Beers Criteria for Inappropriate Medication Use in Older Adults: Update From the American Geriatrics Society

The Beers criteria for potentially inappropriate medication use in older adults are currently managed by the American Geriatrics Society and have been updated seven times since their introduction in 1991. The criteria suggest medications that should be avoided in most older patients and in certain situations and combinations. These recommendations do not apply to patients in hospice or end-of-life care.

Although medication costs were not factored into risk decisions, the panel understands that costs may be important in shared decision-making.

Antithrombotic medications dominated the panel's attention because of new evidence of risk in older adults with nonvalvular atrial fibrillation and venous thromboembolism.

The criteria recommend direct oral anticoagulants for initial treatment, particularly apixaban (Eliquis) or dabigatran (Pradaxa). Rivaroxaban (Xarelto), which has a higher risk of major bleeding and gastrointestinal bleeding and is not preferred, can be considered because of its once-daily dosing. For patients with reduced kidney function, only apixaban is recommended.

The panel recommends not using warfarin as initial therapy because of even higher bleeding risk, although continuation of warfarin in long-term users with well-controlled international normalized ratio levels is recommended.

Aspirin should be avoided for primary prevention of cardiovascular disease in older adults, which is consistent with the U.S. Preventive Services Task Force recommendation (https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/aspirin-to-prevent-cardiovascular-disease-preventive-medication). Ticagrelor (Brilinta) and prasugrel (Effient) increase the risk of major bleeding in older adults compared with clopidogrel, and this risk should be compared with cardiac benefit.

Oral and transdermal estrogen products should be avoided in older patients. Topical vaginal estrogen is appropriate for vaginal atrophy and urinary tract infection prophylaxis.

All sulfonylurea medications should be avoided because of a higher risk of hypoglycemia, cardiovascular events, and all-cause mortalities compared with other treatments. Although the criteria caution against using sodium-glucose cotransporter-2 inhibitors because of increased risk of urogenital infections and euglycemic diabetic ketoacidosis, the panel acknowledges the value of these medications and recommends monitoring during early treatment.

Several medication combinations should be avoided in older patients:

• Three or more medications that act on the central nervous system (e.g., antiepileptics, antidepressants, antipsychotics, opioids, benzodiazepines)
• Renin-angiotensin system inhibitor (e.g., angiotensin-converting enzyme inhibitor, angiotensin receptor blocker) with another renin-angiotensin system inhibitor, a potassium-sparing diuretic, or lithium
• Warfarin with amiodarone, selective serotonin reuptake inhibitors, or certain antibiotics (e.g., ciprofloxacin, macrolides, trimethoprim/sulfamethoxazole)
• Two or more medications with strong anticholinergic properties (Table 1)