American Geriatrics Society 2019 Beers Criteria Update

Polypharmacy in the elderly. A 2015 study in the journal JAMA found that polypharmacy in the prior 30 days among US adults aged ≥65 years increased from 24%-39% between 1999-2012. The same study also found that 39% of older adults reported polypharmacy in the previous 30 days between 2011-2012 alone.¹ It is difficult to definitively state whether polypharmacy is necessary because every patient’s circumstance is different, but, the updated American Geriatrics Society’s Beers Criteria® can increase awareness of polypharmacy and help physicians choose which drugs to avoid prescribing to elderly patients. How have the criteria changed? Find out in the slides above.

2019 Update to Beers Criteria: Key Points for PCPs.^2,3 There were nearly 70 changes made to the Beers Criteria from the prior 2015 criteria. The 2019 Beers Criteria applies to patients aged ≥65 years in ambulatory, acute, and institutional settings, not for hospice or palliative care settings. The focus of the updated criteria is to decrease PIM use in the elderly population. A PIM is associated with unfavorable balance of benefits and harms vs alternative treatments, however, some drugs may be appropriate under certain circumstances for certain patients. 

Drugs to avoid in general. Additions to the 2019 list that are pertinent to PCPs include the rationale to avoid sliding scale insulin being revised to clarify its risk for hypoglycemia without improved management; NSAIDs, COX-2 inhibitors, glitazones, and dronedarone in symptomatic HF; glimepiride; SNRIs in fall/fracture risk; metoclopramide (unless for gastroparesis use of ≤12 weeks); and pyrilamine and methscopolamine. Physicians should avoid or decrease the dose of Cipro and SMX-TMP in reduced renal function. 

Drugs to use with caution. Additions to the 2019 list that are pertinent to PCPs include tramadol (increases hyponatremia/syndrome of inappropriate antidiuretic hormone secretion risk); ASA for primary prevention of CVD and colorectal cancer in patients aged >70 yrs; and NSAIDs, COX-2 inhibitors, glitazones, and dronedarone in asymptomatic HF. 

Combinations to avoid in general. Opioids with benzodiazepines or gabapentinoids except when transitioning from the former to latter; ≥3 concomitant CNS-active drugs; macrolides (except azithromycin) and Cipro with warfarin (increase bleeding risk); Cipro plus theophylline (increase theophylline toxicity risk); SMX-TMP plus phenytoin (increase phenytoin toxicity risk); and SMX-TMP plus ACEI or ARB in patients with decreased renal function (increase hyperkalemia risk). 

Removed from criteria. Medications removed from the avoid list that are pertinent to PCPs include H₂-receptor blockers in dementia/cognitive impairment and 8 insomnia medications. Vasodilators were removed from the use with caution list.