2023 update to Beers Criteria for potentially inappropriate medications in older adults

The American Geriatrics Society (AGS) has released the 2023 version of the Beers Criteria—a list of potentially inappropriate medications that typically are best avoided by older adults in most circumstances or in specific situations (e.g., in certain diseases or conditions). The 2023 version updates the previous edition published in 2019.1 The Beers Criteria are intended to be used by practising clinicians caring for adults 65 years of age or older in all ambulatory, acute and institutionalized settings of care, except for hospice and palliative care settings.1 The ultimate goal is to improve the care of older adults by reducing their exposure to potentially inappropriate medications that have an unfavourable balance of benefits and harms compared with alternate treatment options.1 The 2023 update maintains the same five sections as the 2019 edition: Medications considered as potentially inappropriate Medications that are potentially inappropriate in patients with certain diseases or syndromes Medications to be used with caution Potentially inappropriate drug–drug interactions Medications whose dosages should be adjusted based on renal function.1 Key changes in the 2023 Beers Criteria A special box has been added to summarize the Beers Criteria for anticoagulants (warfarin, rivaroxaban, dabigatran). A separate table lists drugs with strong anticholinergic properties. The rationale for avoiding anticholinergic drugs has been expanded to recognize the risks associated with concurrent use (i.e., cumulative anticholinergic burden). The criterion for the use of aspirin (acetylsalicylic acid) for the primary prevention of cardiovascular disease has been revised, with the new recommendation to avoid initiating aspirin for the primary prevention of cardiovascular disease in older adults. For older adults already taking aspirin for primary prevention, deprescribing should be considered, pending any new data on this issue. The recommendation for rivaroxaban has changed from “use with caution” to “avoid” for long-term treatment of nonvalvular atrial fibrillation and venous thromboembolism (VTE). The rationale is that observational studies and network meta-analyses found that this drug confers a higher risk of major bleeding and gastrointestinal bleeding in older adults than other direct-acting oral anticoagulants (DOACs), particularly apixaban, but also dabigatran. However, there are circumstances when rivaroxaban may be a reasonable choice, including for other clinical conditions and in special circumstances such as when a once-daily DOAC is necessary to facilitate medication adherence. All DOACs have a lower risk of intracranial hemorrhage than warfarin. Warfarin has been added as a medication to be avoided when starting initial therapy for VTE or nonvalvular atrial fibrillation unless alternatives (e.g., DOACs) are contraindicated or there are substantial barriers to the use of an alternative. The initiation of oral and transdermal estrogen is to be avoided in older women; topical vaginal estrogen remains appropriate for its major indications of symptomatic vaginal atrophy or urinary tract infection prophylaxis. Deprescribing should be considered for older women already using nonvaginal estrogen replacement. All sulfonylureas (rather than just long-acting sulfonylureas) should be avoided as first- or second-line monotherapy or add-on therapy because of their association with a higher risk of cardiovascular events, all-cause mortality and hypoglycemia, compared to alternatives. If a sulfonylurea must be used (e.g., due to financial considerations), a short-acting agent is preferred because of the higher risk of prolonged hypoglycemia with longer-acting sulfonylureas (e.g., glimepiride, chlorpropamide, glyburide). The combination of dextromethorphan/quinidine was added to the list of drugs to avoid in patients with heart failure. Opioids have been added to the list of drugs that can exacerbate delirium. A new criterion was added advising that sodium-glucose co-transporter-2 (SGLT2) inhibitors should be used with caution because of the increased risk of urogenital infection and euglycemic diabetic ketoacidosis. Patients taking these drugs should be monitored for possible adverse effects. The table of drugs to avoid or use at reduced doses with varying levels of kidney function has been updated. Apixaban is considered safe to use in patients with end-stage renal disease. Rivaroxaban's dosing in reduced kidney function is variable and is based on indication; product labelling should be consulted. Baclofen should be avoided when eGFR is < 60 mL/min because of the increased risk for encephalopathy in older adults.1 The American Geriatrics Society stresses that the term “avoid” in the Beers Criteria is not an absolute contraindication unless specified in the medication's labelling. Rather, it means that the medication should be avoided except under unusual circumstances, e.g., when a safer alternative did not achieve the desired therapeutic outcome. Also, close attention to the Beers Criteria recommendations is essential to avoid misinterpretation; many criteria note exceptions and other considerations and should not be overly simplified as “avoid in everyone over age 65.”1 The intent of the Beers Criteria is not simply to “swap out a better drug in place of a worse one.” In many cases, nonpharmacologic treatments (or no treatment at all) may be preferable. The AGS Beers Criteria should be a starting point for a comprehensive process of identifying and improving medication appropriateness and safety in older adults.1 Reference 1. 2023 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. (accessed June 8, 2023.

2023 update to Beers Criteria for potentially inappropriate medications in older adults

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