Updated Beers Criteria: Considerations for Pharmacists

The Beers Criteria for Potentially Inappropriate Medication Use in Older Adults developed by the American Geriatric Society (AGS) provides pharmacists with an invaluable, easily referenced tool to help ensure appropriate prescribing in elderly patients.

The Beers Criteria provide a clear list of medications to avoid in older adults, as well as information on which medications should be prescribed at a reduced dosage and monitored carefully. These criteria apply to all elderly adults except those under palliative or hospice care.

It is important to remember that the medications listed in the Beers Criteria are considered potentially, not definitely, inappropriate for use in elderly patients. In addition, each recommendation statement is accompanied by exceptions that would apply to that recommendation.

This provides pharmacists with a specific intervention strategy aimed at decreasing adverse events, reducing inappropriate prescribing, and increasing mortality.

The updated 2015 Beers Criteria includes 3 new medications and 2 new medication classes, as well as 2 new completely new sections:

1. Guidance on avoiding specific combinations of medications known to cause harmful drug— drug interactions.

2. A list of medications for which dose adjustment may be necessary based upon decreased renal function.

Noteworthy additions to the 2015 Beers Criteria include, but are not limited to:

· The recommendation to avoid nitrofurantoin in individuals with decreased renal function has been revised down from a CrCl of 60 ml/min to a CrCl of 30 ml/min. Evidence shows that this medication may actually be used with relative safety in these individuals.

· Sleeping medications such as eszopiclone, zaleplon, and zolpidem are to be avoided without consideration of any duration of time, rather than the previously accepted 90 days. This recommendation is based on this category’s association with confusion, falls, and apparent lack of efficacy in this population. Medications like temazepam and triazolam are still on the Beers Criteria list and are not appropriate substitutes.

· The statement regarding the avoidance of a sliding scale insulin regimen in the elderly was reviewed and strengthened.

· Proton pump inhibitor use beyond 8 weeks is not recommended without medical justification, as longer use of these medications is associated with increased odds of Clostridum difficile infections, bone loss, and fractures.

· Avoid the use of desmopressin for the treatment of nocturia because of the increased risk of hyponatremia.

· Individuals with a history or risk of falls are recommended to avoid all opioids.

· Antipsychotic medications should not be administered as a first-line treatment for elderly delirium because of the potential for significant adverse drug reactions, as well as the limited efficacy for treatment in this specific condition.

· The list of medications with strong anticholinergic activity was updated. Most notably, loratadine was removed.

Pharmacists should take a moment to familiarize themselves with the updated Beers Criteria. Bookmark it, print out a hard copy, or find a useful app with the information readily available.

This is a tool we should all have at our fingertips when filling prescriptions and counseling patients.