Beers Criteria Updates Refine, Introduce New Drug Criteria

The American Geriatrics Society (AGS) has recently updated the Beers Criteria, marking the first revision since 2019. The Beers Criteria is designed to guide health care professionals in the management of medications for adults 65 years or older across various care settings, including ambulatory, acute, and institutionalized care. It is important to note that the criteria do not apply to hospice or other end-of-life care settings.¹

This latest revision introduces a new set of drug criteria, refines the existing ones, and enhances the overall formatting to ensure increased ease of use and clarity for its recommendations. The changes incorporated in this update stem from the analysis of data published since the last revision in 2019. Consequently, this led to the modification and removal of some previous recommendations from the Beers Criteria.¹

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The update maintained the same 5 categories:1 medications to be used with caution; medications considered potentially inappropriate; medications potentially inappropriate in patients with certain diseases or syndromes; potentially inappropriate drug–drug interactions; and medications whose dosages should be adjusted based on renal function.

Medications/Criteria Removed

With the new update there were medications added to the list of medications/criteria removed since the 2019 AGS Beers Criteria. These include the benzodiazepines flurazepam and quazepam; the non-steroidal anti-inflammatory drugs fenoprofen, ketoprofen, meclofenamate, and mefenamic acid; and the H2 blocker ranitidine. These medications are either no longer available in the United States or less than 4000 Medicare beneficiaries were on the medication in 2020.¹

Anticoagulation Updates

The AGS Beers Criteria has incorporated notable changes, including the addition of warfarin and rivaroxaban to the list of agents to be avoided in older adults. For nonvalvular atrial fibrillation or venous thromboembolism (VTE), apixaban is recommended over rivaroxaban, primarily due to a reduced risk of major bleeding. Furthermore, the criteria now include drug-drug interactions between warfarin and selective serotonin reuptake inhibitors (SSRIs) as interactions to be avoided. Nevertheless, it is essential to recognize that for older adults, the use of rivaroxaban or warfarin should not be entirely dismissed, especially when concerns related to cost or adherence come into play.¹

The update also recommends other direct oral anticoagulants (DOACs) over dabigatran. The recommendation states “use with caution” when considering dabigatran in older adults.

Regarding aspirin in primary prevention for older adults, the criteria emphasize the importance of considering deprescribing due to risk of major bleeding. This aligns with the recommendations of the US Preventive Services Task Force pertaining to aspirin use in older adults for primary prevention.² Furthermore, the criteria recommend avoiding the initiation of aspirin for primary prevention of cardiovascular disease.¹

Diabetes Medications Updates

In the previous guidelines, the recommendation to avoid sulfonylureas was limited to long-acting sulfonylureas, such as glyburide and glimepiride, primarily because of their association with an elevated risk of hypoglycemia. However, the 2023 update introduces a broader perspective by adding the recommendation to both short and long-acting glipizide agents. The rationale behind this expansion is due to the risk of cardiovascular events, including mortality, associated with these agents. In cases where sulfonylureas are necessary, the preference now leans towards short-acting agents over long-acting agents to mitigate the risk of hypoglycemia.¹

Additional recommendations were added with using caution with SGLT-2 inhibitors for older adults. These drugs should be administered with prudence, considering the potential risk of developing urogenital infections and the onset of euglycemic diabetic ketoacidosis (DKA). If SGLT-2 inhibitors are being considered, it is recommended to maintain close monitoring for infections and euglycemic diabetic ketoacidosis.¹

Medications That Increase Fall and Fracture Risks

The 2023 update introduces additional criteria pertaining to combining CNS-active agents which heighten risk of falls and fractures. Gabapentinoids and skeletal muscle relaxants were added to the CNS-active agents.¹

Other Notable Updates

In the 2019 Beers Criteria, the recommendation advised patients to abstain from the use of estrogens, with or without progestins. However, the latest update now recommends that these agents should not be initiated and should be considered for deprescribing in older women.¹

The Criteria also considers the associated risks of using Proton Pump Inhibitors (PPIs) and included pneumonia and gastrointestinal malignancies as potential risks linked to PPI usage. The recommendation remains to avoid extended use of these agents beyond a duration of 8 weeks.¹

Conclusion

It is imperative to emphasize that the AGS Beers Criteria recommendations come with certain exceptions, and their application should be tailored to the specific clinical scenario and individual patient. Clinical decisions based on the Beers Criteria should also take into consideration the patient's goals, unique needs, and specific characteristics that pertain to the appropriateness of therapy. As pharmacists, we occupy a unique role in advocating for the safety and well-being of our elderly patients, and should apply these recommendations judiciously to ensure their health and safety.

References

1. American Geriatrics Society Beers Criteria Update Expert Panel. J Am Geriatr Soc. 2023;71(7):2052-2081.

2. Aspirin Use to Prevent Cardiovascular Disease: US Preventive Services Task Force Recommendation Statement. JAMA. 2022;327(16):1577-1584. doi:10.1001/jama