Mackenzie Smith, PharmD, M Health Fairview
Background: The American Geriatrics Society (AGS) Beers Criteria® was developed in 1991 to increase shared clinical decision-making with regard to the appropriate use of medications in older adult patients. It is intended for the safety of patients aged 65 years of age and older in all healthcare settings, except for hospice and end-of-life care. The recommendations are designed to decrease the amount of potentially inappropriate medications (PIMs) that older persons are exposed to by improving medication selection, informing patients and medical providers, and acting as a tool for assessing the cost, quality, and drug use patterns of older adults. Medications and drug classes that the AGS and its expert panel deem to be PIMs are divided into five broad categories: medications considered as potentially inappropriate, medications potentially inappropriate in patients with certain diseases or syndromes, medications to be used with caution, potentially inappropriate drug–drug interactions, and medications whose dosages should be adjusted based on renal function.
Evidence: Prescription medication for older adults requires special consideration due to physiological changes and higher vulnerability to adverse drug reactions. Age-related changes in organ function and body composition can affect many medications' pharmacodynamic and pharmacokinetic properties. Additionally, polypharmacy raises the possibility of drug-drug or drug-disease interactions. In creating the updated 2023 criteria authors searched PubMed for relevant literature between June 1, 2017 and May 31, 2022.
A 2023 systematic review and meta-analysis investigated the prevalence of the use of PIMs among older adults worldwide. PIM use among older adult patients has increased over the past 20 years, with a pooled frequency of 36.7% overall. PIMs were higher in patients over 80 years old and those with more than one prescription. Compared to the overall population of older persons, the oldest patients typically have worse health, higher multimorbidity, and are more likely to be exposed to PIMs.
Discussion: The following table lists the medications or medication classes addressed in the 2023 AGS criteria:
Class/Drug | AGS Recommendation |
Anticoagulants | Direct oral anticoagulants (DOACs) are recommended over warfarin based on increasing evidence that warfarin has shown to be less effective and more likely to cause major bleeds when used as an initial treatment for non-valvular atrial fibrillation (NVAF) and venous thromboembolism (VTE). Rivaroxaban has been changed from "use with caution" to "avoid" for the long-term treatment of NVAF and VTE due to a higher risk of severe gastrointestinal bleeding as compared to other DOACs. Apixaban was determined to be safely used in patients with a CrCl <25 mL/min. |
Aspirin | Updated from “use with caution” to “avoid use” for primary prevention of cardiovascular disease. |
Sulfonylureas | All sulfonylureas (short and long acting) should be avoided as first or second-line treatment, unless there are significant contraindications or limitations to using other diabetes medications. |
Sodium-glucose cotransporter-2 inhibitors | Use with caution due to an increased risk of urogenital infections and euglycemic diabetic ketoacidosis. |
Proton pump inhibitors | Updated to “avoid use” due to increased evidence for the risk of developing pneumonia and gastrointestinal malignancies. |
Estrogen | Avoid starting a transdermal patch or oral tablet regimen. Consider deprescribing in this population. Topical estrogens remain acceptable. |
Baclofen | Updated to “avoid use” when the eGFR <60 mL/min/1.73 m2. |
Clinical Impact: Regarding the recommendations from the 2023 AGS Beers Criteria®, pharmacists will play an important role in identifying PIMs in the older adult patient population. Shared clinical decisions should be made with the patient to address their concerns and health goals, including reluctance or fear of lowering doses or stopping therapies. It is important to avoid starting PIMs in older adult patients and deprescribing PIMs whenever reasonable.
References:
- By the 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. J Am Geriatr Soc. 2023;71(7):2052-2081. doi:10.1111/jgs.18372
- Thürmann PA. Pharmacodynamics and pharmacokinetics in older adults. Curr Opin Anaesthesiol. 2020;33(1):109-113. doi:10.1097/ACO.0000000000000814.
- Delafuente JC. Pharmacokinetic and pharmacodynamic alterations in the geriatric patient. Consult Pharm. 2008;23(4):324-334. doi:10.4140/tcp.n.2008.324
- Proietti M, Raparelli V, Olshansky B, Lip GY. Polypharmacy and major adverse events in atrial fibrillation: observations from the AFFIRM trial. Clin Res Cardiol. 2016;105(5):412-420. doi:10.1007/s00392-015-0936-y.
- Tian F, Chen Z, Zeng Y, Feng Q, Chen X. Prevalence of Use of Potentially Inappropriate Medications Among Older Adults Worldwide: A Systematic Review and Meta-Analysis. JAMA Netw Open. 2023;6(8):e2326910. Published 2023 Aug 1. doi:10.1001/jamanetworkopen.2023.26910