American Geriatrics Society 2023 updated AGS Beers Criteria PDF

Received: 7 March 2023 Accepted: 29 March 2023 DOI: 10.1111/jgs.18372 Journal of the SPECIAL ARTICLE...

Received: 7 March 2023 Accepted: 29 March 2023 DOI: 10.1111/jgs.18372 Journal of the SPECIAL ARTICLE American Geriatrics Society American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults By the 2023 American Geriatrics Society Beers Criteria® Update Expert Panel Correspondence Mary Jordan Samuel, American Geriatrics Abstract Society, 40 Fulton Street, Suite 809, The American Geriatrics Society (AGS) Beers Criteria® (AGS Beers Criteria®) New York, NY 10038, USA. for Potentially Inappropriate Medication (PIM) Use in Older Adults is widely Email: [email protected] used by clinicians, educators, researchers, healthcare administrators, and regu- lators. Since 2011, the AGS has been the steward of the criteria and has pro- duced updates on a regular cycle. The AGS Beers Criteria® is an explicit list of PIMs that are typically best avoided by older adults in most circumstances or under specific situations, such as in certain diseases or conditions. For the 2023 update, an interprofessional expert panel reviewed the evidence published since the last update (2019) and based on a structured assessment process approved a number of important changes including the addition of new cri- teria, modification of existing criteria, and formatting changes to enhance usability. The criteria are intended to be applied to adults 65 years old and older in all ambulatory, acute, and institutionalized settings of care, except hos- pice and end-of-life care settings. Although the AGS Beers Criteria® may be used internationally, it is specifically designed for use in the United States and there may be additional considerations for certain drugs in specific countries. Whenever and wherever used, the AGS Beers Criteria® should be applied thoughtfully and in a manner that supports, rather than replaces, shared clini- cal decision-making. KEYWORDS Beers criteria, Beers list, inappropriate prescribing, medications and drugs, older adults INTRODUCTION criteria to apply to all older adults.2 The criteria was updated by an interprofessional group in 2003 and the The Beers Criteria was developed by the late Mark Beers, American Geriatrics Society took over stewardship in MD, and colleagues at the University of California Los 2010. The 2023 American Geriatrics Society (AGS) Beers Angeles in 1991, with the purpose of identifying medica- Criteria® (AGS Beers Criteria®) for Potentially Inappro- tions for which potential harm outweighed the expected priate Medication (PIM) Use in Older Adults is the sev- benefit and that should be avoided in nursing home resi- enth overall update and fourth since AGS became the dents.1 The 1997 update, led by Dr. Beers, expanded the criteria's steward. As with previous updates, the AGS and its expert panel have attempted to preserve the spirit and Panel Members and Affiliations are provided in Appendix. intent of the original Beers Criteria by providing an J Am Geriatr Soc. 2023;1–30. wileyonlinelibrary.com/journal/jgs © 2023 The American Geriatrics Society. 1  15325415, 0, Downloaded from https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.18372 by CAPES, Wiley Online Library on [10/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 2 BY THE 2023 AMERICAN GERIATRICS SOCIETY BEERS CRITERIA® UPDATE EXPERT PANEL explicit list of PIMs that are best avoided by older adults in most circumstances or under specific situations, such Key points as certain diseases, conditions, or care settings. The AGS Beers Criteria® comprises drugs and drug The intention of the AGS Beers Criteria® is to: classes that the AGS and its expert panel consider to be (1) reduce older adults' exposure to potentially potentially inappropriate medications (PIMs) for use in inappropriate medications (PIMs) by improv- older adults. The expert panel organized the criteria into ing medication selection; (2) educate clinicians the same five general categories that were used in the and patients; and (3) serve as a tool for evaluat- 2019 update: ing the quality of care, cost, and patterns of drug use in older adults. 1. Medications considered as potentially inappropriate The target audience for the 2023 AGS Beers (Table 2); Criteria® is practicing clinicians and others 2. Medications potentially inappropriate in patients with who utilize the criteria including healthcare certain diseases or syndromes (Table 3); consumers, researchers, pharmacy benefits 3. Medications to be used with caution (Table 4); managers, regulators, and policymakers. 4. Potentially inappropriate drug–drug interactions The criteria are intended to be applied to adults (Table 5); and 65 years old and older in all ambulatory, acute, 5. Medications whose dosages should be adjusted based and institutionalized settings of care, except on renal function (Table 6). hospice and end-of-life care settings. Using the five categories of criteria as a framework, Why does this paper matter? an interprofessional expert panel reviewed new data pub- The American Geriatrics Society (AGS) Beers lished since the 2019 update (beginning in 2017, the cut- Criteria® (AGS Beers Criteria®) for Potentially off date for the prior update's literature review) to Inappropriate Medication (PIM) Use in Older identify evidence that would remove, sustain, or alter Adults is widely used by clinicians, educators, existing criteria recommendations, rationale, level of evi- researchers, healthcare administrators, and regu- dence, or strength of recommendations. The panel also lators. Since 2011, the AGS has been the steward considered evidence that would support the addition of of the criteria and has produced updates on a reg- new criteria. For the first time, the panel systematically ular cycle. The AGS Beers Criteria® is an explicit considered usage in the United States to determine list of PIMs that are typically best avoided by whether any medications (and resulting criteria) should older adults in most circumstances or under spe- be removed because of very low or absent usage in the cific situations, such as in certain diseases or con- United States. Finally, the panel aimed to enhance ditions. Although the AGS Beers Criteria® may usability by consolidating the formatting of the criteria be used internationally, it is specifically designed for clarity and space. for use in the United States and there may be additional considerations for certain drugs in spe- cific countries. Whenever and wherever used, the OBJECTIVES AGS Beers Criteria® should be applied thought- fully and in a manner that supports, rather than The specific aim was to update the 2019 AGS Beers replaces, shared clinical decision-making. Criteria® using a comprehensive, systematic review and grading of the evidence on drug-related problems and adverse events in older adults. The strategies to achieve this aim were to:  Incorporate exceptions to the 2023 AGS Beers Convene an interprofessional panel of 12 experts in Criteria® that the panel deemed clinically appropri- geriatric care and pharmacotherapy and three ex- ate. These exceptions were designed to make the cri- officio representatives from key stakeholder groups teria more individualized to clinical practice and who would: more diverse and relevant across settings of care  Review evidence published between 2017 and 2022 and populations of older adults. and use this to update the 2019 AGS Beers Criteria®,  Grade the strength and quality of each PIM criterion with consideration to removing or modifying exist- based on the level of evidence and strength of ing criteria and adding new criteria. recommendation.  15325415, 0, Downloaded from https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.18372 by CAPES, Wiley Online Library on [10/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License AGS 2023 BEERS CRITERIA® 3  Apply a modified Delphi method, informed by the including the rigor of the evidence review and synthesis systematic review and grading, to reach a consensus process.4 These methods were adapted from the Grading on the 2023 update. of Recommendations Assessment, Development and Evaluation (GRADE) guidelines for clinical practice guideline development and are consistent with recom- I N T E N T OF CR I T E R I A mendations from the National Academy of Medicine.5,6 The primary target audience for the 2023 AGS Beers Criteria® is practicing clinicians. The criteria are Panel composition intended to support shared decision-making about phar- macologic therapy with adults 65 years old and older in The AGS Beers Criteria® expert panel included 12 inter- all ambulatory, acute, and institutionalized settings of professional members drawn from medicine, nursing, care, except hospice and end-of-life care settings. The and pharmacy, 10 of whom had participated in the 2019 intention of the AGS Beers Criteria® is to reduce older update. Panelists had experience in different practice set- adults' exposure to PIMs by improving medication selec- tings, including ambulatory care, home care, acute hos- tion; educate clinicians and patients; reduce adverse drug pital care, skilled nursing facilities, and long-term care. events; and serve as a tool for evaluating the quality of In addition, the panel included ex-officio representa- care, cost, and patterns of drug use in older adults. Others tives from the Centers for Medicare & Medicaid Ser- who utilize the criteria include healthcare consumers, vices, the National Committee for Quality Assurance, researchers, pharmacy benefits managers, regulators, and and the Pharmacy Quality Alliance. Potential conflicts policymakers. As with previous updates, the panel had of interest were disclosed at the beginning of the pro- discussions and debates in an effort to attain a balance cess and before each full panel call and are listed in the between the multiple uses and users. We note that the disclosures section of this paper. Panelists were recused criteria are a blunt instrument and that we are unable to from discussion in areas in which they had a potential delineate all specialized use cases and possible exceptions conflict of interest. to the criteria. The AGS and the panel remind users of the AGS Beers Criteria® that the criteria are not to be used in a punitive Literature review manner. Prescribing for older adults is often a complex endeavor involving the consideration of many factors, par- Literature searches were conducted in PubMed from ticularly the preferences and goals of the older person and June 1, 2017, to May 31, 2022. Search terms for each cri- their family. Deprescribing studies have demonstrated how terion included individual drugs, drug classes, specific critical patient and family input and buy-in can be to the conditions, and combinations thereof, each with a focus success of discontinuing medications responsible for actual on “adverse drug events” and “adverse drug reactions,” or potential harm or that provide little to no therapeutic as well as on any specific focus defined by the expert value.3 Quality measures must be clearly defined, easily panel. Searches targeted controlled clinical trials, obser- applied, and measured with limited information and, thus, vational studies, and systematic reviews and meta- although useful, cannot perfectly distinguish appropriate analyses, with filters for human participants, 65 years old from inappropriate care. The panel's review of evidence at and older, and the English language. Clinical reviews times identified subgroups of individuals who should be and guidelines were also included to provide context. exempt from a given criterion or to whom a specific crite- Case reports, case series, letters to the editor, and edito- rion should apply. Such a criterion may not be easily rials were excluded. applied as a quality measure, particularly when such sub- Searches identified 33,965 references; 7352 abstracts groups cannot be easily identified through structured and were sent to panelists for review, of which 1574 references readily accessible electronic data (e.g., when diagnoses, the were selected for full-text review. Among these, 451 manu- purpose of prescribing, or laboratory measures such as kid- scripts were abstracted into evidence tables, and an addi- ney function are not available). tional 148 were included as background reports. METHODS Development process Methods used for the 2023 update of the AGS Beers The full panel convened for a series of conference calls Criteria® were similar to those used in the 2019 update, between December 2020 and November 2022. Between  15325415, 0, Downloaded from https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.18372 by CAPES, Wiley Online Library on [10/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 4 BY THE 2023 AMERICAN GERIATRICS SOCIETY BEERS CRITERIA® UPDATE EXPERT PANEL the full panel calls, work was conducted via email. In guidelines and the American College of Physicians' evi- addition, the panel was divided into four workgroups, dence grading framework (Table 1).7,10 each assigned a subset of the criteria, with each work- Using evidence from the 2017–2022 literature review, group leading the review and synthesis of evidence for its findings from the previous AGS-led 2012, 2015, and 2019 subset of the criteria. updates, and clinical judgment, each workgroup pre- The panel began its work using an anonymous Delphi sented to the full panel their findings and suggestions for process to review the 2019 AGS Beers Criteria®. Using a changes (or no change) to the criteria, with ensuing dis- 5-point Likert scale with anchors of “strongly disagree” cussion. For most criteria, a consensus emerged: to leave and “strongly agree,” criteria receiving three or more panel an existing criterion from the 2019 update unchanged, to votes of “unsure” or below were brought back for group modify it, to remove it entirely, or to add a new criterion. discussion and flagged for the individual workgroups to Possible modifications included which drug(s) to include, review for possible updating. Of note, during the full pro- the recommendation, the rationale, the quality of evi- cess, all legacy criteria were reviewed for accuracy and dence, and the strength of the recommendation. As noted appropriateness. Panelists also provided input about drugs in the GRADE guidelines, the strength of recommenda- to be explored further for possible addition. tion ratings incorporate a variety of considerations, To guide the evidence selection, review, and synthesis including expert opinion and clinical judgment and con- process, each workgroup reviewed and updated work- text, and thus do not always align with the quality of evi- sheets created for the 2019 criteria that identified a priori dence ratings. which clinical outcomes, indications, and comparison After proposed changes to the criteria were drafted, a groups were most relevant when considering the evi- second anonymous Delphi process was used to ascertain dence for each criterion, that is, the “desired evidence” panel consensus on the changes, using the same 5-point for reviewing each criterion. These discussions were not Likert scale as was previously used. As a general rule, cri- considered binding but provided guidance for keeping teria receiving three or more panel votes of “unsure” or the evidence review and synthesis focused on what was disagreement were brought back for group discussion to most clinically relevant. reach a consensus decision. Final edits after a public Each workgroup reviewed abstracts from the litera- comment period were approved through the assent of ture searches for the criteria in its purview and collec- panel members. tively selected a subset for full-text review. This selection In addition to changes made based on available evi- process considered the methodologic quality of each dence, the panel decided on several modifications to study, its relevance to older adults, and its concordance improve the clarity and usability of the AGS Beers with the desired evidence noted above. After reviewing Criteria®. The panel changed the order and wording of the full text of each selected article, the workgroup then certain criteria, recommendations, and rationale state- decided by consensus which papers represented the best ments to improve clarity, avoid possible misinterpreta- available evidence, based on a balance of these same tions, and maintain consistency of formatting. The order three key considerations (methodologic quality, relevance of drugs and categories listed in Table 2 was also modi- to older adults, and concordance with desired evidence). fied for similar reasons. To enhance usability, where fea- Special emphasis was placed on selecting systematic sible we have listed individual drugs that belong to a reviews and meta-analyses when available because specified drug class, not including agents that are rarely resource constraints precluded the panel from conducting or never used in the United States (as defined using the these types of comprehensive analyses. In general, a methods described immediately below). Note that when study was considered relevant to older adults if the mean such drug class labels are used, the general intent is that or median age of participants was at least 65 years, and the criteria apply to all drugs within that class except especially relevant if most or all participants were older when specified otherwise. than this age threshold. To simplify and thereby increase usability, the panel Papers comprising the best available evidence were also voted to omit from key reference tables a number of abstracted into evidence tables. These tables summarized medications included in previous iterations of the criteria the design, study population, and findings of each study, that have low or zero usage in the U.S. Drugs that were and identified markers of methodologic quality moved off the main tables due to low or absent use in the highlighted by the GRADE criteria for clinical trials and United States are shown in Table 8. We defined low use observational studies and by the AMSTAR criteria for as 325 mg/day disease in high-risk groups, including those alternatives are not effective and the Diclofenac >75 years old or taking oral or parenteral patient can take a gastroprotective agent Diflunisal corticosteroids, anticoagulants, or antiplatelet (proton-pump inhibitor or misoprostol). Etodolac agents; use of proton-pump inhibitor or Avoid short-term scheduled use in Flurbiprofen misoprostol reduces but does not eliminate combination with oral or parenteral 11 (Continues) 15325415, 0, Downloaded from https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.18372 by CAPES, Wiley Online Library on [10/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License  12 TABLE 2 (Continued) Organ system, therapeutic Quality of Strength of category, drug(s)a Rationale Recommendation evidenceb recommendationb Ibuprofen risk. Upper GI ulcers, gross bleeding, or corticosteroids, anticoagulants, or Indomethacin perforation caused by NSAIDs occur in 1% of antiplatelet agents unless other Ketorolac patients treated for 3–6 months and in 2%–4% alternatives are not effective and the Meloxicam of patients treated for 1 year; these trends patient can take a gastroprotective agent Nabumetone continue with longer duration of use. Also can (proton-pump inhibitor or misoprostol). Naproxen increase blood pressure and induce kidney Oxaprozin injury. Risks are dose-related. Piroxicam Sulindac Indomethacin Increased risk of GI bleeding/peptic ulcer disease Avoid Moderate Strong Ketorolac (oral and parenteral) and acute kidney injury in older adults. Of all the NSAIDs, indomethacin has the most adverse effects, including a higher risk of adverse CNS effects. Meperidine Oral analgesic not effective in dosages commonly Avoid Moderate Strong used; may have a higher risk of neurotoxicity, including delirium, than other opioids; safer alternatives available. Skeletal muscle relaxants Muscle relaxants typically used to treat Avoid Moderate Strong Carisoprodol musculoskeletal complaints are poorly tolerated Chlorzoxazone by older adults due to anticholinergic adverse Cyclobenzaprine effects, sedation, and increased risk of fractures; Metaxalone effectiveness at dosages tolerated by older adults Methocarbamol is questionable. Orphenadrine This criterion does not apply to skeletal muscle relaxants typically used for the management of spasticity (i.e., baclofen and tizanidine) although these drugs can also cause substantial adverse effects. Abbreviations: CNS, central nervous system; COX, cyclooxygenase; CrCl, creatinine clearance; CV, cardiovascular; DOACs, direct oral anticoagulants; GI, gastrointestinal; HFrEF, heart failure with reduced ejection fraction; HRT, hormone replacement therapy; INR, international normalized ratio; NSAIDs, nonsteroidal anti-inflammatory drugs; NYHA, New York Heart Association; SIADH, syndrome of inappropriate antidiuretic hormone secretion; VTE, venous thromboembolism. a Under each drug class, drugs commonly used in the United States are listed, except in cases where doing so is infeasible due to space considerations. Unless stated otherwise, all drugs within a stated drug class are considered potentially inappropriate in the context of the criterion in which they appear, even if not listed in this table. b Quality of evidence and strength of recommendation ratings apply to all drugs and recommendations within each criterion unless stated otherwise. c When selecting among DOACs and choosing a dose, pay special consideration to kidney function (see Table 6), indication, and body weight. d Antipsychotics used in the United States include: First-generation (“typical”)—chlorpromazine, fluphenazine, haloperidol, perphenazine; Second-generation (“atypical”)—aripiprazole, brexpiprazole, cariprazine, clozapine, lurasidone, olanzapine, paliperidone, pimavanserin, quetiapine, risperidone, ziprasidone. This list does not include antipsychotics rarely or never used in the U.S. among older adults. BY THE 2023 AMERICAN GERIATRICS SOCIETY BEERS CRITERIA® UPDATE EXPERT PANEL 15325415, 0, Downloaded from https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.18372 by CAPES, Wiley Online Library on [10/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License  15325415, 0, Downloaded from https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.18372 by CAPES, Wiley Online Library on [10/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License AGS 2023 BEERS CRITERIA® 13 AGS' regular communication channels for reaching the account of having low usage in the United States, not public. AGS members were also encouraged to submit being currently available in the United States, or for other comments with multiple posts included on the weekly reasons. A summary of modifications and additions to the member listserv and notices in MyAGSOnline, the criteria is shown in Tables 9 and 10. Online supplemental society's online member community. AGS also made out- Appendix S1 contains a list of drugs removed from the reach to 47 organizations to alert them to the public com- AGS Beers Criteria® since the 2012 update. ment period and with a request that they provide expert, In Table 2, the rationale for anticholinergic drugs to external review. Fifty-eight total comment forms were avoid has been expanded to recognize the risks associated submitted comprising more than 200 comments and sug- with concurrent use (cumulative anticholinergic burden) gestions; the expert panel reviewed these and modified and is also recognized in Tables 3 and 5. The criterion for the criteria and accompanying text based on the strength the use of aspirin for the primary prevention of cardiovas- of the evidence supporting each recommended change cular disease has been revised and moved from the “use and clinical judgment. The AGS Executive Committee with caution” table (Table 4) to Table 2, with the new and CPMC Chair and Vice Chair reviewed the resulting recommendation being to avoid initiating aspirin for the draft of the 2023 AGS Beers Criteria®. The Criteria went primary prevention of cardiovascular disease in older through peer review by the Journal of the American Geri- adults (in agreement with the U.S. Preventive Services atrics Society (JAGS). Task Force's recommendation).13 For older adults who are already taking aspirin for primary prevention, the panel recommends deprescribing be considered, pending RESULTS any new data on this issue. Changes to the criteria involving anticoagulation Noteworthy changes to PIMS for older were discussed at length, including the proposed adults changes, the supporting literature, and ramifications. The recommendation for rivaroxaban has changed from “use The drugs and drug class criteria included in the 2023 with caution” to “avoid” for long-term treatment of non- AGS Beers Criteria® are listed in Tables 2–6. To enhance valvular atrial fibrillation and venous thromboembolism clarity, a special box that summarizes the criteria for anti- (VTE), with the rationale being that observational studies coagulants (warfarin, rivaroxaban, and dabigatran) has and network meta-analyses find that this drug confers a been added (Box 1). Table 7 is a list of drugs with strong higher risk of major and gastrointestinal bleeding in anticholinergic properties referred to in Tables 2, 3, and 5. older adults than other direct-acting oral anticoagulants Table 8 is a list of drugs from the 2019 AGS Beers Criteria (DOACs), particularly apixaban, but also dabigatran. The that the panel still considers to be PIMs (unless specified panel recognizes there may be circumstances when rivar- otherwise) but which are now moved off of Tables 2–7 on oxaban may be a reasonable choice, including for other BOX 1 Synthesis of anticoagulation recommendations. Explanation Recommendation This criterion summarizes recommendations for warfarin Warfarin: Avoid starting warfarin as initial therapy for the (Table 2), rivaroxaban (Table 2), and dabigatran treatment of venous thromboembolism (VTE) or nonvalvular (Table 4)—anticoagulants to avoid or to use with caution. atrial fibrillation unless alternative options (e.g., DOACs) are A “use with caution” recommendation reflects less concern contraindicated or there are substantial barriers to their use. and/or less clear evidence than an “avoid” For older adults who have been using warfarin long-term, it recommendation. See individual criteria on these may be reasonable to continue this medication, particularly medications for more information about anticoagulant- among those with well-controlled INRs (i.e., >70% time in the related recommendations. therapeutic range) and no adverse effects. When selecting among DOACs and choosing a dosage, pay Rivaroxaban: Avoid rivaroxaban for long-term treatment of special consideration to kidney function (see Table 6), nonvalvular atrial fibrillation or VTE in favor of safer indication, and body weight. anticoagulant alternatives. Dabigatran: Use caution in selecting dabigatran over other DOACs (e.g., apixaban) for long-term treatment of nonvalvular atrial fibrillation or VTE.  14 T A B L E 3 2023 American Geriatrics Society Beers Criteria® for potentially inappropriate medication use in older adults due to drug–disease or drug–syndrome interactions that may exacerbate the disease or syndrome. Strength of Disease or syndrome Drug(s)a Rationale Recommendation Quality of evidenceb recommendationb Cardiovascular Heart failure Cilostazol Potential to promote fluid retention and/or Avoid: Cilostazol, Strong Dextromethorphan-quinidine exacerbate heart failure (NSAIDs and COX-2 Cilostazol dextromethorphan- inhibitors, non-dihydropyridine CCBs, Dextromethorphan-quinidine quinidine, COX-2 Nondihydropyridine calcium channel thiazolidinediones); potential to increase mortality inhibitors: Low blockers (CCBs) ------------------------------- in older adults with heart failure (cilostazol and Avoid in heart failure with Diltiazem Non-dihydropyridine dronedarone); concerns about QT prolongation reduced ejection fraction: Verapamil CCBs, NSAIDs: (dextromethorphan-quinidine). Nondihydropyridine calcium Moderate Dronedarone Note: This is not a comprehensive list of medications channel blockers (CCBs) Dronedarone, NSAIDs and COX-2 inhibitors to avoid in patients with heart failure. Diltiazem thiazolidenediones: Thiazolidinediones Verapamil High Pioglitazone ------------------------------- Use with caution in patients with heart failure who are asymptomatic; avoid in patients with symptomatic heart failure: Dronedarone NSAIDs and COX-2 inhibitors Thiazolidinediones Pioglitazone Syncope Antipsychotics (selected) Antipsychotics listed and tertiary TCAs increase the Avoid High Antipsychotics, non- Chlorpromazine risk of orthostatic hypotension. selective peripheral Olanzapine AChEIs cause bradycardia and should be avoided in alpha-1 blockers: Cholinesterase inhibitors (AChEIs) older adults whose syncope may be due to Weak Donepezil bradycardia. AChEIs, tertiary TCAs: Galantamine Strong Rivastigmine Non-selective peripheral alpha-1 blockers cause Non-selective peripheral alpha-1 orthostatic blood pressure changes and should be blockers avoided in older adults whose syncope may be due Doxazosin to orthostatic hypotension. Prazosin Terazosin Tertiary tricyclic antidepressants (TCAs) Amitriptyline Clomipramine Doxepin Imipramine BY THE 2023 AMERICAN GERIATRICS SOCIETY BEERS CRITERIA® UPDATE EXPERT PANEL 15325415, 0, Downloaded from https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.18372 by CAPES, Wiley Online Library on [10/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License  TABLE 3 (Continued) Strength of Disease or syndrome Drug(s)a Rationale Recommendation Quality of evidenceb recommendationb Central nervous system Delirium Anticholinergics (see Table 7) Avoid in older adults with or at high risk of delirium Avoid, except in situations listed H2-receptor antagonists: Strong c because of the potential of inducing or worsening under the rationale statement. Low Antipsychotics AGS 2023 BEERS CRITERIA® delirium. All others: Moderate Benzodiazepines Antipsychotics: avoid for behavioral problems of Corticosteroids (oral and parenteral)d dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed H2-receptor antagonists or are not possible and the older adult is Cimetidine threatening substantial harm to self or others. If Famotidine used, periodic deprescribing attempts should be Nizatidine considered to assess ongoing need and/or the lowest effective dose. Nonbenzodiazepine benzodiazepine receptor agonist hypnotics (“Z- Corticosteroids: if needed, use the lowest possible drugs”) dose for the shortest duration and monitor for Eszopiclone delirium. Zaleplon Opioids: emerging data highlights an association Zolpidem between opioid administration and delirium. For Opioids older adults with pain, use a balanced approach, including the use of validated pain assessment tools and multimodal strategies that include nondrug approaches to minimize opioid use. Dementia or cognitive Anticholinergics (see Table 7) Avoid because of adverse CNS effects. See criteria on Avoid Moderate Strong impairment individual drugs for additional information. Antipsychotics, chronic use or persistent as-needed usec Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people Benzodiazepines with dementia. Avoid antipsychotics for Nonbenzodiazepine benzodiazepine behavioral problems of dementia or delirium receptor agonist hypnotics (“Z- unless documented nonpharmacologic options drugs”) (e.g., behavioral interventions) have failed and/or Eszopiclone the patient is threatening substantial harm to self Zaleplon or others. If used, periodic deprescribing attempts Zolpidem should be considered to assess ongoing need and/or the lowest effective dose. History of falls or Anticholinergics (see Table 7) May cause ataxia, impaired psychomotor function, Avoid unless safer alternatives are Antidepressants, opioids: Strong fractures syncope, or additional falls. not available. Moderate Antidepressants (selected classes) Antidepressants (selected classes): evidence for risk SNRIs Antiepileptics: avoid except for All others: High of falls and fractures is mixed; newer evidence SSRIs seizures and mood disorders. suggests that SNRIs may increase falls risk. Tricyclic antidepressants (TCAs) Benzodiazepines: shorter-acting ones are not safer Opioids: avoid except for pain Antiepileptics than long-acting ones. management in the setting of If one of the drugs must be used, consider reducing severe acute pain. Antipsychoticsc the use of other CNS-active medications that Benzodiazepines increase the risk of falls and fractures (Continues) 15 15325415, 0, Downloaded from https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.18372 by CAPES, Wiley Online Library on [10/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License  16 TABLE 3 (Continued) Strength of Disease or syndrome Drug(s)a Rationale Recommendation Quality of evidenceb recommendationb History of falls and Nonbenzodiazepine benzodiazepine (i.e., anticholinergics, selected antidepressants, fractures, cont'd receptor agonist hypnotics (“Z- antiepileptics, antipsychotics, sedative/hypnotics drugs”) including benzodiazepines and, Eszopiclone nonbenzodiazepine benzodiazepine receptor Zaleplon agonist hypnotics, opioids) and implement other Zolpidem strategies to reduce fall risk. Opioids Parkinson disease Antiemetics Dopamine-receptor antagonists with the potential to Avoid Moderate Strong Metoclopramide worsen parkinsonian symptoms Prochlorperazine Exceptions: clozapine, pimavanserin, and quetiapine Promethazine appear to be less likely to precipitate the Antipsychotics (except clozapine, worsening of Parkinson disease than other pimavanserin, and quetiapine) antipsychotics. Gastrointestinal History of gastric or Aspirin May exacerbate existing ulcers or cause Avoid unless other alternatives Moderate Strong duodenal ulcers Non-COX-2 selective NSAIDs new/additional ulcers are not effective and the patient can take a gastroprotective agent (i.e., proton-pump inhibitor or misoprostol). Kidney/urinary tract Urinary incontinence Non-selective peripheral alpha-1 Aggravation of incontinence (alpha-1 blockers), Avoid in women Non-selective peripheral Non-selective (all types) in women blockerse lack of efficacy (oral estrogen) See also recommendation on alpha-1 blockers: peripheral alpha-1 Doxazosin estrogen (Table 2) Moderate blockers: Strong Prazosin Estrogen: High Estrogen: Strong Terazosin Estrogen, oral and transdermal (excludes intravaginal estrogen) Lower urinary tract Strongly anticholinergic drugs, except May decrease urinary flow and cause urinary Avoid in men Moderate Strong symptoms, benign antimuscarinics for urinary retention prostatic hyperplasia incontinence (see Table 7) Abbreviations: AChEI, acetylcholinesterase inhibitor; CCBs, calcium channel blockers; CNS, central nervous system; COPD, chronic obstructive pulmonary disease; COX, cyclooxygenase; CrCl, creatinine clearance; NSAIDs, nonsteroidal anti-inflammatory drugs; SNRIs, serotonin-norepinephrine reuptake inhibitors; SSRIs, selective serotonin reuptake inhibitors; TCAs, tricyclic antidepressants. a Under each drug class, drugs commonly used in the United States are listed, except in cases where doing so is infeasible due to space considerations. Unless stated otherwise, all drugs within a stated drug class are considered potentially inappropriate in the context of the criterion in which they appear, even if not listed in this table. b Quality of evidence and strength of recommendation ratings apply to all drugs and recommendations within each criterion unless stated otherwise. c May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration. d Excludes inhaled and topical forms. Oral and parenteral corticosteroids may be required for conditions such as exacerbation of COPD but should be prescribed in the lowest effective dose and for the shortest possible duration. e Data are limited for selective peripheral alpha-1 blockers (e.g., tamsulosin, silodosin, and others) but may apply as well. BY THE 2023 AMERICAN GERIATRICS SOCIETY BEERS CRITERIA® UPDATE EXPERT PANEL 15325415, 0, Downloaded from https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.18372 by CAPES, Wiley Online Library on [10/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License  15325415, 0, Downloaded from https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.18372 by CAPES, Wiley Online Library on [10/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License AGS 2023 BEERS CRITERIA® 17 T A B L E 4 2023 American Geriatrics Society Beers Criteria® for potentially inappropriate medications: drugs to be used with caution in older adultsa. Quality of Strength of Drug(s)b Rationale Recommendation evidencec recommendationc Dabigatran for long-term Increased risk of GI bleeding compared Use caution in selecting Moderate Strong treatment of nonvalvular with warfarin (based on head-to-head dabigatran over other DOACs atrial fibrillation or venous clinical trials) and of GI bleeding and (e.g., apixaban) for long-term thromboembolism (VTE) major bleeding compared with apixaban treatment of nonvalvular (based on observational studies and atrial fibrillation or VTE. meta-analyses) in older adults when See also criteria on warfarin used for long-term treatment of and rivaroxaban (Table 2) nonvalvular atrial fibrillation or VTE. and footnoted regarding choice among DOACs. Prasugrel Both increase the risk of major bleeding in Use with caution, particularly Moderate Strong Ticagrelor older adults compared with clopidogrel, in adults 75 years old and especially among those 75 years old and older. older. However, this risk may be offset If prasugrel is used, consider a by cardiovascular benefits in select lower dose (5 mg) for those patients. 75 years old and older. Antidepressants (selected) May exacerbate or cause SIADH or Use with caution Moderate Strong Mirtazipine hyponatremia; monitor sodium levels SNRIs closely when starting or changing SSRIs dosages in older adults. TCAs Antiepileptics (selected) Carbamazepine Oxcarbazepine Antipsychotics Diuretics Tramadol Dextromethorphan- Limited efficacy in patients with Use with caution Moderate Strong quinidine behavioral symptoms of dementia (does not apply to the treatment of pseudobulbar affect). May increase the risk of falls and concerns with clinically significant drug interactions and with use in those with heart failure (see Table 3). Trimethoprim- Increased risk of hyperkalemia when used Use with caution in patients on Low Strong sulfamethoxazole concurrently with an ACEI, ARB, or ACEI, ARB, or ARNI and ARNI in presence of decreased CrCl. decreased CrCl. Sodium-glucose co- Older adults may be at increased risk of Use with caution. Moderate Weak transporter-2 (SGLT2) urogenital infections, particularly Monitor patients for urogenital inhibitors women in the first month of treatment. infections and ketoacidosis. Canigliflozin An increased risk of euglycemic diabetic Dapagliflozin ketoacidosis has also been seen in older Emplaglifozin adults. Ertuglifozin Abbreviations: ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; ARNI, angiotensin receptor-neprilysin inhibitor; CrCl, creatinine clearance; DOAC, direct oral anticoagulant; GI, gastrointestinal; SIADH, syndrome of inappropriate antidiuretic hormone secretion; SGLT2, sodium glucose co-transporter-2; SNRIs, serotonin-norepinephrine reuptake inhibitors; SSRIs, selective serotonin reuptake inhibitors; TCAs, tricyclic antidepressants; VTE, venous thromboembolism. a “Use with caution” recommendations reflect concern about the balance of benefits and harms of medication compared with alternatives in the situation when those concerns do not rise to the level of “avoid” recommendations in other Tables because of limited evidence, a lesser degree of potential harm compared with alternative therapies, and/or extenuating clinical circumstances. b Under each drug class, drugs commonly used in the United States are listed, except in cases where doing so is infeasible due to space considerations. Unless stated otherwise, all drugs within a stated drug class are considered potentially inappropriate in the context of the criterion in which they appear, even if not listed in this table. c Quality of evidence and strength of recommendation ratings apply to all drugs and recommendations within each criterion unless stated otherwise. d When selecting among DOACs and choosing a dosage, pay special consideration to kidney function (see Table 6), indication, and body weight.  15325415, 0, Downloaded from https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.18372 by CAPES, Wiley Online Library on [10/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 18 BY THE 2023 AMERICAN GERIATRICS SOCIETY BEERS CRITERIA® UPDATE EXPERT PANEL clinical conditions and in special circumstances such as sulfonylureas (e.g., glimepiride, chlorpropramide, or glybur- when a once-daily DOAC is necessary to facilitate medi- ide, which is also known as glibenclamide). cation adherence, and that all DOACs have a lower risk Changes to the criteria involving PIMs exacerbating of intracranial hemorrhage than warfarin. specific drug diseases and drug syndromes (Table 3) are Warfarin has been added to Table 2 as a medication relatively minimal. The combination of dextromethor- to be avoided when starting initial therapy for VTE or phan/quinidine was added to the list of drugs to avoid nonvalvular atrial fibrillation unless alternatives in patients with heart failure. In the criterion of PIMs (e.g., DOACs) are contraindicated or there are substantial to avoid in older adults with a history of falls or frac- barriers to the use of an alternative. The distinction tures, the level of evidence for antidepressants has been between starting warfarin as initial therapy versus main- lowered to “moderate.” Modifications and clarifications taining warfarin among current long-term users (espe- were made to the criteria for delirium, dementia, and cially those with well-controlled international Parkinson disease, including adding opioids to the list normalized ratio [INR] levels) reflects different evidence of drugs that can exacerbate delirium. The update con- for these scenarios as well as considerations of shared tinues to stress the need to avoid antipsychotics and decision-making. The AGS is concerned that there are other medications for behavioral problems of dementia significant barriers to the use of newer alternatives and delirium as their use is frequently associated with including high out-of-pocket drug costs and formulary harm and increased during and after pandemic restrictions. These barriers could lead to inequitable lockdowns.14–16 The use of behavioral interventions access to DOACs that may be safer for older adults. We and search for modifiable triggers for behavior14,17 urge policymakers, insurers, and organizations in the remains the preferred management strategy and should pharmaceutical supply chain to ensure that out-of-pocket be clearly documented in the health record. The use of costs and access restrictions are not a barrier to safe and antipsychotics and other medications listed in these cri- effective anticoagulation for all of us as we age. AGS and teria should be a last resort in collaboration and with the expert panel recognize that cost and access will con- the use of shared decision-making with older adults tinue to be a factor in individualized decision-making and their care partners. Many evidence-based between warfarin and DOACs and among different approaches for behavior in persons with dementia are DOACs until payment policies are enacted that support now available including the Describe, Investigate, Cre- equitable access for all individuals regardless of their eco- ate, Evaluate (DICE) approach and others.18,19 We nomic and insurance status. The recommendation for remind readers that the AGS Beers Criteria® do not dabigatran remains as “use with caution” for the long- apply to care in hospice and at the end of life, in which term treatment of nonvalvular atrial fibrillation and VTE setting decision-making about these and other drugs (Table 4) because of evidence suggesting an increased may require other considerations. risk of gastrointestinal and major bleeding compared As mentioned above, the criteria for aspirin and rivar- with alternatives such as apixaban. oxaban have been moved from Table 4 to Table 2. Tica- Another change from the 2019 criteria pertains to the grelor has been added to the criterion about prasugrel, initiation and continuation of estrogen in postmeno- advising that it be used with caution, particularly among pausal women. The initiation of oral and transdermal adults 75 years old and older because of concerns of estrogen is to be avoided in older women; topical vaginal major bleeding. A new criterion was added advising that estrogen remains appropriate for its major indications of sodium-glucose co-transporter-2 (SGLT2) inhibitors be symptomatic vaginal atrophy or urinary tract infection used with caution because of the increased risk of uro- prophylaxis. Deprescribing should be considered for older genital infection and euglycemic diabetic ketoacidosis, women already using nonvaginal estrogen replacement. and recommends monitoring early during treatment. Of The recommendation for sulfonylureas has been expanded note, the panel recognizes the value of SGLT2-inhibitors to avoid all sulfonylureas as first- or second-line monother- but also wishes to emphasize that patients taking these apy or add on-therapy in recognition of their association drugs should be monitored actively for possible adverse with a higher risk of cardiovascular events, all-cause mor- effects. tality, and hypoglycemia than alternative choices. Here the The panel worked to clarify and consolidate the clini- panel recognizes there may be substantial barriers to or cally important drug–drug interactions (Table 5), most pressures opposing the recommendation, including finan- notably the use of multiple agents with anticholinergic cial ones, with similar considerations as those discussed activity, the concurrent use of ≥3 CNS-active drugs from above for anticoagulants. If a sulfonylurea must be used, specific therapeutic categories (which now include skele- then a short-acting agent is preferred because of the higher tal muscle relaxants), and the addition of SSRIs to the list risk of prolonged hypoglycemia with longer-acting of warfarin drug–drug interactions.  TABLE 5 2023 American Geriatrics Society Beers Criteria® for potentially clinically important drug–drug interactions that should be avoided in older adults. Interacting drug or Quality of Strength of Object drug or class class Risk rationale Recommendation evidencea recommendationa RAS inhibitors (ACEIs, Another RAS inhibitor Increased risk of hyperkalemia. Avoid routinely using 2 or more RAS Moderate Strong ARBs, ARNIs, aliskiren) or a potassium- inhibitors, or a RAS inhibitor and or potassium-sparing sparing diuretic potassium-sparing diuretic, diuretics (amiloride, concurrently in those with chronic AGS 2023 BEERS CRITERIA® triamterene) kidney disease Stage 3a or higher. Opioids Benzodiazepines Increased risk of overdose and adverse Avoid Moderate Strong events. Opioids Gabapentin Increased risk of severe sedation-related Avoid; exceptions are when Moderate Strong Pregabalin adverse events, including respiratory transitioning from opioid therapy to depression and death. gabapentin or pregabalin, or when using gabapentinoids to reduce opioid dose, although caution should be used in all circumstances. Anticholinergic Anticholinergic Use of more than one medication with Avoid; minimize the number of Moderate Strong anticholinergic properties increases the anticholinergic drugs (Table 7). risk of cognitive decline, delirium, and falls or fractures. Antiepileptics (including Any combination of ≥3 Increased risk of falls and of fracture with Avoid concurrent use of ≥3 CNS-active High Strong gabapentinoids) of these CNS-active the concurrent use of ≥3 CNS-active drugs (among types as listed at left); Antidepressants (TCAs, drugs agents (antiepileptics including minimize the number of CNS-active SSRIs, and SNRIs) gabapentinoids, antidepressants, drugs. antipsychotics, benzodiazepines, Antipsychotics nonbenzodiazepine benzodiazepine Benzodiazepines receptor agonist hypnotics, opioids, and skeletal muscle relaxants). Nonbenzodiazepine benzodiazepine receptor agonist hypnotics (i.e., “Z-drugs”) Opioids Skeletal muscle relaxants Lithium ACEIs Increased risk of lithium toxicity. Avoid; monitor lithium concentrations. Moderate Strong ARBs ARNIs Lithium Loop diuretics Increased risk of lithium toxicity. Avoid; monitor lithium concentrations. Moderate Strong Non-selective peripheral Loop diuretics Increased risk of urinary incontinence in Avoid in older women, unless Moderate Strong alpha-1 blockersb older women. conditions warrant both drugs. Phenytoin Trimethoprim- Increased risk of phenytoin toxicity Avoid Moderate Strong sulfamethoxazole 19 (Continues) 15325415, 0, Downloaded from https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.18372 by CAPES, Wiley Online Library on [10/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License  15325415, 0, Downloaded from https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.18372 by CAPES, Wiley Online Library on [10/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 20 BY THE 2023 AMERICAN GERIATRICS SOCIETY BEERS CRITERIA® UPDATE EXPERT PANEL The anticoagulants also dominated the panel's atten- Abbreviations: ACEIs, angiotensin-converting enzyme inhibitors; ARBs, angiotensin receptor blockers; ARNIs, angiotensin receptor-neprilysin inhibitors; CNS, central nervous system; INR, international normalized recommendationa tion when updating drugs to avoid or reduce doses with varying levels of kidney function (Table 6). The criterion Strength of for apixaban has been removed given the evidence for its ratio; NSAIDs, nonsteroidal anti-inflammatory drugs; RAS, renin-angiotensin system; SNRIs = serotonin-norepinephrine reuptake inhibitors; SSRIs, selective serotonin reuptake inhibitors; TCAs, tricyclic safe use in patients with end-stage renal disease. Rivarox- Strong Strong Strong aban's dosing in reduced kidney function is variable and is based on indication; thus, the criteria refer to the prod- uct label. Baclofen has been added with a recommenda- Quality of evidencea Moderate Moderate