In the News: Beers Criteria

In early 2019, the American Geriatrics Society (AGS) released an update to the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, otherwise referred to as the Beers Criteria. The Beers Criteria provides a framework for safe medication prescribing in older adults, based on an expert panel’s systematic review of available evidence surrounding drug-related problems and adverse events in patients 65 years and older. The panel evaluated over 1,400 publications that had been released since the last update in 2015 - including clinical studies, reviews and guidelines.

Although a number of changes can be found in the 2019 update (Table 1), the five categories within the criteria for medication use in older adults remain unchanged:

  • potentially inappropriate medications in most older adults
  • potentially inappropriate medications due to drug-disease interactions
  • medications to be used with caution
  • drug-drug interactions that should be avoided
  • medications that should be avoided or that require dose adjustments based on kidney function

Some criteria that were removed in the latest revision were related to medications that are no longer available in the US or pertaining to drug-related problems that aren’t necessarily unique to older patients (e.g., stimulants in patients with insomnia, vasodilators in patients with syncope).

Table 1. Notable Changes in 2019 Updated AGS Beers Criteria

Deletions since 2015 AGS Beers Criteria

H2-antagonists (eg., ranitidine, famotidine, cimetidine) removed as potentially inappropriate in older patients with dementia or cognitive dysfunction due to weak evidence and to avoid overly restricting options for older adults with dementia and GERD (or similar issues) given coexisting criterion advising against chronic PPI use

Aripiprazole removed as preferred antipsychotic for use in older adults with Parkinson disease due to safety and efficacy concerns

Additions since 2015 AGS Beers Criteria

Glimepiride added as potentially inappropriate in older adults since it can cause severe and prolonged hypoglycemia.

SNRIs (eg., duloxetine, venlafaxine) added to list of other antidepressant classes (TCAs, SSRIs) as potentially inappropriate in older adults with history of falls or fractures since they are associated with increased risk for falls/fractures (however, there isn’t compelling evidence that certain antidepressants confer less risk than others)

Pimavanserin added as acceptable antipsychotic for treatment of Parkinson disease psychosis. It wasn’t available as an FDA-approved treatment until 2016 (following the publication of 2015 Beers Criteria)

Medications to use with caution

  • Rivaroxaban evidence of increased bleeding risk compared with other anticoagulants
  • Tramadol risk of SIADH/hyponatremia
  • Dextromethorphan/quinidine limited efficacy in treating patients with dementia symptoms in absence of pseudobulbar affect; increased risk for falls and drug-drug interactions
  • SMX/TMP increased risk for hyperkalemia in combinations with ACE-inhibitors and ARBs in patients with impaired renal function

Clinically important drug-drug interactions

  • Opioids and benzodiazepines or gabapentinoids increased risk of overdose
  • Phenytoin and SMX/TMP increased risk of phenytoin toxicity
  • Theophylline and ciprofloxacin increased risk of theophylline toxicity
  • Warfarin and ciprofloxacin or SMX/TMP or macrolides (except azithromycin) increased bleeding risk

Special considerations for renal impairment

  • Ciprofloxacin reduce dose for CrCl <30 mL/min due to increased risk of CNS effects, tendon rupture
  • SMX/TMP reduce dose for CrCl 15-29 mL/min and avoid if CrCl <15 mL/min due to increased risk of worsening renal function and hyperkalemia

Other notable changes since 2015 AGS Beers Criteria

Metoclopramide duration of use should rarely exceed 12 weeks due to risk for extrapyramidal effects, including tardive dyskinesia

Aspirin for primary prevention of cardiovascular disease and colorectal cancer use with caution in adults ≥70 years due to new evidence demonstrating marked increase in risk for major bleeding in older patients and possible lack of net benefit when used for these indications.

Apixaban, dabigatran, edoxaban, rivaroxaban thresholds for renal dose adjustments changed to reflect current labeling and exclusion parameters in clinical trials

Abbreviations: ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; CrCl, creatinine clearance; GERD, gastroesophageal reflux disease; PPI, proton pump inhibitor; SIADH, syndrome of inappropriate antidiuretic hormone secretion; SMX/TMP, sulfamethoxazole/trimethoprim; SNRI, serotonin-norepinephrine reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor; TCA, tricyclic antidepressant

The panel acknowledges that the recommendations aren’t intended for hospice and palliative care patients- likely because of these patients’ short prognosis and palliative goals of care.  However, studying the clinical rationale for why these medications are included on the list definitely provides valuable clinical insights that can be rationally applied in our population. As such, the Beers Criteria should still be considered by hospice clinicians who make medication-related decisions for terminally ill patients because of their vulnerability to harmful consequences of polypharmacy, prescribing inertia, and prescribing cascades.

Written by:

Shayna Cruz, PharmD Candidate 2019, Roosevelt University

Reviewed by:

Melissa Corak, PharmD, Clinical Pharmacist, OnePoint Patient Care

References:

  1. American Geriatrics Society 2019 Beers Criteria Update Expert Panel. American Geriatrics Society 2019 updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2019; 00(0):1-21.

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Charlie Otterbeck

OnePoint Patient Care

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