Beers Criteria for Potentially Inappropriate Medication Use in Older Adults

Publication Date: May 4, 2023

Disclaimer for the 2023 American Geriatrics Society Updated Beers Criteria Guideline Summary

The guideline summary for the 2023 American Geriatrics Society Updated Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults has been removed upon request from the American Geriatrics Society. To purchase access to the 2023 Beers Criteria, visit this link provided by the AGS.

Drug-Disease or Drug-Syndrome Interactions That May Exacerbate the Disease or Syndrome

For 2023 Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults Due to Drug-Disease or Drug-Syndrome Interactions That May Exacerbate the Disease or Syndrome, please refer to the full text guideline here.

Drug-Drug Interactions That Should Be Avoided in Older Adults

For 2023 Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults Drug-Drug Interactions That Should Be Avoided in Older Adults, please refer to the full text guideline here.

Medications/Criterion Added, Removed or Modified Since 2019

For Medications/Criterion Added, Removed or Modified Since 2019 American Geriatrics Society Beers Criteria®, please refer to the full text guideline here.

Select Highlights for Medications to Avoid, Adjust Dosage for or Use with Caution

Drug Table 2023

Medication Comments
Alprazolam Avoid
Amiloride Avoid if CrCl <30 mL/min
Amiodarone Avoid as first-line therapy for atrial fibrillation for most patients
Amitriptyline Avoid; has strong anticholinergic properties
Amobarbital Removed from 2023 versiom - per 2019, Avoid
Amoxapine Avoid; has strong anticholinergic properties
Androgens Avoid unless indicated for symptomatic hypogonadism
Apixaban Per 2023, Emerging evidence and clinical experience supporting safe use at lower levels of renal function, Per 2019, Avoid if CrCl <25 mL/min
Aripiprazole Avoid, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy)
Asenapine Avoid, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy)
Aspirin Avoid initiating aspirin for primary prevention of cardiovascular disease. Consider deprescribing aspirin in older adults already taking it for primary prevention.; Use with caution in adults ≥70 years; Avoid in most patients with history of gastric or duodenal ulcers; avoid chronic use with >325 mg/day
Atropine (excludes ophthalmic) Avoid; has strong anticholinergic properties
Baclofen Avoid in older adults with impaired kidney function (eGFR <60 mL/min); If cannot be avoided, use the lowest effective dose and monitor for signs of CNS toxicity, including altered mental status
Belladonna alkaloids Avoid; has strong anticholinergic properties
Benztropine (oral) Avoid; has strong anticholinergic properties
Brexpiprazole Avoid, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy)
Brompheniramine Avoid; has strong anticholinergic properties
Butobarbital Removed from 2023 versiom - per 2019, Avoid
Butalbital Avoid
Canigliflozin Use with caution. Monitor patients for urogenital infections and ketoacidosis.
Carbamazepine Use with caution
Carbinoxamine Removed from 2023 versiom - per 2019, Avoid; has strong anticholinergic properties
Cariprazine Avoid, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy)
Carisoprodol Avoid
Chlordiazepoxide (alone or in combination with amitriptyline or clidinium) Avoid
Chlorpheniramine Avoid; has strong anticholinergic properties
Chlorpromazine Avoid, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy); has strong anticholinergic properties
Chlorpropamide Avoid
Chlorzoxazone Avoid
Cilostazol Avoid for most patients; Use with caution in patients with heart failure
Cimetidine Reduce dose if CrCl <50 mL/min; avoid in patients with delirium
Ciprofloxacin Reduce dose if CrCl <30 mL/min
Citalopram Use with caution
Clemastine Removed from 2023 versiom - per 2019, Avoid; has strong anticholinergic properties
Clidinium-chlordiazepoxide Avoid; has strong anticholinergic properties
Clomipramine Avoid; has strong anticholinergic properties
Clonazepam Avoid
Clonidine for first-line treatment Avoid as an antihypertensive
Clorazepate Avoid
Clozapine Avoid*, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy); has strong anticholinergic properties
Colchicine Reduce dose if CrCl <30 mL/min and monitor
Cyclobenzaprine Avoid; has strong anticholinergic properties
Cyproheptadine Avoid; has strong anticholinergic properties
Dabigatran Use with caution for treatment of VTE or atrial fibrillation in adults ≥75 years; Avoid; dose adjustment advised when CrCl >30 mL/min in the presence of drug-drug interactions
Dapagliflozin Use with caution. Monitor patients for urogenital infections and ketoacidosis.
Darifenacin Has strong anticholinergic properties
Desiccated thyroid Avoid
Desipramine Avoid; has strong anticholinergic properties
Desmopressin Avoid for nocturia or nocturnal polyuria
Desvenlafaxine Use with caution
Dexbrompheniramine Avoid; has strong anticholinergic properties
Dexchlorpheniramine Removed from 2023 versiom - per 2019, Avoid; has strong anticholinergic properties
Dexlansoprazole Avoid scheduled use for >8 weeks for most patients
Dextromethorphan/quinidine Use with caution
Diazepam Avoid
Diclofenac Avoid chronic use
Dicyclomine Has strong anticholinergic properties; Avoid in men with lower urinary tract symptoms, benign prostatic hyperplasia
Dicyclomine Homatropine (excludes opthalmic) Avoid
Diflunisal Avoid chronic use
Digoxin Avoid as first line therapy for atrial fibrillation and for heart failure; if used for atrial fibrillation or heart failure, avoid dosages >0.125 mg/day; Avoid as first-line therapy for heart failure
Diltiazem Avoid for most patients; Use with caution in patients with heart failure
Dimenhydrinate Avoid; has strong anticholinergic properties
Diphenhydramine (oral) Avoid; has strong anticholinergic properties
Dipyridamole, oral short acting Avoid
Disopyramide Removed from 2023 versiom - per 2019, Avoid; has strong anticholinergic properties
Diuretics Use with caution
Dofetilide Reduce dose if CrCl 20-59 mL/min; Avoid if CrCl <20 mL/min
Doxazosin Avoid use as an antihypertensive; Avoid in patients with syncope and in females with urinary incontinence
Doxepin (>6 mg / day) Avoid; has strong anticholinergic properties
Doxylamine Avoid; has strong anticholinergic properties
Dronedarone Avoid in individuals with permanent atrial fibrillation or some types of heart failure; Use caution in patients with HFrEF with less severe symptoms (NYHA class I or II)
Duloxetine Use with caution; Avoid if CrCl <30 mL/min
Edoxaban Reduce dose if CrCl 15-50 mL/min; Avoid if CrCl <15 or >95 mL/min
Emplaglifozin Use with caution. Monitor patients for urogenital infections and ketoacidosis.
Enoxaparin Reduce dose if CrCl <30 mL/min
Ergoloid mesylates (dehydrogenated ergot alkaloids) Avoid
Ertuglifozin Use with caution. Monitor patients for urogenital infections and ketoacidosis.
Escitalopram Use with caution
Esomeprazole Avoid scheduled use for >8 weeks for most patients
Estazolam Avoid
Estrogens with or without progestins Avoid systemic estrogen - consider deprescribing among older women already using this medication; Vaginal cream or vaginal tablets: acceptable to use low-dose intravaginal estrogen for some patients
Eszopiclone Avoid
Etodolac Avoid chronic use
Famotidine Reduce dose if CrCl <50 mL/min; Avoid in patients with delirium
Fenoprofen Removed from 2023 versiom - per 2019, Avoid chronic use
Fesoterodine Has strong anticholinergic properties
Flavoxate Has strong anticholinergic properties
Fluoxetine Use with caution
Fluphenazine Avoid, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy)
Flurazepam Removed from 2023 versiom - per 2019, Avoid
Fluvoxamine Use with caution
Fondaparinux Avoid if CrCl <30 mL/min
Gabapentin Reduce if CrCl <60 mL/min
Glimepiride Avoid
Glyburide (also known as glibenclamide) Avoid
Growth hormone Avoid, except for some patients with growth hormone deficiency
Guanabenz Avoid other CNS alpha-agonists as listed
Guanfacine Avoid other CNS alpha-agonists as listed
Haloperidol Avoid, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy)
Homatropine (excludes ophthalmic) Has strong anticholinergic properties; Avoid in men with lower urinary tract symptoms, benign prostatic hyperplasia
Hydroxyzine Avoid; has strong anticholinergic properties
Hyoscyamine Avoid; has strong anticholinergic properties
Ibuprofen Avoid chronic use
Iloperidone Avoid, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy)
Imipramine Avoid; has strong anticholinergic properties
Indomethacin Avoid
Insulin, sliding scale Avoid
Isoxsuprine Avoid
Ketoprofen Removed from 2023 versiom - per 2019, Avoid chronic use
Ketorolac, includes parenteral Avoid
Lansoprazole Avoid scheduled use for >8 weeks for most patients
Levetiracetam Reduce dose if CrCl ≤80 mL/min
Levomilnacipran Use with caution
Lorazepam Avoid
Loxapine Removed from 2023 versiom - per 2019, Avoid, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy); has strong anticholinergic properties
Lumateperone Avoid, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy)
Lurasidone Avoid, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy)
Meclizine Avoid
Meclofenamate Removed from 2023 versiom - per 2019, Avoid chronic use
Mefenamic acid Removed from 2023 versiom - per 2019, Avoid chronic use
Megestrol Avoid
Meloxicam Avoid chronic use
Meperidine Avoid
Mephobarbital Avoid
Meprobamate Avoid
Mesoridazine Avoid, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy)
Metaxalone Avoid
Methocarbamol Avoid
Methscopolamine Removed from 2023 versiom - per 2019, Avoid; has strong anticholinergic properties
Methyldopa Avoid other CNS alpha-agonists as listed
Methyltestosterone Avoid unless indicated for symptomatic hypogonadism
Metoclopramide Avoid, unless for gastroparesis use less than 12 weeks for most cases; Avoid in patients with Parkinson Disease
Milnacipran Use with caution
Mineral oil, given orally Avoid
Mirtazapine Use with caution
Molindone Avoid, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy)
Nabumetone Avoid chronic use
Naproxen Avoid chronic use
Nifedipine, immediate release Avoid
Nitrofurantoin Avoid in individuals with creatinine clearance <30 mL/min or for long-term suppression
Nizatidine Reduce dose if CrCl <50 mL/min; Avoid in patients with delirium
Nortriptyline Avoid; has strong anticholinergic properties
Olanzapine Avoid, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy); has strong anticholinergic properties
Omeprazole Avoid scheduled use for >8 weeks for most patients
Omeprazole / sodium bicarbonate Avoid scheduled use for >8 weeks for most patients
Orphenadrine Avoid; has strong anticholinergic properties
Other 1st and 2nd Generation Antipsychotics Avoid, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy)
Other PPIs Avoid scheduled use for >8 weeks for most patients
Other SNRIs Use with caution
Other SSRIs Use with caution
Other TCAs Use with caution
Oxaprozin Avoid chronic use
Oxazepam Avoid
Oxcarbazepine Use with caution
Oxybutynin Has strong anticholinergic properties
Paliperidone Avoid, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy)
Pantoprazole Avoid scheduled use for >8 weeks for most patients
Paroxetine Avoid; has strong anticholinergic properties
Pentobarbital Avoid
Perphenazine Avoid, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy); has strong anticholinergic properties
Phenobarbital Avoid
Pimavanserin Avoid*, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy)
Pioglitazone Avoid for most patients; Use with caution in patients with heart failure
Piroxicam Avoid chronic use
Prasugrel Use with caution in adults ≥75 years - If prasugrel is used, consider a lower dose (5 mg) for those 75 years old and older
Prazosin Avoid use as an antihypertensive; Avoid in patients with syncope and in females with urinary incontinence
Pregabalin Reduce if CrCl <60 mL/min
Probenecid Avoid if CrCl <30 mL/min
Prochlorperazine Avoid in patients with Parkinson Disease
Prochlorperazine Has strong anticholinergic properties; Avoid in men with lower urinary tract symptoms, benign prostatic hyperplasia
Promethazine Avoid; has strong anticholinergic properties
Propantheline Avoid; has strong anticholinergic properties
Protriptyline Removed from 2023 versiom - per 2019, Avoid; has strong anticholinergic properties
Pyrilamine Avoid; has strong anticholinergic properties
Quazepam Removed from 2023 versiom - per 2019, Avoid; has strong anticholinergic properties
Quetiapine Avoid*, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy)
Rabeprazole Avoid scheduled use for >8 weeks for most patients
Ranitidine Reduce dose if CrCl <50 mL/min; Avoid in patients with delirium
Reserpine (>0.1 mg/day) Avoid other CNS alpha-agonists as listed
Risperidone Avoid, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy)
Rivaroxaban Avoid for long-term treatment of atrial fibrillation or VTE in favor of safer anticoagulant alternatives - see also criteria regarding DOACs; Avoid if CrCl <15 mL/min and reduce the dose if CrCl is 15–50 mL/min following manufacturer dosing recommendations based on indication-specific dosing
Rosiglitazone Avoid for most patients; Use with caution in patients with heart failure
Scopolamine (excludes ophthalmic) Avoid; has strong anticholinergic properties
Secobarbital Avoid
Sertraline Use with caution
Solifenacin Has strong anticholinergic properties
Spironolactone Avoid if CrCl <30 mL/min
Sulindac Avoid chronic use
Temazepam Avoid
Terazosin Avoid use as an antihypertensive; Avoid in patients with syncope and in females with urinary incontinence
Testosterone Avoid unless indicated for symptomatic hypogonadism
Thioridazine Avoid, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy); has strong anticholinergic properties
Thiothixene Avoid, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy)
Ticagrelor Use with caution, particularly in adults 75 years old and older. If prasugrel is used, consider a lower dose (5 mg) for those 75 years old and older.
Tolmetin Avoid chronic use
Tolterodine Has strong anticholinergic properties
Tramadol Use with caution; If CrCl <30 mL/min, may require reduction with immediate release or avoid with extended release
Triamterene Avoid if CrCl <30 mL/min
Triazolam Avoid
Trifluoperazine Removed from 2023 versiom - per 2019, Avoid, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy); has strong anticholinergic properties
Trihexyphenidyl Avoid; has strong anticholinergic properties
Trimethoprimsulfamethoxazole Use with caution in patients on ACEI or ARB or ARNI and decreased creatinine clearance; Reduce dosage if CrCl is 15–29 mL/min and avoid if CrCl <15 mL/min
Trimipramine Removed from 2023 versiom - per 2019, Avoid; has strong anticholinergic properties
Triprolidine Avoid; has strong anticholinergic properties
Trospium Has strong anticholinergic properties
Venlafaxine Use with caution
Verapamil Avoid for most patients; Use with caution in patients with heart failure
Warfarin Avoid starting warfarin as initial therapy for the treatment of nonvalvular atrial fibrillation or VTE unless alternative options (i.e., DOACs) are contraindicated or there are substantial barriers to their use. For older adults who have been using warfarin long-term, it may be reasonable to continue this medication, particularly among those with well-controlled INRs (i.e., >70% time in the therapeutic range) and no adverse effects. See also criteria regarding DOACs.
Zaleplon Avoid
Ziprasidone Avoid, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy)
Zolpidem Avoid
*Exceptions: clozapine, pimavanserin, and quetiapine appear to be less likely to precipitate the worsening of Parkinson disease than other antipsychotics

This table is not intended as a replacement for or comprehensive summary of the whole or of any part of the AGS 2023 Beers Criteria. For a full and complete listing of medications, along with recommendations, rationale and grading, please refer to the full text Beers Criteria guideline here.

Additional Comment

  • Warfarin: Avoid starting warfarin as initial therapy for the treatment of venous thromboembolism (VTE) or nonvalvular atrial fibrillation unless alternative options (e.g., DOACs) are contraindicated or there are substantial barriers to their use. For older adults who have been using warfarin long-term, it may be reasonable to continue this medication, particularly among those with well-controlled INRs (i.e., >70% time in the therapeutic range) and no adverse effects.
  • Rivaroxaban: Avoid rivaroxaban for long-term treatment of nonvalvular atrial fibrillation or VTE in favor of safer anticoagulant alternatives.
  • Dabigatran: Use caution in selecting dabigatran over other DOACs (e.g., apixaban) for long-term treatment of nonvalvular atrial fibrillation or VTE.

Recommendation Grading

Disclaimer

Overview

Title

AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults

Authoring Organization

Publication Month/Year

May 4, 2023

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

With more than 90% of older people using at least one prescription and more than 66% using three or more in any given month, the AGS Beers Criteria® plays a vital role in helping health professionals, older adults, and caregivers work together to ensure medications are appropriate. The American Geriatrics Society (AGS) Beers Criteria® (AGS Beers Criteria®) for Potentially Inappropriate Medication (PIM) Use in Older Adults is widely used by clinicians, educators, researchers, healthcare administrators, and regulators. Since 2011, the AGS has been the steward of the criteria and has produced updates on a regular cycle. The AGS Beers Criteria® is an explicit list of PIMs that are typically best avoided by older adults in most circumstances or under specific situations, such as in certain diseases or conditions. For the 2023 update, an interprofessional expert panel reviewed the evidence published since the last update (2019) and based on a structured assessment process approved a number of important changes including the addition of new criteria, modification of existing criteria, and formatting changes to enhance usability. The criteria are intended to be applied to adults 65 years old and older in all ambulatory, acute, and institutionalized settings of care, except hospice and end-of-life care settings. Although the AGS Beers Criteria® may be used internationally, it is specifically designed for use in the United States and there may be additional considerations for certain drugs in specific countries. Whenever and wherever used, the AGS Beers Criteria® should be applied thoughtfully and in a manner that supports, rather than replaces, shared clinical decision-making.

Target Patient Population

Older adults taking one or more medications

Target Provider Population

All healthcare providers that care for older patients

Inclusion Criteria

Male, Female, Older adult

Health Care Settings

Ambulatory, Home health, Hospital, Long term care, Outpatient

Intended Users

Healthcare business administration, nurse, nurse practitioner, community pharmacist, health systems pharmacist, pharmacy technician, physician, physician assistant

Scope

Treatment, Management, Prevention

Diseases/Conditions (MeSH)

D008508 - Medication Errors, D000067561 - Potentially Inappropriate Medication List, D054539 - Medication Therapy Management

Keywords

Beers Criteria, beers, Beer's, Beer's Criteria, beers list, medication use, beer criteria

Source Citation

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 May 4. doi: 10.1111/jgs.18372. Epub ahead of print. PMID: 37139824.

Supplemental Methodology Resources

Data Supplement

Methodology

Number of Source Documents
36
Literature Search Start Date
June 1, 2017
Literature Search End Date
May 31, 2022