This guideline is provided by the American Geriatric Society (AGS) regarding potentially inappropriate medications (not definitively inappropriate medications) for individuals ages 65 and older; these standards are known as the Beers Criteria . This 2023 guideline is an update of the 2019 version. This guideline was created to assist healthcare providers in decision-making while also taking into consideration a patient s preferences, needs, and goals, especially when there are numerous medications prescribed for multiple chronic diseases. A literature review in PubMed was performed by 10 experts in geriatric care and pharmacotherapy, including doctors, nurses, and pharmacists, from June 1, 2017, to May 31, 2022. Key Clinical Considerations Become familiar with the recommendations and best-practice statements provided in this guideline, especially if you care for older adults in acute care or ambulatory care settings. Potentially Inappropriate Medications READ MORE...
Antihistamines to be avoided due to their highly anticholinergic effects include the following: Brompheniramine Chlorpheniramine maleate Cyroheptadine Dimenhydrinate DiphenhydrAMINE hydrochloride (use may be appropriate in the treatment of acute, severe allergic reactions) Doxylamine HydrOXYzine hydrochloride Meclizine Promethazine Triprolidine
Nitrofurantoin macrocrystals should be avoided due to the potential for multisystem organ toxicity and peripheral neuropathy. Cardiovascular medications and antithrombotics to be avoided include the following: Aspirin should be avoided for the primary prevention of cardiovascular disease (CVD); the use of aspirin for secondary prevention in older adults with established CVD may be appropriate. Warfarin sodium should be avoided as initial therapy due to higher risk of major bleeding, unless direct oral anticoagulants (DOACs) are contraindicated. Rivaroxaban should be avoided for the long-term treatment of atrial fibrillation or venous thromboembolism (VTE). Dipyridamole should be avoided due to the risk of orthostatic hypotension. Nonselective peripheral alpha-1 blockers, including doxazosin mesylate, prazosin hydrochloride, and terazosin hydrochloride should be avoided. CloNIDine and guanFACINE hydrochloride should be avoided due to the high risk of adverse central nervous system effects. NIFEdipine (immediate release) should be avoided. Amiodarone hydrochloride should be avoided as first-line therapy for atrial fibrillation. Dronedarone should be avoided. Digoxin should be avoided as first-line treatment for atrial fibrillation or heart failure.
Desipramine hydrochloride Doxepin hydrochloride, with a dose of more than 6 mg per day Imipramine hydrochloride Nortriptyline hydrochloride PAroxetine hydrochloride
Antiparkinsonian agents, such as benztropine mesylate and trihexyphenidyl Antipsychotics (first and second generation) that should be avoided due to the increased risk of stroke and incidence of cognitive decline and mortality are as follows: ARIPiprazole Haloperidol OLANZapine QUetiapine fumarate RisperiDINE
ALPRAZolam ChlordiazePOXIDE hydrochloride (alone or in combination with amitriptyline or clidinium) CloBAZam ClonazePAM Clorazepate DiazePAM Estazolam LORazepam Midazolam hydrochloride Oxazepam Temazepam Triazolam
Nonbenzodiazepines, including eszopiclone, zaleplon, and zolpidem. These medications are associated with delirium, falls, and fractures. Meprobamate Ergoloid mesylates
Androgens (may be appropriate for symptomatic hypogonadism) Estrogen, with or without progestins (vaginal creams or tablets may be appropriate) Sliding scale insulin Sulfonylureas that should be avoided due to a higher risk of cardiovascular events and hypoglycemia, include Gliclazide Glimepiride GlipiZIDE GlyBURIDE
Desiccated thyroid Megestrol acetate should be avoided because it increases the risk of thrombotic events. Growth hormone
Proton-pump inhibitors due to increased risk of Clostridium difficile infection, pneumonia, GI malignancies, bone loss, and fractures. But the following may be appropriate for select conditions: Dexlansoprazole Esomeprazole magnesium Lansoprazole Omeprazole Pantoprazole sodium Rabeprazole
Metoclopramide should be avoided due to extrapyramidal side effects. GI antispasmodics that should be avoided due to their anticholinergic side effects include the following: Atropine sulfate Clidinium-chlordiazepoxide Dicyclomine Hyoscyamine Scopolamine
The genitourinary medication desmopressin should be avoided due to the increased risk of hyponatremia. Pain medications to be avoided include the following: Non-cyclooxygenase (COX)-2-selective nonsteroidal anti-inflammatory drugs (NSAIDS), due to increased risk of bleeding: Aspirin Diclofenac Diflunisal Etodolac Flurbiprofen Ibuprofen Indomethacin Ketorolac tromethamine (oral, nasal, injection) Meloxicam Nabumetone Naproxen sodium Oxaprozin Piroxicam Sulindac
Meperidine, due to an increased risk of neurotoxicity Skeletal muscle relaxants, due to sedation, anticholinergic effects, and increased risk of fractures, including Carisoprodol Chlorzoxazone Cyclobenzaprine Metaxalone Methocarbamol Orphenadrine
Potentially Inappropriate Medications for Patients with Certain Diseases or Syndromes READ MORE...
NSAIDS, COX-2 inhibitors, non-dihydropyridine calcium channel blockers, and thiazolidinediones should be avoided due to the potential to promote fluid retention and/or exacerbate heart failure. Cilostazol and dronedarone should be avoided due to the potential to increase mortality in older adults. Dextromethorphan-quinidine should be avoided due to concerns regarding QT prolongation.
Due to the increased risk of orthostatic hypotension, the following antipsychotics and tertiary tricyclic antidepressants should be avoided: Chlorpromazine Olanzapine Amitriptyline Clomipramine Doxepin Imipramine
Due to the side effect of bradycardia, the following cholinesterase inhibitors should be avoided: Donepezil Galantamine Rivastigmine
Due to causing orthostatic blood pressure changes, the following nonselective peripheral alpha-1 blockers should be avoided: Doxazosin Prazosin Terazosin
For patients with dementia or cognitive impairment, the following medications should be avoided: Antipsychotics Benzodiazepines Anticholinergics Nonbenzodiazepine receptor agonist hypnotics
For patients with a history of falls or fractures, the following medications should be avoided: Anticholinergics Antidepressants, including serotonin-norepinephrine reuptake inhibitors (SNRIs), selective serotonin reuptake inhibitors (SSRIs), and tricyclic antidepressants Antiepileptics Antipsychotics Benzodiazepines Opioids Nonbenzodiazepine receptor agonist hypnotics
For patients with Parkinson disease, the following medications should be avoided, due to the worsening of parkinsonian symptoms: Antiemetics, including Metoclopramide Prochlorperazine Promethazine
For patients with a history of gastric or duodenal ulcers, aspirin and non-COX-2 selective NSAIDS should be avoided due to the risk of exacerbating existing ulcers or causing new ulcers.
For female patients with urinary incontinence, the following medications should be avoided: Nonselective peripheral alpha-1 blockers Doxazosin mesylate Prazosin hydrochloride Terazosin hydrochloride
For male patients with lower urinary tract symptoms and/or benign prostatic hyperplasia, certain anticholinergic drugs should be avoided as they may decrease urinary flow and cause retention.
Dabigatran may increase the risk of GI bleeding. Prasugrel and ticagrelor increase the risk of major bleeding. The following medications may exacerbate or cause syndrome of inappropriate antidiuretic hormone or hyponatremia: Mirtazipine SNRIs SSRIs Tricyclic antidepressants CarBAMazepine OXcarbazepine Antipsychotics Diuretics TraMADol hydrochloride
Dextromethorphan-quinidine may increase the risk of falls, and it shows limited efficacy in select patients with dementia. Trimethoprim-sulfamethoxazole may increase the risk of hyperkalemia when used with an angiotensin-converting enzyme (ACE) inhibitor, angiotensin receptor blocker (ARB), or angiotensin receptor-neprilysin inhibitor (ARNI). The following medications may increase the risk of urogenital infections and euglycemic diabetic ketoacidosis: Canagliflozin Dapagliflozin Empagliflozin Ertugliflozin
Potentially Inappropriate Drug-Drug Interactions READ MORE...
Renin-angiotensin system (RAS) inhibitors or potassium-sparing diuretics may increase the risk of hyperkalemia when used concurrently with another RAS inhibitor or potassium-sparing diuretic. Opioids used concurrently with benzodiazepines may increase the risk of overdose. Opioids used concurrently with gabapentin or pregabalin may increase the risk of severe sedation, including respiratory depression and death. Multiple anticholinergic medications used concurrently increase the risk of cognitive decline, delirium, and falls/fractures. Any combination of three or more antiepileptics, antidepressants (tricyclic antidepressants, SNRIs, and SSRIs), antipsychotics, benzodiazepines, nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants may increase the risk of falls. The use of lithium with ACE inhibitors, ARBs, ARNIs, or loop diuretics may increase the risk of lithium toxicity. Concomitant use of nonselective peripheral alpha-1 blockers and loop diuretics may increase the risk of urinary incontinence in older women. The use of phenytoin with trimethoprim-sulfamethoxazole may increase the risk of phenytoin toxicity. Concomitant use of theophylline with cimetidine or ciprofloxacin may increase the risk of theophylline toxicity. Warfarin used concurrently with amiodarone, ciprofloxacin, macrolides (except azithromycin), trimethoprim-sulfamethoxazole, or SSRIs may increase the risk of bleeding.
Medications to be Avoided or Have Their Dosage Reduced READ MORE...
Reference: READ MORE... 2023 American Geriatrics Society Beers Criteria Update Expert Panel. (2023). American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 71(7), 2052 2081. https://doi.org/10.1111/jgs.18372 Download PDF Version
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