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AGS Beers Criteria® (2019 Update): Potentially Inappropriate Medication Use in Older Adults

By Cynthia C. Nwaubani, Pharm.D, BCGP

The American Geriatrics Society (AGS) recently released its latest update to a highly utilized reference tool: The AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. 

First developed in 1991 by Dr. Mark Beers, a geriatrician, and colleagues, the report is based on expert panel recommendations and has been updated every three years since 2011. The Beers Criteria or “Beers List” has become a vital tool in our effort to improve the health of older adults. By identifying medications that have the potential to harm our elderly patients, we can proactively prevent medication-related harm. Given that more than 90% of older patients use at least one prescription drug, and more than 66% use three or more drugs, it is crucial that we prevent harm by avoiding those drugs which are inappropriate for use in our geriatric population.  

The Beers Criteria Break Down Their Evidence Into Five Lists Which Describe Certain Medications And Situations:

  1.  Potentially Inappropriate Medication Use in Older Adults;

  2.  Potentially Inappropriate Medication Use in Older Adults Due to Drug- Disease or Drug-Syndrome Interactions that May Exacerbate the Disease or Syndrome;

  3. Drugs to be Used With Caution in Older Adults;

  4. Clinically Important Drug Interactions That Should Be Avoided in Older Adults;

  5. Medications That Should Be Avoided or Have Their Dosage Reduced With Varying Levels of Kidney Function in Older Adults.

In the 2019 update, 25 medications including ticlopidine, pentazocine, vasodilators and chemotherapeutic agents were removed based on new evidence. Histamine Receptor Antagonists (famotidine, ranitidine) were changed from avoiding in all older adults to avoid in patients with delirium based on limited evidence of adverse effects. Their use also provides an alternative for proton-pump inhibitors (PPI), which can be problematic having been associated with risk of fractures, pneumonia, Clostridium difficile diarrhea, hypomagnesemia, vitamin B12 deficiency, chronic kidney disease, and dementia. 

Newly added medications include:

  • Tramadol due to hyponatremia;

  • Glimepiride due to prolonged hypoglycemia;

  • Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) such as venlafaxine, duloxetine, desvenlafaxine, and levomilnacipran, due to the risk of falls;

  • Aspirin, when used for primary prevention of cardiovascular events or colon cancer, is now on the list for patients ≥70 years old or who have a creatinine clearance (CrCl) of <30 mL/min. The age break was changed to ≥70 years old from ≥80  years old due to the risk of bleeding;

  • Rivaroxaban (Xarelto) now joins dabigatran (Pradaxa) to be avoided in people age ≥75 or CrCl <30 due to GI bleeding risk;

  • Trimethoprim-sulfamethoxazole (TMP-SMX) should be used with caution in patients with reduced kidney function due to the risk of hyperkalemia.  This risk is increased when TMP-SMX is used in combination with drugs that can raise potassium levels such as ACE Inhibitors, (lisinopril, benazepril, others);  ARBs (losartan, valsartan, telmisartan, and others); potassium-sparing diuretics (spironolactone);

  • Gabapentinoids (pregabalin and gabapentin) which had been on the list to be used in only low doses due to ataxia and falls are now recommended to be avoided in combination with opioids due to sedation, respiratory depression, and death;

  • For patients with Parkinson’ disease, the guidelines have changed from avoiding all antipsychotics, to accepting quetiapine, clozapine, and pimavanserin;

  • For patients with heart failure, non-dihydropyridine calcium channel blockers (diltiazem, verapamil) should be avoided in older adults with reduced ejection fraction heart failure  In addition, NSAIDs (ibuprofen, naproxen, others), COX-2 inhibitors (celecoxib), thiazolidinediones (pioglitazone) and dronedarone should be used with caution to patients who are asymptomatic and should be avoided in patients who have symptoms;

  • Macrolides (excluding azithromycin) or ciprofloxacin should not be used in conjunction with warfarin due to bleeding risk;

  • Dextromethorphan/quinidine (Neudexta) should be used with caution due to limited efficacy and increase the risk of falls and drug interactions.    

It is important to remember that the Beers Criteria are recommendations, and as with any such guidelines, should not be misconstrued as universally unacceptable in all geriatric patient cases or scenarios. It is always up to the prescriber to weigh the risks versus the benefits while considering the individual patient’s circumstances and goals of care. The authors of the Beers Criteria have also stressed that the criteria should not be used to restrict access to these medications excessively or unnecessarily.  

How we can help:

The dedicated and clinically trained pharmacists at PharmD Live are well-equipped and uniquely positioned to apply their advanced training and extensive knowledge of drug pharmacology, drug-drug interactions, therapeutic interchanges, informatics, and patient care, to help prescribers provide the best care possible to our older adults. 

PharmD Live’s solutions include a nationwide network of clinical pharmacists who utilize our innovative medication risk management technology with powerful analytics to identify and mitigate these medication-related risks so as to optimize patients’ medication regimens and ultimately achieve value-based care outcomes.

References:

National Center for Health Statistics. (2018). Table 79. In Health, the United States, 2017. https://www.cdc.gov/nchs/data/hus/2017/079.pdf American Geriatrics Society 2019 https://nicheprogram.org/sites/niche/files/2019-02/Panel-2019-Journal_of_the_American_Geriatrics_Society.pdfSource: American Geriatrics Society 2019 https://nicheprogram.org/sites/niche/files/2019-02/Panel-2019-Journal_of_the_American_Geriatrics_Society.pdfTagged: AGS Beers Criteria 2019, inappropriate medication use in older adults, medication use in older adults