5/6/2020 2019 Beers Criteria for Drug Use in the Elderly, Updated

CME & EDUCATION

Wednesday, May 6, 2020

News & Perspective Drugs & Diseases CME & Education Academy Consult Video

From Medscape Education Clinical Briefs

CME / ABIM MOC / CE
2019 Beers Criteria for Drug Use in the
Elderly, Updated
Authors: News Author: Ricki Lewis, PhD; CME Author: Charles P. Vega, MD Faculty and Disclosures

THIS ACTIVITY HAS EXPIRED

CME / ABIM MOC / CE Released: 3/7/2019 Valid for credit through: 3/7/2020

Clinical Context
Clinicians are generally aware that
medications can result in more severe
adverse events among older adults, and
the Beers Criteria have helped define
those drugs that are best avoided in this
population. But is there a link between
taking potentially harmful drugs and a
higher risk for hospitalization among
older adults? Varga and colleagues
addressed this issue in a November 2017
issue of the British Journal of Clinical
Pharmacology.[1]

Researchers assessed an Italian database

that contained health information on
1,480,137 older adults. They evaluated
the rates of potentially inappropriate
medications (PIMs) among this
population, and they performed an
adjusted analysis to determine the risk for
hospitalization associated with these
medications
https://www.medscape.org/viewarticle/909799 1/12
5/6/2020 2019 Beers Criteria for Drug Use in the Elderly, Updated
medications.
CME & EDUCATION
More than half of study subjects used at
least 1 PIM, and subjects were exposed to
a PIM 10.9% of the time during the study
period. Nonsteroidal anti-inflammatory
drugs were the most common class of
PIM, and ketorolac was the PIM
associated with the highest rate of
hospitalization. The crude rates of
hospitalization during time exposed and
not exposed to a PIM were 228.1 and
152.1 per 1000 person-years, which
translated to an adjusted hazard ratio of
1.16 (95% CI, 1.14-1.18) for
hospitalization while receiving a PIM.

The current document updates the Beers

criteria for clinicians.

Study Synopsis and

Perspective
The American Geriatrics Society (AGS)
has released the 2019 update to the Beers
Criteria for Potentially Inappropriate
Medication Use in Older Adults. The
update was published online January 29
in the Journal of the American Geriatrics
Society.[2]

"Medications play an important role in

health and well-being for many older
people," Donna M. Fick, PhD, RN, co-
chair of the expert panel responsible for
the 2019 AGS Beers Criteria, said in a
news release. "With this new update, we
hope the latest information on what
makes medications appropriate for older
people can play an equally important role
in decisions about treatment options that
https://www.medscape.org/viewarticle/909799 2/12
5/6/2020
p2019 Beers Criteria for Drug Use in the Elderly, Updated
meet the needs of older adults while alsoCME & EDUCATION
keeping them as safe as possible."

The Beers Criteria are intended to

improve medication selection, reduce
adverse drug events, and provide a tool to
assess cost, patterns, and quality of care
of drugs used for people aged 65 years or
older. It lists drugs that should be avoided
in the treatment of older adults, either
generally or in patients with specific
diseases or conditions. Clinicians,
researchers, educators, healthcare
administrators, and regulators use the
criteria, which were first published in
1991 and have been updated every 3
years since 2011.

The 2019 criteria include 30 medications

or medication classes to be avoided in
older adults in general, and 40
medications or medication classes that
should be used with caution or avoided in
certain patients with certain diseases or
conditions. Two criteria were added in
response to the worsening opioid crisis:
not prescribing opioids with
benzodiazepines or gabapentinoids.

The criteria dropped 8 seizure

medications, 8 drugs for insomnia, and
vasodilators for syncope. Some of these
drugs were dropped because the problems
associated with their use are not unique to
older patients. Two (ticlopidine and
pentazocine) were dropped because they
are no longer available in the United
States.

Removed From the Criteria

https://www.medscape.org/viewarticle/909799 3/12
5/6/2020 2019 Beers Criteria for Drug Use in the Elderly, Updated

H2-receptor antagonists were removed CME & EDUCATION

from the criteria for dementia because the
evidence that they harm people with
dementia is weak. These drugs, which
relieve gastric reflux, can continue to be
used with caution in patients with high
risk dementia but should be avoided in
older adults with or at high risk of
delirium because of potential of inducing
or worsening delirium.

The chemotherapeutic drugs carboplatin,

cisplatin, vincristine, and
cyclophosphamide were removed from
the criteria because the panel considered
them to be "highly specialized" and
outside the scope of the criteria.

"Use With Caution"

Dextromethorphan/quinidine should be
used with caution because it has limited
efficacy in alleviating behavioral
symptoms of dementia in patients without
pseudobulbar affect and because it
potentially increases the risk for falls and
drug-drug interactions.

Rivaroxaban is to be used with caution

for venous thromboembolism or atrial
fibrillation in patients older than 75 years
because of the risk for gastrointestinal
bleeding.

Trimethoprim and sulfamethoxazole can

elevate risk for hyperkalemia in patients
with decreased kidney function who are
receiving angiotensin-converting enzyme
inhibitors or angiotensin receptor
blockers.
https://www.medscape.org/viewarticle/909799 4/12
5/6/2020 2019 Beers Criteria for Drug Use in the Elderly, Updated
blockers.
CME & EDUCATION
Carbamazepine, mirtazapine,
oxcarbazepine, serotonin, norepinephrine
reuptake inhibitors, selective serotonin
reuptake inhibitors, tricyclic
antidepressants, and tramadol should be
used with caution because they may
exacerbate or cause what is known as
syndrome of inappropriate antidiuretic
hormone secretion. Sodium levels should
be monitored closely when using these
drugs.
Aspirin should be used with caution for
primary protection against cardiovascular
disease or colorectal cancer in patients
older than 70 years, not 80 years, because
new data show that the age at which the
risk of bleeding is elevated has fallen.

Serotonin and norepinephrine reuptake

inhibitors should be prescribed with
caution for patients at risk of falling or
sustaining fractures.

Also New

For Parkinson's disease, the general

advice to avoid all antipsychotics has
been revised to except quetiapine,
clozapine, and pimavanserin.

For heart failure, nondihydropyridine and

calcium channel blockers should not be
prescribed for patients with low ejection
fractions, and nonsteroidal anti-
inflammatory drugs, COX-2 inhibitors,
thiazolidinediones, and dronedarone
should be prescribed with caution in
patients who have no symptoms of heart
failure.

https://www.medscape.org/viewarticle/909799 5/12
5/6/2020 2019 Beers Criteria for Drug Use in the Elderly, Updated

Macrolides (except azithromycin) or CME & EDUCATION

ciprofloxacin should not be prescribed
with warfarin because of bleeding risk.

Ciprofloxacin and theophylline should

not be prescribed because of increased
theophylline toxicity.

For patients with reduced kidney

function, use of ciprofloxacin is
associated with increased risk for tendon
rupture and increased central nervous

system effects. Use of trimethoprim-

sulfamethoxazole is associated with
worsening renal failure and
hyperkalemia.

"The AGS Beers Criteria are an essential

evidence-based tool that should be used
as a guide for drugs to avoid in older
adults. However, they are not meant to
supplant clinical judgment or an
individual patient's preferences, values,
care goals, and needs, nor should they be
used punitively or to excessively restrict
access to medications," the authors
conclude.

Limitations of the criteria are that

consideration was given only to studies
published in English, including
observational studies, and consideration
was not given to subpopulations of
patients.

In an accompanying editorial, panel

members Michael A. Steinman, MD,
from the Division of Geriatrics, the
University of California, San Francisco,
and Donna Fick, PhD, RN, from the
College of Nursing and the College of
https://www.medscape.org/viewarticle/909799 6/12
5/6/2020 2019 Beers Criteria for Drug Use in the Elderly, Updated
College of Nursing and the College of
Medicine, Pennsylvania State University,CME & EDUCATION
Hershey, remind readers that the drugs
that were deemed unsafe for older
patients in the 2019 criteria are
potentially inappropriate, not definitely
inappropriate, and advise close reading of
the details.[3]

"Optimal application of the AGS Beers

Criteria involves identifying potentially
inappropriate medications and where
appropriate offering safer
nonpharmacologic and pharmacologic
therapies," they write. Clinicians should
view the criteria as a starting point for
individual prescribing.

"[Ensuring] the safe and effective use of

medications by older adults is a
cornerstone of high-quality medical care
and a superb arena for interprofessional
practice.... Use the AGS Beers Criteria
well, and use them wisely," Dr Steinman
and Dr Fick conclude.

For the 2019 update, an expert panel

reviewed evidence published since the
last update to evaluate whether to add,
remove, or change specific criteria. The
13 members of the panel were physicians,
pharmacists, or nurses who had
participated in the 2015 update.

The panel fully reviewed 1422 articles.

Of those, 377 were abstracted into
evidence tables; these articles included 29
controlled clinical trials, 281
observational studies, and 67 systematic
meta-analyses and/or reviews. Comments
were collected from August 13, 2018, to
September 4 2018 and included 79
https://www.medscape.org/viewarticle/909799 7/12
5/6/2020 2019 Beers Criteria for Drug Use in the Elderly, Updated
September 4, 2018, and included 79
comments from 47 individuals, 10 CME & EDUCATION

comments from six pharmaceutical

companies, and 155 comments from 22
peer organizations.

One coauthor consults for Wolters-

Klewer. Another coauthor consults for
Institute for HealthCare Improvement, is
section editor for SLACK Inc, and
received a grant from IMPAQ on MTM.
Another coauthor consults for the
Colorado Access Pharmacy and
Therapeutics Committee. Another
coauthor is an editor for Lexi-Comp.
Another coauthor reviews physicians for
CVS/Caremark. The remaining authors
have disclosed no relevant financial
relationships. Dr Fick consults for
SLACK Inc and Precision Health
Economics. Dr Steinman consulted for
iodine.com.

J Am Geriatr Soc. Published online

January 29, 2019.

Study Highlights
The Beers Criteria are designed for
use by practicing clinicians. The
authors encourage their application
for teaching and measuring quality
of care, but not as a punitive
measure.
The authors acknowledge that drugs
on their list are not always
inappropriate for a given patient.
Clinical rationale and shared
decision-making are the most
important elements for safe
ibi
https://www.medscape.org/viewarticle/909799 8/12
5/6/2020 2019 Beers Criteria for Drug Use in the Elderly, Updated
prescribing.
CME & EDUCATION
A multidisciplinary team of 13
healthcare providers assessed 377
articles published between 2015 and
2017 to create the current update.
H2-receptor antagonists were
removed from the "avoid" list
among adults with dementia or
cognitive impairment. The degree of
evidence that these drugs cause
negative cognitive effects is weak.

Use of H2-receptor antagonists is

not recommended in patients with
delirium and remain on the “avoid”
list for this indication.
Glimepiride was added to the list of
sulfonylureas, which can increase
the risk for severe prolonged
hypoglycemia.
Serotonin-norepinephrine reuptake
inhibitors were added to the list of
drugs to avoid among adults with a
history of falls or fractures.
Although most antipsychotic
medications should be avoided
among patients with Parkinson
disease, quetiapine, clozapine, and
pimavanserin may be preferred in
this setting.
Nondihydropyridine calcium
channel blockers should not be used
among patients with heart failure.
Nonsteroidal anti-inflammatory
drugs and thiazolidinediones should
be used with caution in cases of
heart failure.
The age limit for the safe use of
https://www.medscape.org/viewarticle/909799 9/12
5/6/2020
g 2019 Beers Criteria for Drug Use in the Elderly, Updated

aspirin as primary prophylaxis CME & EDUCATION

against cardiovascular disease and
colorectal cancer was lowered from
80 to 70 years.
Rivaroxaban was added to
dabigatran as increasing the risk for
gastrointestinal bleeding compared
with warfarin and other direct oral
anticoagulants among adults at age
75 years and older.

Dextromethorphan/quinidine is
deemed inappropriate in the
treatment of the behavioral
symptoms of dementia. This drug
has limited evidence of efficacy and
may increase the risk for falls and
drug interactions. This
recommendation did not apply to the
treatment of pseudobulbar affect.
Multiple drugs should be avoided
because of their associated risk for
hyponatremia and syndrome of
inappropriate diuretic hormone,
including carbamazepine, diuretics,
tramadol, and multiple forms of
antidepressants.
Trimethoprim-sulfamethoxazole was
cited for its associated risk for
hyperkalemia when used with a
renin-angiotensin inhibitor in the
setting of reduced creatinine
clearance. Trimethoprim-
sulfamethoxazole can also increase
the risk for phenytoin toxicity and
bleeding among patients treated with
warfarin. Finally, trimethoprim-
sulfamethoxazole was added to the
https://www.medscape.org/viewarticle/909799 10/12
5/6/2020 2019 Beers Criteria for Drug Use in the Elderly, Updated
sulfamethoxazole was added to the
CME & EDUCATION
warning list among older adults with
renal dysfunction.
Nonsteroidal anti-inflammatory
drugs should be avoided if possible
among older adults, especially for
prolonged periods of treatment. The
authors note that indomethacin is
associated with the highest rate of
adverse effects of all nonsteroidal
anti-inflammatory drugs.

Ciprofloxacin can cause

neurological adverse effects among
adults with reduced renal function,
and it can promote a higher risk for
tendon rupture among these patients.

Clinical Implications
A previous study found that more
than half of older adults used at least
1 PIM, and participants were
exposed to a PIM during more than
10% of the study period.
Nonsteroidal anti-inflammatory
drugs were the most common class
of PIM. Use of a PIM was
independently associated with a
higher risk for hospitalization.
The current update to the Beers
Criteria includes warnings regarding
glimepiride, trimethoprim-
sulfamethoxazole, ciprofloxacin,
rivaroxaban and nonsteroidal anti-
inflammatory drugs; as well as the
deletion of multiple drugs from the
list due to availability. There is a
clear warning for the avoidance of
https://www.medscape.org/viewarticle/909799 11/12
5/6/2020 2019 Beers Criteria for Drug Use in the Elderly, Updated
clear warning for the avoidance of
dextromethorphan/quinidine in the CME & EDUCATION
treatment of behavioral symptoms of
dementia.
Implications for the Healthcare
Team: The healthcare team should
proactively reconcile medications
for older adults and eliminate PIMs
when possible. Health care
professionals should engage in
active communication with each
other and across care transitions to

enable appropriate selection of

medication for the elderly. The beers
guideline should be utilized as an
essential tool to identify and
improve medication appropriateness
and safety.

https://www.medscape.org/viewarticle/909799 12/12