TABLE 1.

2019 American Geriatrics Society Beers Criteria® for Potentially

Inappropriate Medication Use in Older Adults

From THE AMERICAN GERIATRICS SOCIETY Organ System, Therapeutic

Category, Drug(s)
Recommendation, Rationale, Quality of Evidence
(QE), Strength of Recommendation (SR)
A POCKET GUIDE TO THE Anticholinergics *
First-generation Avoid
2019 AGS BEERS CRITERIA® antihistamines:
■ Brompheniramine
Highly anticholinergic; clearance reduced with advanced age,
and tolerance develops when used as hypnotic; risk of confusion,
This guide has been developed as a tool to assist healthcare providers in improving ■ Carbinoxamine dry mouth, constipation, and other anticholinergic effects or
medication safety in older adults. The role of this guide is to inform clinical decision- ■ Chlorpheniramine toxicity
■ Clemastine Use of diphenhydramine in situations such as acute treatment of
making, research, training, quality measures and regulations concerning the prescribing of
■ Cyproheptadine
medications for older adults to improve safety and quality of care. It is based on The 2019 severe allergic reaction may be appropriate
■ Dexbrompheniramine
AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. ■ Dexchlorpheniramine QE = Moderate; SR = Strong
Originally conceived of in 1991 by the late Mark Beers, MD, a geriatrician, the Beers ■ Dimenhydrinate
Criteria catalogues medications that cause side effects in older adults due to the ■ Diphenhydramine (oral)
physiologic changes of aging. In 2011, the AGS sponsored its first update of the criteria, ■ Doxylamine
assembling a team of experts and using an enhanced, evidence-based methodology. ■ Hydroxyzine
Since 2011, the AGS has been the steward of the criteria and has produced updates ■ Meclizine
■ Promethazine
using an evidence-based methodology and rating each Criterion (quality of evidence
■ Pyrilamine
and strength of evidence) using the American College of Physicians’ Guideline Grading
■ Triprolidine
System, which is based on the GRADE scheme developed by Guyatt et al.
Antiparkinsonian agents Avoid
The full document, along with accompanying resources, can be found in its ■ Benztropine (oral) Not recommended for prevention of extrapyramidal symptoms
entirety online at geriatricscareonline.org. ■ Trihexyphenidyl with antipsychotics; more effective agents available for
treatment of Parkinson disease
INTENDED USE
QE = Moderate; SR = Strong
The goal of this guide is to improve care of older adults by reducing their Antispasmodics: Avoid
exposure to Potentially Inappropriate Medications (PIMs). ■ Atropine (excludes Highly anticholinergic, uncertain effectiveness
■ This should be viewed as a guideline for identifying medications for which ophthalmic) QE = Moderate; SR = Strong
■ Belladonna alkaloids
the risks of their use in older adults outweigh the benefits.
■ Clidinium-
■ These criteria are not meant to be applied in a punitive manner.
■ This list is not meant to supersede clinical judgment or an individual Chlordiazepoxide
■ Dicyclomine
patient’s values and needs. Prescribing and managing disease conditions
■ Homatropine (excludes
should be individualized and involve shared decision-making. ophthalmic)
■ These criteria also underscore the importance of using a team approach to ■ Hyoscyamine
prescribing and the use of non-pharmacological approaches and of having ■ Methscopolamine
economic and organizational incentives for this type of model. ■ Propantheline
■ A companion piece that addresses the best way for patients, providers, ■ Scopolamine
and health systems to use (and not use) the AGS Beers Criteria® was also Antithrombotics
developed. The document can be found on geriatricscareonline.org.
■ Dipyridamole, oral Avoid
The criteria are not applicable in all circumstances (i.e. patients receiving palliative and short-acting (does not Rationale: May cause orthostatic hypotension; more effective
hospice care). If a provider is not able to find an alternative and chooses to continue to apply to the extended- alternatives available; IV form acceptable for use in cardiac
use a drug on this list in an individual patient, designation of the medication as potentially release combination stress testing
inappropriate can serve as a reminder for close monitoring so that adverse drug effects with aspirin) QE = Moderate; SR = Strong
can be incorporated into the electronic health record and prevented or detected early.

*See also criterion on highly anticholinergic antidepressants

AGS THE AMERICAN GERIATRICS SOCIETY Geriatrics

Health Professionals.
CNS=central nervous system; NSAIDs=nonsteroidal anti-inflammatory drugs; SIADH,
syndrome of inappropriate antidiuretic hormone.
Leading change. Improving care for older adults.

PAGE 1 PAGE 2 Table 1 (continued on page 3)

 Table 1 Continued Table 1 Continued
Organ System, Therapeutic Recommendation, Rationale, QE, SR Organ System, Therapeutic Recommendation, Rationale, QE, SR
Category, Drug(s) Category, Drug(s)
Anti-infective Digoxin for first-line Avoid this rate control agent as first-line therapy for atrial
■ Nitrofurantoin Avoid in individuals with creatinine clearance <30 mL/min or treatment of atrial fibrillation. Avoid as first-line therapy for heart failure. If used
for long-term suppression fibrillation or of heart for atrial fibrillation or heart failure, avoid dosages >0.125 mg/d
Potential for pulmonary toxicity, hepatoxicity, and peripheral failure Use in atrial fibrillation: should not be used as a first-line agent
neuropathy, especially with long-term use; safer alternatives available in atrial fibrillation, because there are safer and more effective
QE = Low; SR = Strong alternatives for rate control supported by high-quality evidence.
Use in heart failure: evidence for benefits and harms of digoxin is
Cardiovascular conflicting and of lower quality; most but not all of the evidence
concerns use in heart failure with reduced ejection fraction
Peripheral alpha-1 Avoid use as an antihypertensive (HFrEF). There is strong evidence for other agents as first-line
blockers for treatment High risk of orthostatic hypotension and associated therapy to reduce hospitalizations and mortality in adults wiht
of hypertension harms, especially in older adults; not recommended as HFrEF. In heart failure, higher dosages are not associated with
■ Doxazosin additional benefit and may increase toxicity.
routine treatment for hypertension; alternative agents
■ Prazosin
have superior risk/benefit profile Decreased renal clearance of digoxin may lead to increased risk
■ Terazosin
QE = Moderate; SR = Strong of toxic effects; further dose reduction may be necessary in
Central-alpha agonists Avoid clonidine as first-line antihypertensive. Avoid other CNS those with Stage 4 or 5 chronic kidney disease.
Clonidine for first-line alpha-agonists as listed QE = Atrial fibrillation: Low. Heart failure: Low.
treatment of hypertension High risk of adverse CNS effects; may cause bradycardia and Dosage >0.125 mg/d: Moderate; SR = Atrial fibrillation: Strong.
Other CNS alpha-agonists orthostatic hypotension; not recommended as routine treatment Heart failure: Strong. Dosage >0.125 mg/d: Strong
■ Guanabenz for hypertension Nifedipine, immediate Avoid
■ Guanfacine QE = Low; SR = Strong release Potential for hypotension; risk of precipitating myocardial
■ Methyldopa ischemia
■ Reserpine (>0.1 mg/d) QE = High; SR = Strong
Disopyramide Avoid
May induce heart failure in older adults because of potent Amiodarone Avoid as first-line therapy for atrial fibrillation unless the patient
negative inotropic action; strongly anticholinergic; other has heart failure or substantial left ventricular hypertrophy
antiarrhythmic drugs preferred
Effective for maintaining sinus rhythm but has greater toxicities
QE = Low; SR = Strong than other antiarrhythmics used in atrial fibrillation; may be
Dronedarone Avoid in individuals with permanent atrial fibrillation or severe reasonable first-line therapy in patients with concomitant heart
or recently decompensated heart failure failure or substantial left ventricular hypertrophy if rhythm
control is preferred over rate control
Worse outcomes have been reported in patients taking
dronedarone who have permanent atrial fibrillation or severe or QE = High; SR = Strong
recently decompensated heart failure Central nervous system
QE = High; SR = Strong Antidepressants, alone or Avoid
in combination: Highly anticholinergic, sedating, and cause
■ Amitriptyline orthostatic hypotension; safety profile of low-dose
■ Amoxapine
doxepin (≤6 mg/d) comparable to that of placebo
■ Clomipramine
QE = High; SR = Strong
■ Desipramine
■ Doxepin >6 mg/d
■ Imipramine
■ Nortriptyline
■ Paroxetine
■ Protriptyline
■ Trimipramine

PAGE 3 Table 1 (continued on page 4) PAGE 4 Table 1 (continued on page 5)

Table 1 Continued Table 1 Continued
Organ System, Therapeutic Recommendation, Rationale, QE, SR Organ System, Therapeutic Recommendation, Rationale, QE, SR
Category, Drug(s) Category, Drug(s)
Antipsychotics, first- Avoid, except in schizophrenia, bipolar disorder, or for short- Ergoloid mesylates Avoid
(conventional) and term use as antiemetic during chemotherapy (dehydrogenated ergot Lack of efficacy
second- (atypical) Increased risk of cerebrovascular accident (stroke) and greater alkaloids) QE = High; SR = Strong
generation rate of cognitive decline and mortality in persons with dementia Isoxsuprine
Avoid antipsychotics for behavioral problems of dementia or Endocrine
delirium unless nonpharmacological options (e.g., behavioral Androgens Avoid unless indicated for confirmed hypogonadism with
interventions) have failed or are not possible and the older adult ■ Methyltestosterone clinical symptoms
is threatening substantial harm to self or others ■ Testosterone Potential for cardiac problems; contraindicated in men with
QE = Moderate; SR = Strong prostate cancer
Barbiturates Avoid QE = Moderate; SR = Weak
■ Amobarbital High rate of physical dependence, tolerance to sleep benefits, Desiccated thyroid Avoid
■ Butabarbital greater risk of overdose at low dosages Concerns about cardiac effects; safer alternatives available
■ Butalbital QE = High; SR = Strong
■ Mephobarbital QE = Low; SR = Strong
■ Pentobarbital Estrogens with or without Avoid systemic estrogen (eg, oral and topical patch). Vaginal
■ Phenobarbital progestins cream or vaginal tablets: acceptable to use low-dose
■ Secobarbital intravaginal estrogen for management of dyspareunia, recurrent
Benzodiazepines Avoid lower urinary tract infections, and other vaginal symptoms
Short- and intermediate- Older adults have increased sensitivity to benzodiazepines and Evidence of carcinogenic potential (breast and endometrium);
acting: decreased metabolism of long-acting agents; in general, all lack of cardioprotective effect and cognitive protection in older
■ Alprazolam women.
benzodiazepines increase risk of cognitive impairment, delirium,
■ Estazolam
falls, fractures, and motor vehicle crashes in older adults Evidence indicates that vaginal estrogens for the treatment of
■ Lorazepam
May be appropriate for seizure disorders, rapid eye movement vaginal dryness are safe and effective; women with a history of
■ Oxazepam
sleep behavior disorder, benzodiazepine withdrawal, ethanol breast cancer who do not respond to nonhormonal therapies
■ Temazepam
withdrawal, severe generalized anxiety disorder, and are advised to discuss the risk and benefits of low-dose vaginal
■ Triazolam estrogen (dosages of estradiol <25 mcg twice weekly) with their
periprocedural anesthesia
Long-acting: healthcare provider
■ Chlordiazepoxide (alone
QE = Moderate; SR = Strong
QE = Oral and patch: High. Vaginal cream or tablets: Moderate.;
or in combination SR = Oral and patch: Strong. Topical vaginal cream or tablets: Weak
with amitriptyline or
clidinium) Growth hormone Avoid, except for patients rigorously diagnosed by evidence-based
■ Clonazepam
criteria with growth hormone deficiency due to an established
■ Clorazepate etiology
■ Diazepam Impact on body composition is small and associated with edema,
■ Flurazepam arthralgia, carpal tunnel syndrome, gynecomastia, impaired fasting
■ Quazepam glucose
Meprobamate Avoid QE = High; SR = Strong
High rate of physical dependence; sedating Insulin, sliding scale Avoid
QE = Moderate; SR = Strong (insulin regimens Higher risk of hypoglycemia without improvement in hyperglycemia
containing only short- or management regardless of care setting; Avoid insulin regimens that
Nonbenzodiazepine, Avoid
rapid-acting insulin dosed include only short- or rapid-acting insulin dosed according to current
benzodiazepine receptor Nonbenzodiazepine benzodiazepine-receptor agonist hypnotics according to current blood glucose levels without concurrent use of basal or long-acting
agonist hypnotics (ie, “Z drugs”) have adverse events similar to those of blood gluclose levels insulin. This recommendation does not apply to regimens that contain
(ie, “Z-drugs”) benzodiazepines in older adults (e.g., delirium, falls, fractures); without concurrent use basal insulin or long-acting insulin.
■ Eszopiclone increased emergency room visits/hospitalizations; motor vehicle of basal or long-acting QE = Moderate; SR = Strong
■ Zaleplon crashes; minimal improvement in sleep latency and duration insulin)
■ Zolpidem QE = Moderate; SR = Strong Megestrol Avoid
Minimal effect on weight; increases risk of thrombotic events
and possibly death in older adults
QE = Moderate; SR = Strong

PAGE 5 Table 1 (continued on page 6) PAGE 6 Table 1 (continued on page 7)

Table 1 Continued Table 1 Continued
Organ System, Therapeutic Recommendation, Rationale, QE, SR Organ System, Therapeutic Recommendation, Rationale, QE, SR
Category, Drug(s) Category, Drug(s)
Sulfonylureas, long-acting Avoid ■ Indomethacin Avoid
■ Chlorpropamide Chlorpropamide: prolonged half-life in older adults; can cause ■ Ketorolac, includes Increased risk of gastrointestinal bleeding/peptic ulcer
■ Glimeperide prolonged hypoglycemia; causes SIADH parenteral disease, and acute kidney injury in older adults
■ Glyburide (also known Glimepiride and Glyburide: higher risk of severe prolonged Indomethacin is more likely than other NSAIDs to have
as glibenclamide) adverse CNS effects. Of all the NSAIDs, indomethacin
hypoglycemia in older adults has the most adverse effects.
QE = High; SR = Strong QE = Moderate; SR = Strong
Gastrointestinal Skeletal muscle relaxants Avoid
Metoclopramide Avoid, unless for gastroparesis with duration of use not to ■ Carisoprodol Most muscle relaxants poorly tolerated by older adults because
exceed 12 weeks except in rare cases ■ Chlorzoxazone some have anticholinergic adverse effects, sedation, increased
■ Cyclobenzaprine risk of fractures; effectiveness at dosages tolerated by older
Can cause extrapyramidal effects, including tardive dyskinesia; ■ Metaxalone adults questionable
risk may be greater in frail older adults and with prolonged ■ Methocarbamol QE = Moderate; SR = Strong
exposure Orphenadrine
■
QE = Moderate; SR = Strong Genitourinary
Mineral oil, given orally Avoid Desmopressin Avoid for treatment of nocturia or nocturnal polyuria
Potential for aspiration and adverse effects; safer alternatives High risk of hyponatremia; safer alternative treatments
available QE = Moderate; SR = Strong
QE = Moderate; SR = Strong
Proton-pump inhibitors Avoid scheduled use for >8 weeks unless for high-risk patients TABLE 2. 2019 American Geriatrics Society Beers Criteria® for Potentially
(e.g., oral corticosteroids or chronic NSAID use), erosive Inappropriate Medication Use in Older Adults Due to Drug–Disease or Drug–
esophagitis, Barrett’s esophagitis, pathological hypersecretory Syndrome Interactions That May Exacerbate the Disease or Syndrome
condition, or demonstrated need for maintenance treatment
(e.g., because of failure of drug discontinuation trial or H2- Recommendation, Rationale,
receptor antagonists Disease or Quality of Evidence (QE), Strength
Risk of C difficile infection and bone loss and fractures Syndrome Drug(s) of Recommendation (SR)
QE = High; SR = Strong Cardiovascular
Pain medications Heart failure Avoid: Cilostazol As noted, avoid or use with caution
Meperidine Avoid Avoid in heart failure with Potential to promote fluid retention
Oral analgesic not effective in dosages commonly used; may reduced ejection fraction: Non- and/or exacerbate heart failure
have higher risk of neurotoxicity, including delirium, than other dihydropyridine CCBs (diltiazem, (NSAIDs and COX-2 inhibitors,
opioids; safer alternatives available verapamil) non-dihydropyridine CCBs,
QE = Moderate; SR = Strong Use with caution in patients with thiazoildinediones); potential to
Non-cyclooxygenase- Avoid chronic use, unless other alternatives are not heart failure who are asymptomatic; increase mortality in older adults
selective NSAIDs, oral: effective and patient can take gastroprotective agent avoid in patients with symptomatic with heart failure (cilostazol and
■ Aspirin >325 mg/d (proton-pump inhibitor or misoprostol) heart failure: dronedarone)
■ Diclofenac
Increased risk of gastrointestinal bleeding or peptic ulcer NSAIDs and COX-2 inhibitors QE = Cilostazol: Low Non-
■ Diflunisal
disease in high-risk groups, including those aged >75 or taking dihydropyridine CCBs: Moderate
■ Etodolac Thiazolidinediones (pioglitazone,
oral or parenteral corticosteroids, anticoagulants, or NSAIDs: Moderate COX-2 inhibitors:
■ Fenoprofen
■ Ibuprofen
antiplatelet agents; use of proton-pump inhibitor or misoprostol rosiglitazone)
reduces but does not eliminate risk. Upper gastrointestinal Low. Thiazolidinediones: High.
■ Ketoprofen Dronedarone Dronedarone: High; SR = Strong
■ Meclofenamate ulcers, gross bleeding, or perforation caused by NSAIDs occur
■ Mefenamic acid in ~1% of patients treated for 3–6 months and in ~2–4% of
■ Meloxicam patients treated for 1 year; these trends continue with longer
■Nabumetone duration of use. Also can increase blood pressure and induce *See Table 7 in full criteria available on www.geriatricscareonline.org.
■Naproxen ■ kidney injury. Risks are dose-related. aMay be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health
Oxaprozin ■ QE = Moderate; SR = Strong conditions but should be prescribed in the lowest effective dose and shortest possible duration.
Piroxicam ■ bExcludes inhaled and topical forms. Oral and parenteral corticosteroids may be required for conditions such as
Sulindac ■ exacerbation of COPD but should be prescribed in the lowest effective dose and for the shortest possible duration.
Tolmetin
CCB=calcium channel blocker; AChEI=acetylcholinesterase inhibitor; CNS=central nervous system;
COX=cyclooxygenase; NSAIDs=nonsteroidal antiinflammatory drug; SNRI=serotoninnorepinephrine
reuptake inhibitor; SSRI=selective serotonin reuptake inhibitor; TCAs=tricyclic antidepressant.

PAGE 7 Table 1 (continued on page 8) PAGE 8 Table 2 (continued on page 9)

Table 2 Continued
Disease or Recommendation, Rationale, QE, SR
Syndrome Drug(s)
Syncope Acetylcholinesterase inhibitors Avoid
(AChEIs) AChEIs cause bradycardia and should
Non-selective peripheral alpha-1 be avoided in older adults whose
blockers (ie, doxazosin, prazosin, syncope may be due to bradycardia.
terazosin) Non-selective peripheral alpha-1
Tertiary TCAs blockers cause orthostatic blood
Antipsychotics pressure changes and should be
■ Chlorpromazine avoided in older adults whose syncope
■ Thioridazine may be due to orthostatic hypotension.
■ Olanzapine Tertiary TCAs and the antipsychotics
listed increase the risk of orthostatic
hypotension or bradycardia.
QE = AChEIs, TCAs and antipsychotics:
High. Non-selective peripheral alpha-1
blockers: High; SR = AChEIs, TCAs:
Strong. Non-selective peripheral
alpha-1 blockers, antipsychotics: Weak
Central nervous system
Delirium Anticholinergics* Avoid
Antipsychoticsa Avoid in older adults with or at high
Benzodiazepines risk of delirium because of potential
Corticosteroids (oral and of inducing or worsening delirium
parenteral)b Avoid antipsychotics for behavioral
H2-receptor antagonists problems of dementia and/or delirium
■ Cimetidine unless nonpharmacological options
■ Famotidine (e.g., behavioral interventions) have
■ Nizatidine failed or are not possible and the older
■ Ranitidine adult is threatening substantial harm to
Meperidine self or others. Antipsychotics are
Nonbenzodiazepine, associated with greater risk of
benzodiazepine receptor cerebrovascular accident (stroke) and
agonist hypnotics: eszopiclone, mortality in persons with dementia
zaleplon, zolpidem QE = H2-receptor antagonists: Low.
All others: Moderate; SR = Strong
Dementia Anticholinergics* Avoid
or cognitive
Benzodiazepines Avoid because of adverse CNS effects
impairment
Nonbenzodiazepine, Avoid antipsychotics for behavioral
benzodiazepine receptor problems of dementia and/or delirium
agonist hypnotics unless nonpharmacological options
■ Eszopiclone (e.g., behavioral interventions) have
■ Zaleplon failed or are not possible and the older
■ Zolpidem adult is threatening substantial harm to
Antipsychotics, chronic and self or others. Antipsychotics are
as-needed usea associated with greater risk of
cerebrovascular accident (stroke) and
mortality in persons with dementia
QE = Moderate; SR = Strong
PAGE 9 Table 2 (continued on page 10)
Table 2 Continued
Disease or Recommendation, Rationale, QE, SR
Syndrome Drug(s)
History of Antiepileptics Avoid unless safer alternatives are
falls or Antipsychoticsa not available; avoid antiepileptics
fractures Benzodiazepines except for seizure and mood disorders.
Nonbenzodiazepine, Opioids: avoid except for pain
benzodiazepine receptor agonist management in the setting of severe
hypnotics acute pain, eg, recent fractures or joint
■ Eszopiclone replacement
■ Zaleplon May cause ataxia, impaired
■ Zolpidem psychomotor function, syncope,
Antidepressants additional falls; shorter-acting
■ TCAs benzodiazepines are not safer than
■ SSRIs long-acting ones
■ SNRIs If one of the drugs must be used,
Opioids consider reducing use of other CNS-
active medications that increase risk
of falls and fractures (ie, antiepileptics,
opioid-receptor agonists, antipsychotics,
antidepressants, nonbenzodiazepine
and benzodiazepine-receptor agonists,
other sedatives/hypnotics) and
implement other strategies to reduce
fall risk. Data for antidepressants are
mixed but no compelling evidence that
certain antidepressants confer less fall
risk than others.
QE = Opioids: Moderate. All others:
High; SR = Strong
Parkinson Antiemetics Avoid
disease ■ Metoclopramide Dopamine-receptor antagonists with
■ Prochlorperazine potential to worsen parkinsonian
■ Promethazine symptoms
All antipsychotics (except Exceptions: Pimavanserin and clozapine
quetiapine, clozapine, appear to be less likely to precipitate
pimavanserin) worsening of Parkinson disease.
Quetiapine has only been studied in
low quality clinical trials with efficacy
comparable to that of placebo in 5 trials
and to that of clozapine in 2 others.
QE = Moderate; SR = Strong
Gastrointestinal
History of Aspirin (>325 mg/d) Non- Avoid unless other alternatives are
gastric or not effective and patient can take
COX-2 selective NSAIDs
duodenal gastroprotective agent (ie, proton-
ulcers pump inhibitor or misoprostol)
May exacerbate existing ulcers
or cause new/additional ulcers
QE = Moderate; SR = Strong
PAGE 10 Table 2 (continued on page 11)
Table 2 Continued Table 3 Continued
Disease or Recommendation, Rationale, QE, SR Prasugrel Use with caution in adults ≥75 years old
Syndrome Drug(s) Increased risk of bleeding in older adults; benefit in highest-risk older
Kidney/Urinary tract adults (e.g., those with prior myocardial infarction or diabetes mellitus)
Chronic NSAIDs (non-COX and COX- Avoid may offset risk when used for its approved indication of acute coronary
kidney selective, oral and parenteral, May increase risk of acute kidney syndrome to be managed with percutaneous coronary intervention
disease Stage nonacetylated salicylates)
IV or higher
injury and further decline of renal QE = Moderate; SR = Weak
(creatinine function Antipsychotics Use with caution
QE = Moderate; SR = Strong Carbamazepine May exacerbate or cause SIADH or hyponatremia; monitor sodium
clearance <30
Diuretics level closely when starting or changing dosages in older adults
mL/min)
Mirtazapine
Oxcarbazepine QE = Moderate; SR = Strong
Urinary Estrogen oral and transdermal Avoid in women SNRIs
incontinence (excludes intravaginal estrogen) Lack of efficacy (oral estrogen) SSRIs
(all types) in Peripheral alpha-1 blockers and aggravation of incontinence TCAs
women ■ Doxazosin (alpha-1 blockers) Tramadol
■ Prazosin QE = Estrogen: High. Peripheral alpha-1 Dextromethorphan/ Use with caution
■ Terazosin blockers: Moderate; SR = Estrogen: quinidine Limited efficacy in patients with behavioral symptoms of
Strong. Peripheral alpha-1 blockers:
Strong dementia (does not apply to treatment of PBA). May increase
risk of falls and concerns with clinically significant drug
interactions. Does not apply to

Lower Strongly anticholinergic drugs, Avoid in men treatment of pseudobulbar affect.

urinary tract except antimuscarinics for urinary May decrease urinary flow and cause QE = Moderate; SR = Strong
symptoms, incontinence.* urinary retention Trimethoprim- Use with caution in patients on ACEI or ARB and
benign QE = Moderate; SR = Strong
prostatic decreased sulfamethoxazole creatinine clearance.
hyperplasia Increased risk of hyperkalemia when used concurrently with an
TABLE 3. 2019 American Geriatrics Society Beers Criteria® for Potentially Inappropriate ACEI or ARB in presence of decreased creatinine clearance.
QE = Low; SR = Strong
Medications to Be Used with Caution in Older Adults ACEI= angiotensin-converting enzyme inhibitor; ARB=angiotensin receptor blocker; CrCl=
creatinine clearance; SIADH= syndrome of inappropriate antidiuretic hormone secretion;
Recommendation, Rationale, Quality of Evidence (QE), SNRIs = Serotonin-nonrepinephrine reuptake inhibitors; SSRIs = Selective serotonin reuptake
Drug(s) Strength of Recommendation (SR) inhibitors; TCA=tricyclic antidepressant; VTE=venous thromboembolism
Aspirin for primary Use with caution in adults ≥70 years old
prevention of Risk of major bleeding from aspirin increases markedly in older age.
cardiovascular TABLE 4. 2019 American Geriatrics Society Beers Criteria ® for Potentially Clinically
Several studies suggest lack of net benefit when used for primary
disease and prevention in older adult with cardiovascular risk factors, but evidence is Important Drug–Drug Interactions That Should Be Avoided in Older Adults
colorectal cancer not conclusive. Aspirin is generally indicated for secondary prevention in Interacting Drug Recommendation, Risk Rationale, Quality of Evidence
older adults with established cardiovascular disease. Object Drug and Class and Class (QE), Strength of Recommendation (SR)
QE = Moderate; SR = Strong RAS inhibitor Another RAS Avoid routine use in those with chronic kidney
(ACEIs, ARBs, inhibitor disease Stage 3a or higher
Dabigatran Use with caution for treatment of VTE or atrial fibrillation in
aliskiren) or (ACEIs, ARBs, Increased risk of hyperkalemia
Rivaroxaban adults ≥75 years old potassium-sparing aliskiren) QE = Moderate; SR = Strong
Increased risk of gastrointestinal bleeding compared with diuretics (amiloride,
warfarin and reported rates with other direct oral anticoagulants triamterene)
when used for long-term treatment of venous thromboembolism Opioids Benzo- Avoid
(VTE) or atrial fibrillation in adults ≥75 years old. diazepines Increased risk of overdose
QE = Moderate; SR = Strong QE = Moderate; SR = Strong

PAGE 11 Table 3 (continued on page 12)

PAGE 12 Table 4 (continued on page 13)
 Warfarin Ciprofloxacin Avoid when possible; if used together, monitor INR
Table 4 Continued closely
Increased risk of bleeding
Opioids Gabapentin, Avoid; exceptions are when transitioning from opioid
QE = Moderate; SR = Strong
pregabalin therapy to gabapentin or pregabalin, or when using
gabapentinoids to reduce opioid dose, although Warfarin Macrolides Avoid when possible; if used together, monitor INR
(excluding closely
caution should be used in all circumstances. azithromycin) Increased risk of bleeding
Increased risk of severe sedation-related adverse
QE = Moderate; SR = Strong
events, including respiratory depression and death
Warfarin Trimethoprim- Avoid when possible; if used together, monitor INR
QE = Moderate; SR = Strong sulfamethox- closely
Anticholinergic Anticholinergic Avoid, minimize number of anticholinergic drugs azole Increased risk of bleeding
Increased risk of cognitive decline QE = Moderate; SR = Strong
QE = Moderate; SR = Strong Warfarin NSAIDs Avoid when possible; if used together, monitor closely
Antidepressants Any Avoid total of ≥3 CNS-active drugsa; minimize number for bleeding
(TCAs, SSRIs, and combination of CNS-active drugs Increased risk of bleeding
SNRIs) of ≥3 of Increased risk of falls (all) and of fracture QE = High; SR = Strong
these
Antipsychotics CNS-active (benzodiazepines and nonbenzodiazepine,
Antiepileptics drugsa benzodiazepine receptor agonist hypnotics) TABLE 5. 2019 American Geriatrics Society Beers Criteria® for Medications That
Benzodiazepines QE: Combinations including benzodiazepines and Should Be Avoided or Have Their Dosage Reduced with Varying Levels of Kidney
and nonbenzodiaz- nonbenzodiazepine, benzodiazepine receptor agonist Function in Older Adults
epine, benzodi- hypnotics or opioids: High. All other combinations:
azepine receptor Moderate; SR: Strong Medication Class Creatinine Clearance, Recommendation, Rationale, Quality of Evidence (QE),
agonist hypnotics mL/min, at Which
(ie, “Z-drugs”) and Medication Action Required Strength of Recommendation (SR)
Opioids Anti-infective
Corticosteroids, NSAIDs Avoid; if not possible, provide gastrointestinal Ciprofloxacin <30 Doses used to treat common infections typically
oral or parenteral protection require reduction when CrCl <30 mL/min
Increased risk of peptic ulcer disease or Increased risk of CNS effects (eg, seizures, confusion)
gastrointestinal bleeding and tendon rupture
QE = Moderate; SR = Strong QE = Moderate; SR = Strong
Lithium ACEIs Avoid, monitor lithium concentrations Trimethoprim- <30 CrCl 15-29 mL/min:Reduce Dose
Increased risk of lithium toxicity sulfamethox- <15 mL/min: Avoid
QE = Moderate; SR = Strong azole Increased risk of worsening of renal function and
Lithium Loop diuretics Avoid, monitor lithium concentrations hyperkalemia
Increased risk of lithium toxicity
QE = Moderate; SR = Strong
QE = Moderate; SR = Strong
Peripheral Loop diuretics Avoid in older women, unless conditions warrant
aCentral nervous system (CNS)-active drugs: antiepileptics, antipsychotics; benzodiazepines;
alpha-1 blockers both drugs
nonbenzodiazepine, benzodiazepine receptor agonist hypnotics; tricyclic antidepressants (TCAs); selective
Increased risk of urinary incontinence in older women serotonin reuptake inhibitors (SSRIs); serotonin-norepinephrine reuptake inhibitors (SNRIs); and opioids
QE = Moderate; SR = Strong ACEIs=angiotensin-converting enzyme inhibitors; ARBs=angiotensin receptor blockers; INR=international
Phenytoin Trimethoprim- Avoid normalized ratio; NSAIDs=nonsteroidal anti-inflammatory drugs; RAS=renin-angiotensin system
sulfamethox- Increased risk of phenytoin toxicity
Copyright © 2019 by the American Geriatrics Society. All rights reserved. Except where authorized, no part
azole QE = Moderate; SR = Strong of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any
Theophylline Cimetidine Avoid means, electronic, mechanical, photocopying, recording, or otherwise without written permission of the
Increased risk of theophylline toxicity American Geriatrics Society, 40 Fulton Street, 18th Floor, New York, NY 10038. The Criteria published by
QE = Moderate; SR = Strong The American Geriatrics Society (AGS) incorporate data obtained from a literature review of the most recent
studies available at the time. As with all clinical reference resources, they reflect the best understanding of
Theophylline Ciprofloxacin Avoid the science of medicine at the time of publication, but they should be used with the clear understanding that
Increased risk of theophylline toxicity continued research may result in new knowledge and recommendations. The Criteria are intended for
QE = Moderate; SR = Strong general information only, are not medical advice, and do not replace professional medical care and
physician advice, which always should be sought for any specific condition.
Warfarin Amiodarone Avoid when possible; if used together, monitor INR
closely
Increased risk of bleeding
QE = Moderate; SR = Strong

PAGE 13 Table 4 (continued on page 14) PAGE 14 Table 5 (continued on page 15)
Table 5 Continued Table 5 Continued
Medication Class Creatinine Clearance, Medication Class Creatinine Clearance,
mL/min, at Which Recommendation, Rationale, QE, SR mL/min, at Which Recommendation, Rationale, QE, SR
and Medication Action Required and Medication Action Required
Cardiovascular or hemostasis Central nervous system and analgesics
Amiloride <30 Avoid Duloxetine <30 Avoid
Increased potassium and decreased sodium Increased gastrointestinal adverse effects (nausea,
QE = Moderate; SR = Strong diarrhea)
Apixaban <25 Avoid QE = Moderate; SR = Weak
Lack of evidence for efficacy and safety in patients Gabapentin <60 Reduce dose
with a CrCl <25 mL/min CNS adverse effects
QE = Moderate; SR = Strong QE = Moderate; SR = Strong
Dabigatran <30 Avoid; dose adjustment advised when CrCl >30 mL/ Levetiracetam ≤80 Reduce dose
min in the presence of drug-drug interactions CNS adverse effects
Lack of evidence for efficacy and safety in individuals QE = Moderate; SR = Strong
with a CrCl <30 mL/min. Label dose for patients with a Pregabalin <60 Reduce dose
CrCl 15-30 mL/min based on pharmacokinetic data. CNS adverse effects
QE = Moderate; SR = Strong QE = Moderate; SR = Strong
Dofetilide <60 CrCl 20-59 mL/min: Reduce dose Tramadol <30 Immediate release: Reduce dose
CrCl <20 mL/min: Avoid Extended release: avoid
QTc prolongation and torsades de pointes CNS adverse effects
QE = Moderate; SR = Strong QE = Low; SR = Weak
Edoxaban 15–50 CrCl 15-50: Reduce dose Gastrointestinal
<15 or >95 CrCl <15 or >95: Avoid
Cimetidine <50 Reduce dose
Lack of evidence of efficacy or safety in patients with Mental status changes
a CrCl <30 mL/min
QE = Moderate; SR = Strong
QE = Moderate; SR = Strong
Famotidine <50 Reduce dose
Enoxaparin <30 Reduce dose Mental status changes
Increased risk of bleeding
QE = Moderate; SR = Strong
QE = Moderate; SR = Strong
Nizatidine <50 Reduce dose
Fondaparinux <30 Avoid Mental status changes
Increased risk of bleeding
QE = Moderate; SR = Strong
QE = Moderate; SR = Strong
Ranitidine <50 Reduce dose
Rivaroxaban <50 Nonvalvular atrial fibrillation: reduce dose if CrCl Mental status changes
15-50 mL/min; avoid if CrCl <15 mL/min
QE = Moderate; SR = Strong
Venous thromboembolism treatment and for VTE
prophylaxis with hip or knee replacement: avoid if Hyperuricemia
CrCl <30 mL/min Colchicine <30 Reduce dose; monitor for adverse effects
Lack of efficacy or safety evidence in patients with a Gastrointestinal, neuromuscular, bone marrow toxicity
CrCl <30 mL/min QE = Moderate; SR = Strong
QE = Moderate; SR = Strong Probenecid <30 Avoid
Spironolactone <30 Avoid Loss of effectiveness
Increased potassium QE = Moderate; SR = Strong
QE = Moderate; SR = Strong CNS=central nervous system; QTc=corrected QT interval; CrCl=creatinine clearance
Triamterene <30 Avoid The primary target audience is the practicing clinician. The intentions of the criteria include 1)
Increased potassium and decreased sodium improving the selection of prescription drugs by clinicians and patients; 2) evaluating patterns
QE = Moderate; SR = Strong of drug use within populations; 3) educating clinicians and patients on proper drug usage;
and 4) evaluating health-outcome, quality-of-care, cost, and utilization data.

PAGE 15 Table 5 (continued on page 16) PAGE 16