r e a t i n i n e

c l e a r a n c e < 3 0 m L / m i n o r f o r l o n g - t e r m

s u p p r e s s i o n o f b a c t e r i a

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S t r o n g

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P e r i p h e r a l a l p h a - 1 b l o c k e r s

D o x a z o s i n

P r a z o s i n

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H i g

h r i s k o f o r t h o s t a t i c h y p o t e n s i o n ; n o t

r e c

o m m e n d e d a s r o u t i n e t r e a t m e n t f o r

h y p e r t e n s i o n ; a l t e r n a t i v e a g e n t s h a v e s u p e r i o r

r i s k – b e n e fi t p r o fi l e

A v o i d u s e a s a n a n t i h y p e r t e n s i v e

M o d e r a t e

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( C o n t i n u e d )



6/20

T a b l e 2 ( C o n t d . )

O r g a n

S y s

t e m

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f

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t h o

f

R e c o m m e n

d a

t i o n

C e n t r a l a l p h a b l o c k e r s

C l o n i d i n e

G u a n a b e n z

G u a n f a c i n e

M e t h y l d o p a

R e s e r p i n e ( > 0 . 1 m g / d )

H i g

h r i s k o f a d v e r s e C N S e f f e c t s ; m a y c a u s e

b r a

d y c a r d i a a n d o r t h o s t a t i c h y p o t e n s i o n ; n o t

r e c

o m m e n d e d a s r o u t i n e t r e a t m e n t f o r

h y p e r t e n s i o n

A v o i d c l o n i d i n e a s fi r s t - l i n e

a n t i h y p e r t e n s i v e

A v o i d o t h e r s a s l i s t e d

L o w

S t r o n g

D i s o p y r a m i d e

D i s

o p y r a m i d e i s a p o t e n t n e g a t i v e i n o t r o p e a n d

t h e

r e f o r e m a y i n d u c e h e a r t f a i l u r e i n o l d e r

a d u l t s ; s t r o n g l y a n t i c h o l i n e r g i c ; o t h e r

a n t i a r r h y t h m i c d r u g s p r e f e r r e d

A v o i d

L o w

S t r o n g

D r o n e d a r o n e

W o

r s e o u t c o m e s h a v e b e e n r e p o r t e d i n p a t i e n t s

t a k

i n g d r o n e d a r o n e w h o h a v e p e r m a n e n t a t r i a l

fi b r i l l a t i o n o r s e v e r e o r r e c e n t l y d e c o m p e n s a t e

d

h e a r t f a i l u r e

A v o i d i n i n d i v i d u a l s w i t h p e r m a n e n t a t r i a l

fi b r i l l a t i o n o r s e v e r e o r r e c e n t l y

d e c o m p e n s a t e d h e a r t f a i l u r e

H i g h

S t r o n g

D i g o x i n

U s e i n a t r i a l fi b r i l l a t i o n : s h o u l d n o t b e u s e d a s

a

fi r s

t - l i n e a g e n t i n a t r i a l fi b r i l l a t i o n ,

b e c a u s e

m o

r e - e f f e c t i v e a l t e r n a t i v e s e x i s t a n d i t m a y b e

a s s

o c i a t e d w i t h i n c r e a s e d m o r t a l i t y

A v o i d a s fi r s t - l i n e t h e r a p y f o r a t r i a l

fi b r i l l a t i o n

A t r i a l fi b r i l l a t i o n : m o d e r a t e

A t r i a l fi b r i l l a t i o n : s t r o n g

U s e i n h e a r t f a i l u r e : q u e s t i o n a b l e e f f e c t s o n r i s k

o f h o s p i t a l i z a t i o n a n d m a y b e a s s o c i a t e d w i t h

i n c

r e a s e d m o r t a l i t y i n o l d e r a d u l t s w i t h h e a r t

f a i l u r e ; i n h e a r t f a i l u r e ,

h i g h e r d o s a g e s n o t

a s s

o c i a t e d w i t h a d d i t i o n a l b e n e fi t a n d m a y

i n c

r e a s e r i s k o f t o x i c i t y

A v o i d a s fi r s t - l i n e t h e r a p y f o r h e a r t f a i l u r e

H e a r t f a i l u r e : l o w

H e a r t f a i l u r e : s t r o n g

D e c r e a s e d r e n a l c l e a r a n c e o f d i g o x i n m a y l e a d

t o i n c r e a s e d r i s k o f t o x i c e f f e c t s ; f u r t h e r d o s e

r e d

u c t i o n m a y b e n e c e s s a r y i n p a t i e n t s w i t h

S t a

g e 4 o r 5 c h r o n i c k i d n e y d i s e a s e

I f u s e d f o r a t r i a l fi b r i l l a t i o n o r h e a r t

f a i l u r e , a v o i d d o s a g e s > 0 . 1

2 5 m g / d

D o s a g e > 0 . 1

2 5 m g / d : m o d e r a t e

D o s a g e > 0 . 1

2 5 m g / d :

s t r o n g

N i f e d i p i n e ,

i m m e d i a t e

r e l e a s e

P o t e n t i a l f o r h y p o t e n s i o n ; r i s k o f p r e c i p i t a t i n g

m y

o c a r d i a l i s c h e m i a

A v o i d

H i g h

S t r o n g

A m i o d a r o n e

A m

i o d a r o n e i s e f f e c t i v e f o r m a i n t a i n i n g s i n u s

r h y

t h m

b u t h a s g r e a t e r t o x i c i t i e s t h a n o t h e r

a n t i a r r h y t h m i c s u s e d i n a t r i a l fi b r i l l a t i o n ; i t m a y

b e

r e a s o n a b l e fi r s t - l i n e t h e r a p y i n p a t i e n t s w i t h

c o n c o m i t a n t h e a r t f a i l u r e o r s u b s t a n t i a l l e f t

v e n

t r i c u l a r h y p e r t r o p h y i f r h y t h m

c o n t r o l i s

p r e

f e r r e d o v e r r a t e c o n t r o l

A v o i d a m i o d a r o n e a s fi r s t - l i n e t h e r a p y

f o r

a t r i a l fi b r i l l a t i o n u n l e s s p a t i e n t h a s h e a

r t

f a i l u r e o r s u b s t a n t i a l l e f t v e n t r i c u l a r

h y p e r t r o p h y

H i g h

S t r o n g

C e n t r a l n e r v o u s s y s t e m




7/20

T a b l e 2 ( C o n t d . )

O r g a n

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t e m

,

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t i c

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t e g o r y

, D r u g s

R a

t i o n a

l e

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d a

t i o n

Q u a

l i t y o

f

E v

i d e n c e

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t h o

f

R e c o m m e n

d a

t i o n

A n t i d e p r e s s a n t s , a l o n e o r i n

c o m b i n a t i o n

A m i t r i p t y l i n e

A m o x a p i n e

C l o m i p r a m i n e

D e s i p r a m i n e

D o x e p i n > 6 m g / d

I m i p r a m i n e

N o r t r i p t y l i n e

P a r o x e t i n e

P r o t r i p t y l i n e

T r i m i p r a m i n e

H i g

h l y a n t i c h o l i n e r g i c , s e d a t i n g , a n d c a u s e

o r t

h o s t a t i c h y p o t e n s i o n ; s a f e t y p r o fi l e o f l o w -

d o s e d o x e p i n ( ≤ 6 m g / d ) c o m p a r a b l e w i t h t h a t

o f

p l a

c e b o

A v o i d

H i g h

S t r o n g

A n t i p s y c h o t i c s ,

fi r s t - ( c o n v e n t i o n a l )

a n d s e c o n d - ( a t y p i c a l ) g e n e r a t i o n

I n c

r e a s e d r i s k o f c e r e b r o v a s c u l a r a c c i d e n t

( s t r o k e ) a n d g r e a t e r r a t e o f c o g n i t i v e d e c l i n e

a n d m o r t a l i t y i n p e r s o n s w i t h d e m e n t i a

A v o i d a n t i p s y c h o t i c s f o r b e h a v i o r a l p r o b l e m s o f

d e m e n t i a o r d e l i r i u m

u n l e s s n o n p h a r m a c o l o g i c a l

o p t i o n s ( e . g . ,

b e h a v i o r a l i n t e r v e n t i o n s ) h a v e

f a i l e d o r a r e n o t p o s s i b l e a n d

t h e o l d e r a d u l t i s

t h r

e a t e n i n g s u b s t a n t i a l h a r m

t o s e l f o r o t h e r s

A v o i d , e x c e p t f o r s c h i z o p h r e n i a ,

b i p o l a

r

d i s o r d e r , o r s h o r t - t e r m

u s e a s a n t i e m e t i c

d u r i n g c h e m o t h e r a p y

M o d e r a t e

S t r o n g

B a r b i t u r a t e s

A m o b a r b i t a l

B u t a b a r b i t a l

B u t a l b i t a l

M e p h o b a r b i t a l

P e n t o b a r b i t a l

P h e n o b a r b i t a l

S e c o b a r b i t a l

H i g

h r a t e o f p h y s i c a l d e p e n d e n c e ,

t o l e r a n c e t o

s l e

e p b e n e fi t s , g r e a t e r r i s k o f o v e r d o s e a t l o w

d o s a g e s

A v o i d

H i g h

S t r o n g

B e n z o d i a z e p i n e s

S h o r t - a n d i n t e r m e d i a t e - a c t i n g

A l p r a z o l a m

E s t a z o l a m

L o r a z e p a m

O x a z e p a m

T e m a z e p a m

T r i a z o l a m

O l d

e r a d u l t s h a v e i n c r e a s e d s e n s i t i v i t y t o

b e n z o d i a z e p i n e s a n d d e c r e a s e d m e t a b o l i s m o f

l o n

g - a c t i n g a g e n t s ; i n g e n e r a l , a l l

b e n z o d i a z e p i n e s i n c r e a s e r i s k o f c o g n i t i v e

i m p a i r m e n t , d e l i r i u m ,

f a l l s ,

f r a c t u r e s , a n d m o t o r

v e h i c l e c r a s h e s i n o l d e r a d u l t s

A v o i d

M o d e r a t e

S t r o n g




8/20

T a b l e 2 ( C o n t d . )

O r g a n

S y s

t e m

,

T h e r a p e u

t i c

C a

t e g o r y

, D r u g s

R a

t i o n a

l e

R e c o m m e n

d a

t i o n

Q u a

l i t y o

f

E v

i d e n c e

S t r e n g

t h o

f

R e c o m m e n

d a

t i o n

L o n g - a c t i n g

C l o r a z e p a t e

C h l o r d i a z e p o x i d e ( a l o n e o r i n

c o m b i n a t i o n w i t h a m i t r i p t y l i n e o r

c l i d i n i u m )

C l o n a z e p a m

D i a z e p a m

F l u r a z e p a m

Q u a z e p a m

M a

y b e a p p r o p r i a t e f o r s e i z u r e d i s o r d e r s , r a p i d

e y e m o v e m e n t s l e e p d i s o r d e r s ,

b e n z o d i a z e p i n e

w i t

h d r a w a l , e t h a n o l w i t h d r a w a l , s e v e r e

g e n e r a l i z e d a n x i e t y d i s o r d e r , a n d p e r i p r o c e d u r a l

a n e s t h e s i a

M e p r o b a m a t e

H i g

h r a t e o f p h y s i c a l d e p e n d e n c e ; v e r y s e d a t i n

g

A v o i d

M o d e r a t e

S t r o n g

N o n b e n z o d i a z e p i n e ,

b e n z o d i a z e p i n e

r e c e p t o r a g o n i s t h y p n o t i c s

E s z o p i c l o n e

Z o l p i d e m

Z a l e p l o n

B e n z o d i a z e p i n e - r e c e p t o r a g o n i s t s h a v e a d v e r s e

e v e n t s s i m i l a r t o t h o s e o f b e n z o d i a z e p i n e s i n

o l d

e r a d u l t s ( e . g . ,

d e l i r i u m ,

f a l l s ,

f r a c t u r e s ) ;

i n c

r e a s e d e m e r g e n c y d e p a r t m e n t v i s i t s a n d

h o s p i t a l i z a t i o n s ; m o t o r v e h i c l e c r a s h e s ; m i n i m a l

i m p r o v e m e n t i n s l e e p l a t e n c y a n d d u r a t i o n

A v o i d

M o d e r a t e

S t r o n g

E r g o l o i d m e s y l a t e s

( d e h y d r o g e n a t e d e r g o t a l k a l o i d s )

I s o x s u p r i n e

L a c k o f e f fi c a c y

A v o i d

H i g h

S t r o n g

E n d o c r i n e

A n d r o g e n s

M e t h y

updated beers criteria nov 12015

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