Last updated March 15, 2022

Beers Criteria for Potentially Inappropriate Medication Use in Older Adults

Table 1. Designations of Quality of Evidence and Strength of Recommendationsa

Quality of Evidence
Quality of evidence ratings for each criterion are based on synthetic assessment of two complementary approaches to evaluating the quality of evidence.
ACP-based approach GRADE-based approach
High-quality evidence “Evidence…obtained from 1 or more well-designed and well-executed randomized, controlled trials (RCTs) that yield consistent and directly applicable results. This also means that further research is very unlikely to change our confidence in the estimate of effect.” Consider the following five factors for the studies that comprise the best-available evidence for a given criterion:
  1. Risk of bias: Severity of threats to studies’ internal validity (eg, randomized vs observational design, potential for confounding, bias in measurement)
  2. Inconsistency: Do different studies provide similar or different estimates of effect size
  3. Indirectness: How relevant are the studies to the clinical question at hand (eg, nature of study of population, comparison group, type of outcomes measured)
  4. Imprecision: Precision of estimates of effect
  5. Publication bias: Risk of bias due to selective publication of results
Moderate-quality evidence “Evidence…obtained from RCTs with important limitations…. In addition, evidence from welldesigned controlled trials without randomization, well-designed cohort or case-control analytic studies, and multiple time series with or without intervention are in this category. Moderatequality evidence also means that further research will probably have an important effect on our confidence in the estimate of effect and may change the estimate.”
Low-quality evidence “Evidence obtained from observational studies would typically be rated as low quality because of the risk for bias. Low-quality evidence means that further research is very likely to have an important effect on our confidence in the estimate of effect and will probably change the estimate. However, the quality of evidence may be rated as moderate or even high, depending on circumstances under which evidence is obtained from observational studies.”
↓ ↓ ↓ ↓ ↓
Overall quality of evidence that supports a given criterion: high, moderate, low
Strength of Evidence
Strength of evidence ratings for each criterion are based on synthetic integration of the quality of evidence, the frequency and severity of potential adverse events and relationship to potential benefits, and clinical judgment.
Strong Harms, adverse events, and risks clearly outweigh benefits.
Weak Harms, adverse events, and risks may not outweigh benefits.

aAdapted from: Qaseem A, Snow V, Owens DK, et al. The development of clinical practice guidelines and guidance statements of the American College of Physicians: summary of methods. Ann Intern Med. 2010;153:194-–199. Guyatt G, Oxman AD, Sultan S, et al. GRADE guidelines,: 11.: making an overall rating of confidence in effect estimates for a single outcome and for all outcomes. J Clin Epidemiol. 2013;66(2):151-–157. Andrews JC, Schünemann HJ, Oxman AD, et al. GRADE guidelines,: 15.: going from evidence to recommendation-determinants of a recommendation’s direction and strength. J Clin Epidemiol. 2013;66(7):726–735.

Table 2. 2019 American Geriatrics Society Beers Criteria® for Potentially Inappropriate Medication Use in Older Adultsa

Organ System, Therapeutic Category, Drug(s) Rationale Recommendation Quality of Evidence Strength of Recommendation
Anticholinergicsb
First-generation antihistamines
  • Brompheniramine
  • Carbinoxamine
  • Chlorpheniramine
  • Clemastine
  • Cyproheptadine
  • Dexbrompheniramine
  • Dexchlorpheniramine
  • Dimenhydrinate
  • Diphenhydramine (oral)
  • Doxylamine
  • Hydroxyzine
  • Meclizine
  • Promethazine
  • Pyrilamine
  • Triprolidine
Highly anticholinergic; clearance reduced with advanced age, and tolerance develops when used as hypnotic; risk of confusion, dry mouth, constipation, and other anticholinergic effects or toxicity.
Use of diphenhydramine in situations such as acute treatment of severe allergic reaction may be appropriate.
Avoid Moderate Strong
Antiparkinsonian agents
  • Benztropine (oral)
  • Trihexyphenidyl
Not recommended for prevention or treatment of extrapyramidal symptoms with antipsychotics; more effective agents available for treatment of Parkinson disease Avoid Moderate Strong
Antispasmodics
  • Atropine (excludes ophthalmic)
  • Belladonna alkaloids
  • Clidinium-chlordiazepoxide
  • Dicyclomine Homatropine (excludes opthalmic)
  • Hyoscyamine
  • Methscopolamine
  • Propantheline
  • Scopolamine
Highly anticholinergic, uncertain effectiveness Avoid Moderate Strong
Antithrombotics
Dipyridamole, oral short acting (does not apply to the extended-release combination with aspirin) May cause orthostatic hypotension; more effective alternatives available; IV form acceptable for use in cardiac stress testing Avoid Moderate Strong
Anti-infective
Nitrofurantoin Potential for pulmonary toxicity, hepatoxicity, and peripheral neuropathy, especially with long-term use; safer alternatives available Avoid in individuals with creatinine clearance <30 mL/min or for long-term suppression Low Strong
Cardiovascular
Peripheral alpha-1 blockers for treatment of hypertension
  • Doxazosin
  • Prazosin
  • Terazosin
High risk of orthostatic hypotension and associated harms, especially in older adults; not recommended as routine treatment for hypertension; alternative agents have superior risk/benefit profile Avoid use as an antihypertensive Moderate Strong
Central alpha-agonists
  • Clonidine for first-line treatment
High risk of adverse CNS effects; may cause bradycardia and orthostatic hypotension; not recommended as routine treatment for hypertension Avoid as first-line antihypertensive Low Strong
Other CNS alpha-agonists
  • Guanabenz
  • Guanfacine
  • Methyldopa
  • Reserpine (>0.1 mg/day)
Avoid other CNS alpha-agonists as listed Low Strong
Disopyramide May induce heart failure in older adults because of potent negative inotropic action; strongly anticholinergic; other antiarrhythmic drugs preferred Avoid Low Strong
Dronedarone Worse outcomes have been reported in patients taking dronedarone who have permanent atrial fibrillation or severe or recently decompensated heart failure. Avoid in individuals with permanent atrial fibrillation or severe or recently decompensated heart failure High Strong
Digoxin for first-line treatment of atrial fibrillation or of heart failure Use in atrial fibrillation: should not be used as a first-line agent in atrial fibrillation, because there are safer and more effective alternatives for rate control supported by high-quality evidence. Avoid this rate control agent as first-line therapy for atrial fibrillation Atrial fibrillation: low Atrial fibrillation: strong
Use in heart failure: evidence for benefits and harms of digoxin is conflicting and of lower quality; most but not all of the evidence concerns use in HFrEF. There is strong evidence for other agents as first-line therapy to reduce hospitalizations and mortality in adults with HFrEF. In heart failure, higher dosages are not associated with additional benefit and may increase risk of toxicity. Avoid as first-line therapy for heart failure Heart failure: low Heart failure: strong
Decreased renal clearance of digoxin may lead to increased risk of toxic effects; further dose reduction may be necessary in those with stage 4 or 5 chronic kidney disease. If used for atrial fibrillation or heart failure, avoid dosages >0.125 mg/day Dosage >0.125 mg/day: moderate Dosage >0.125 mg/day: strong
Nifedipine, immediate release Potential for hypotension; risk of precipitating myocardial ischemia Avoid High Strong
Amiodarone Effective for maintaining sinus rhythm but has greater toxicities than other antiarrhythmics used in atrial fibrillation; may be reasonable first-line therapy in patients with concomitant heart failure or substantial left ventricular hypertrophy if rhythm control is preferred over rate control Avoid as first-line therapy for atrial fibrillation unless patient has heart failure or substantial left ventricular hypertrophy High Strong
Central nervous system
Antidepressants, alone or in combination
  • Amitriptyline
  • Amoxapine
  • Clomipramine
  • Desipramine
  • Doxepin >6 mg/day
  • Imipramine
  • Nortriptyline
  • Paroxetine
  • Protriptyline
  • Trimipramine
Highly anticholinergic, sedating, and cause orthostatic hypotension; safety profile of low-dose doxepin (≤6 mg/day) comparable to that of placebo Avoid High Strong
Antipsychotics, first (conventional) and second (atypical) generation Increased risk of cerebrovascular accident (stroke) and greater rate of cognitive decline and mortality in persons with dementia
Avoid antipsychotics for behavioral problems of dementia or delirium unless nonpharmacological options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others
Avoid, except in schizophrenia or bipolar disorder, or for short-term use as antiemetic during chemotherapy Moderate Strong
Barbiturates
  • Amobarbital
  • Butabarbital
  • Butalbital
  • Mephobarbital
  • Pentobarbital
  • Phenobarbital
  • Secobarbital
High rate of physical dependence, tolerance to sleep benefits, greater risk of overdose at low dosages Avoid High Strong
Benzodiazepines
Short and intermediate acting:
  • Alprazolam
  • Estazolam
  • Lorazepam
  • Oxazepam
  • Temazepam
  • Triazolam
Long acting:
  • Chlordiazepoxide (alone or in combination with amitriptyline or clidinium)
  • Clonazepam
  • Clorazepate
  • Diazepam
  • Flurazepam
  • Quazepam
Older adults have increased sensitivity to benzodiazepines and decreased metabolism of longacting agents; in general, all benzodiazepines increase risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes in older adults
May be appropriate for seizure disorders, rapid eye movement sleep behavior disorder, benzodiazepine withdrawal, ethanol withdrawal, severe generalized anxiety disorder, and periprocedural anesthesia
Avoid Moderate Strong
Meprobamate High rate of physical dependence; sedating Avoid Moderate Strong
Nonbenzodiazepine, benzodiazepine receptor agonist hypnotics (ie, “Z-drugs”)
  • Eszopiclone
  • Zaleplon
  • Zolpidem
Nonbenzodiazepine benzodiazepine receptor agonist hypnotics (ie, Z drugs) have adverse events similar to those of benzodiazepines in older adults (eg, delirium, falls, fractures); increased emergency room visits/hospitalizations; motor vehicle crashes; minimal improvement in sleep latency and duration Avoid Moderate Strong
Ergoloid mesylates (dehydrogenated ergot alkaloids)
Isoxsuprine
Lack of efficacy Avoid High Strong
Endocrine
Androgens
  • Methyltestosterone
  • Testosterone
Potential for cardiac problems; contraindicated in men with prostate cancer Avoid unless indicated for confirmed hypogonadism with clinical symptoms Moderate Weak
Desiccated thyroid Concerns about cardiac effects; safer alternatives available Avoid Low Strong
Estrogens with or without progestins Evidence of carcinogenic potential (breast and endometrium); lack of cardioprotective effect and cognitive protection in older women Avoid systemic estrogen (eg, oral and topical patch) Oral and patch: high Oral and patch: strong
Evidence indicates that vaginal estrogens for the treatment of vaginal dryness are safe and effective; women with a history of breast cancer who do not respond to nonhormonal therapies are advised to discuss the risks and benefits of low-dose vaginal estrogen (dosages of estradiol <25 μg twice weekly) with their healthcare provider Vaginal cream or vaginal tablets: acceptable to use low-dose intravaginal estrogen for management of dyspareunia, recurrent lower urinary tract infections, and other vaginal symptoms Vaginal cream or vaginal tablets: moderate Topical vaginal cream or tablets: weak
Growth hormone Impact on body composition is small and associated with edema, arthralgia, carpal tunnel syndrome, gynecomastia, impaired fasting glucose Avoid, except for patients rigorously diagnosed by evidence-based criteria with growth hormone deficiency due to an established etiology High Strong
Insulin, sliding scale (insulin regimens containing only short- or rapid-acting insulin dosed according to current blood glucose levels without concurrent use of basal or long-acting insulin) Higher risk of hypoglycemia without improvement in hyperglycemia management regardless of care setting. Avoid insulin regimens that include only short- or rapidacting insulin dosed according to current blood glucose levels without concurrent use of basal or long-acting insulin. This recommendation does not apply to regimens that contain basal insulin or long-acting insulin. Avoid Moderate Strong
Megestrol Minimal effect on weight; increases risk of thrombotic events and possibly death in older adults Avoid Moderate Strong
Sulfonylureas, long acting
  • Chlorpropamide
  • Glimepiride
  • Glyburide (also known as glibenclamide)
Chlorpropamide: prolonged half-life in older adults; can cause prolonged hypoglycemia; causes SIADH Glimepiride and glyburide: higher risk of severe prolonged hypoglycemia in older adults Avoid High Strong
Gastrointestinal
Metoclopramide Can cause extrapyramidal effects, including tardive dyskinesia; risk may be greater in frail older adults and with prolonged exposure Avoid, unless for gastroparesis with duration of use not to exceed 12 weeks except in rare cases Moderate Strong
Mineral oil, given orally Potential for aspiration and adverse effects; safer alternatives available Avoid Moderate Strong
Proton-pump inhibitors Risk of Clostridium difficile infection and bone loss and fractures Avoid scheduled use for >8 weeks unless for high-risk patients (eg, oral corticosteroids or chronic NSAID use), erosive esophagitis, Barrett esophagitis, pathological hypersecretory condition, or demonstrated need for maintenance treatment (eg, because of failure of drug discontinuation trial or H2-receptor antagonists) High Strong
Pain medications
Meperidine Oral analgesic not effective in dosages commonly used; may have higher risk of neurotoxicity, including delirium, than other opioids; safer alternatives available Avoid Moderate Strong
Non–cyclooxygenase-selective NSAIDs, oral:
  • Aspirin >325 mg/day
  • Diclofenac
  • Diflunisal
  • Etodolac
  • Fenoprofen
  • Ibuprofen
  • Ketoprofen
  • Meclofenamate
  • Mefenamic acid
  • Meloxicam
  • Nabumetone
  • Naproxen
  • Oxaprozin
  • Piroxicam
  • Sulindac
  • Tolmetin
Increased risk of gastrointestinal bleeding or peptic ulcer disease in high-risk groups, including those >75 years or taking oral or parenteral corticosteroids, anticoagulants, or antiplatelet agents; use of proton-pump inhibitor or misoprostol reduces but does not eliminate risk. Upper gastrointestinal ulcers, gross bleeding, or perforation caused by NSAIDs occur in ~1% of patients treated for 3-6 months and in ~2%-4% of patients treated for 1 year; these trends continue with longer duration of use. Also can increase blood pressure and induce kidney injury. Risks are dose related. Avoid chronic use, unless other alternatives are not effective and patient can take gastroprotective agent (proton-pump inhibitor or misoprostol) Moderate Strong
Indomethacin
Ketorolac, includes parenteral
Increased risk of gastrointestinal bleeding/peptic ulcer disease and acute kidney injury in older adults Indomethacin is more likely than other NSAIDs to have adverse CNS effects. Of all the NSAIDs, indomethacin has the most adverse effects. Avoid Moderate Strong
Skeletal muscle relaxants
  • Carisoprodol
  • Chlorzoxazone
  • Cyclobenzaprine
  • Metaxalone
  • Methocarbamol
  • Orphenadrine
Most muscle relaxants poorly tolerated by older adults because some have anticholinergic adverse effects, sedation, increased risk of fractures; effectiveness at dosages tolerated by older adults questionable Avoid Moderate Strong
Genitourinary
Desmopressin High risk of hyponatremia; safer alternative treatments Avoid for treatment of nocturia or nocturnal polyuria Moderate Strong

The primary target audience is the practicing clinician. The intentions of the criteria include (1) improving the selection of prescription drugs by clinicians and patients; (2) evaluating patterns of drug use within populations; (3) educating clinicians and patients on proper drug usage; and (4) evaluating health-outcome, quality-of-care, cost, and utilization data.
See also criterion on highly anticholinergic antidepressants.

Table 3. 2019 American Geriatrics Society 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

Disease or Syndrome Drug Rationale Recommendation Quality & Strength
Cardiovascular
Heart Failure Avoid: Cilostazol
Avoid in heart failure with reduced ejection fraction:
Nondihydropyridine CCBs (diltiazem, verapamil)
Use with caution in patients with heart failure who are asymptomatic; avoid in patients with symptomatic heart failure: NSAIDs and COX-2 inhibitors
Thiazolidinediones (pioglitazone,rosiglitazone)
Dronedarone
Potential to promote fluid retention and/or exacerbate heart failure (NSAIDs and COX-2 inhibitors, nondihydropyridine CCBs, thiazolidinediones); potential to increase mortality in older adults with heart failure (cilostazol and dronedarone) As noted, avoid or use with caution Cilostazol: low, strong
Nondihydropyridine CCBs: moderate, strong
NSAIDs: moderate, strong
COX-2 inhibitors: low, strong
Thiazolidinediones: high, strong
Dronedarone: high, strong
Syncope AChEIs

Nonselective peripheral alpha-1 blockers (ie, doxazosin, prazosin, terazosin)

Tertiary TCAs

Antipsychotics: Chlorpromazine, Thioridazine, Olanzapine
AChEIs cause bradycardia and should be avoided in older adults whose syncope may be due to bradycardia. Nonselective peripheral alpha-1 blockers cause orthostatic blood pressure changes and should be avoided in older adults whose syncope may be due to orthostatic hypotension. Tertiary TCAs and the antipsychotics listed increase the risk of orthostatic hypotension or bradycardia. Avoid AChEIs, TCAs, and antipsychotics: high, strong
Nonselective peripheral alpha-1 blockers: high, weak
Central Nervous System
Delirium Anticholinergics
Antipsychotics
Benzodiazepines
Corticosteroids (oral and parenteral)
H2-receptor antagonists
Cimetidine
Famotidine
Nizatidine
Ranitidine
Meperidine
Nonbenzodiazepine, benzodiazepine receptor agonist hypnotics:
eszopiclone, zaleplon, zolpidem
Avoid in older adults with or at high risk of delirium because of potential of inducing or worsening delirium

Avoid antipsychotics for behavioral problems of dementia and/or delirium unless nonpharmacological options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. Antipsychotics are associated with greater risk of cerebrovascular accident (stroke) and mortality in persons with dementia.
Avoid H2-receptor antagonists: low, strong
All others: moderate, strong
Dementia or Cognitive Impairment Anticholinergics
Benzodiazepines
Nonbenzodiazepine, benzodiazepine receptor agonist hypnotics
Eszopiclone
Zaleplon
Zolpidem
Antipsychotics, chronic and as-needed use
Avoid because of adverse CNS effects

Avoid antipsychotics for behavioral problems of dementia and/or delirium unless nonpharmacological options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. Antipsychotics are associated with greater risk of cerebrovascular accident (stroke) and mortality in persons with dementia.
Avoid  
History of falls or fractures Antiepileptics

Antipsychotics Benzodiazepines
Nonbenzodiazepine, benzodiazepine receptor agonist hypnotics
Eszopiclone
Zaleplon
Zolpidem

Antidepressants
TCAs
SSRIs
SNRIs

Opioids
May cause ataxia, impaired psychomotor function, syncope, additional falls; shorteracting benzodiazepines are not safer than
long-acting ones.

If one of the drugs must be used, consider reducing use of other CNS-active medications that increase risk of falls and fractures (ie, antiepileptics, opioid-receptor agonists, antipsychotics, antidepressants, nonbenzodiazepine and benzodiazepine receptor agonist hypnotics, other sedatives/hypnotics) and implement other strategies to reduce fall risk. Data for antidepressants are mixed but no compelling evidence that certain antidepressants confer less fall risk than others.
Avoid unless safer alternatives are not available; avoid antiepileptics except for seizure and mood disorders

Opioids: avoid except for pain management in the setting of severe acute pain (eg, recent fractures or joint replacement)
Opioids: moderate, strong
All others: high, strong
Parkinson Disease Antiemetics
Metoclopramide
Prochlorperazine
Promethazine

All antipsychotics (except quetiapine, clozapine, pimavanserin)
Dopamine-receptor antagonists with potential to worsen parkinsonian symptoms

Exceptions:
Pimavanserin and clozapine appear to be less likely to precipitate worsening of Parkinson disease. Quetiapine has only been studied in low-quality clinical trials with efficacy comparable to that of placebo in five trials and to that of clozapine in two others.
Avoid Moderate, strong
Gastrointestinal
History of gastric or duodenal ulcers Aspirin >325 mg/day
Non–COX-2–selective NSAIDs
May exacerbate existing ulcers or cause new/additional ulcers Avoid unless other alternatives are not effective and patient can take gastroprotective agent (ie, proton-pump inhibitor or misoprostol) Moderate, strong
Kidney/urinary tract
Chronic kidney disease stage 4 or higher NSAIDs (non-COX and COX selective, oral and parenteral, nonacetylated salicylates) May increase risk of acute kidney injury and further decline of renal function Avoid Moderate, strong
Urinary incontinence in women Estrogen oral and transdermal (excludes intravaginal estrogen)

Peripheral alpha-1 blockers
Doxazosin
Prazosin
Terazosin
May decrease urinary flow and cause urinary retention Avoid in women Estrogen: high, strong
Peripheral alpha-1 blockers: moderate, strong
Lower urinary tract symptoms, benign prostatic hyperplasia Strongly anticholinergic drugs, except antimuscarinics for urinary incontinence Lack of efficacy (oral estrogen) and aggravation of incontinence (alpha-1 blockers) Avoid in men Moderate, strong

Table 4. 2019 American Geriatrics Society Beers Criteria® for Potentially Inappropriate Medications: Drugs To Be Used With Caution in Older Adultsa

Drug(s) Rationale Recommendation Quality of Evidence Strength of Recommendation
Aspirin for primary prevention of cardiovascular disease and colorectal cancer Risk of major bleeding from aspirin increases markedly in older age. Several studies suggest lack of net benefit when used for primary prevention in older adult with cardiovascular risk factors, but evidence is not conclusive. Aspirin is generally indicated for secondary prevention in older adults with established cardiovascular disease. Use with caution in adults ≥70 years Moderate Strong
Dabigatran
Rivaroxaban
Increased risk of gastrointestinal bleeding compared with warfarin and reported rates with other direct oral anticoagulants when used for long-term treatment of VTE or atrial fibrillation in adults ≥75 years. Use with caution for treatment of VTE or atrial fibrillation in adults ≥75 years Moderate Strong
Prasugrel Increased risk of bleeding in older adults; benefit in highest-risk older adults (eg, those with prior myocardial infarction or diabetes mellitus) may offset risk when used for its approved indication of acute coronary syndrome to be managed with percutaneous coronary intervention. Use with caution in adults ≥75 years Moderate Weak
Antipsychotics
Carbamazepine
Diuretics
Mirtazapine
Oxcarbazepine
SNRIs
SSRIs
TCAs
Tramadol
May exacerbate or cause SIADH or hyponatremia; monitor sodium level closely when starting or changing dosages in older adults Use with caution Moderate Strong
Dextromethorphan/quinidine Limited efficacy in patients with behavioral symptoms of dementia (does not apply to treatment of PBA). May increase risk of falls and concerns with clinically significant drug interactions. Does not apply to treatment of pseudobulbar affect. Use with caution Moderate Strong
Trimethoprim-sulfamethoxazole Increased risk of hyperkalemia when used concurrently with an ACEI or ARB in presence of decreased creatinine clearance Use with caution in patients on ACEI or ARB and decreased creatinine clearance Low Strong

The primary target audience is the practicing clinician. The intentions of the criteria include (1) improving the selection of prescription drugs by clinicians and patients; (2) evaluating patterns of drug use within populations; (3) educating clinicians and patients on proper drug usage; and (4) evaluating health outcome, quality-of-care, cost, and utilization data.

Table 5. 2019 American Geriatrics Society Beers Criteria® for Potentially Clinically Important Drug-Drug Interactions That Should Be Avoided in Older Adults

Object Drug and Class Interacting Drug and Class Risk Rationale Recommendation Quality & Strength
RAS inhibitor (ACEIs, ARBs, aliskiren) or potassium-sparing diuretics (amiloride, triamterene) Another RAS inhibitor (ACEIs, ARBs, aliskiren) Increased risk of hyperkalemia Avoid routine use in those with chronic kidney disease stage 3a or higher Moderate, strong
Opioids Benzodiazepines Increased risk of overdose Avoid Moderate, strong
Opioids Gabapentin, pregabalin Increased risk of severe sedation-related adverse events, including respiratory depression and death Avoid; exceptions are when transitioning from opioid therapy to gabapentin or pregabalin, or when using gabapentinoids to reduce opioid dose, although caution should be used in all circumstances. Moderate, strong
Anticholinergic Anticholinergic Increased risk of cognitive decline Avoid; minimize number of anticholinergic drugs Moderate, strong
Antidepressants (TCAs, SSRIs, and SNRIs)
Antipsychotics
Antiepileptics
Benzodiazepines and nonbenzodiazepine, benzodiazepine receptor agonist hypnotics (ie, “Z-drugs”)
Opioids
Any combination of three or more of these CNS-active drugs Increased risk of falls (all) and of fracture (benzodiazepines and nonbenzodiazepine, benzodiazepine receptor agonist hypnotics) Avoid total of three or more CNS-active drugsa; minimize number of CNS-active drugs Combinations including benzodiazepines and nonbenzodiazepine, benzodiazepine receptor agonist hypnotics or opioids: high, strong

All other combinations: moderate, strong
Corticosteroids, oral or parenteral NSAIDs Increased risk of peptic ulcer disease or gastrointestinal bleeding Avoid; if not possible, provide gastrointestinal protection Moderate, strong
Lithium ACEIs Increased risk of lithium toxicity Avoid; monitor lithium concentrations Moderate, strong
Lithium Loop diuretics Increased risk of lithium toxicity Avoid; monitor lithium concentrations Moderate, strong
Peripheral α-1 blockers Loop diuretics Increased risk of urinary incontinence in older women Avoid in older women, unless conditions warrant both drugs Moderate, strong
Phenytoin Trimethoprim-sulfamethoxazole Increased risk of phenytoin toxicity Avoid Moderate, strong
Theophylline Cimetidine Increased risk of theophylline toxicity Avoid Moderate, strong
Theophylline Ciprofloxacin Increased risk of theophylline toxicity Avoid Moderate, strong
Warfarin Amiodarone Increased risk of bleeding Avoid when possible; if used together, monitor INR closely Moderate, strong
Warfarin Ciprofloxacin Increased risk of bleeding Avoid when possible; if used together, monitor INR closely Moderate, strong
Warfarin Macrolides (excluding azithromycin) Increased risk of bleeding Avoid when possible; if used together, monitor INR closely Moderate, strong
Warfarin Trimethoprim-sulfamethoxazole Increased risk of bleeding Avoid when possible; if used together, monitor INR closely Moderate, strong
Warfarin NSAIDs Increased risk of bleeding Avoid when possible; if used together, monitor closely for bleeding High, strong

CNS-active drugs: antiepileptics; antipsychotics; benzodiazepines; nonbenzodiazepine, benzodiazepine receptor agonist hypnotics; TCAs; SSRIs; SNRIs; and opioids.

Table 6. 2019 American Geriatrics Society Beers Criteria® for Medications That Should Be Avoided or Have Their Dosage Reduced With Varying Levels of Kidney Function in Older Adults

Medication Class or Medication Creatinine Clearance at Which Action Required, mL/min Rationale Recommendation Quality & Strength
Anti-infective
Ciprofloxacin <30 Increased risk of CNS effects (eg, seizures, confusion) and tendon rupture Doses used to treat common infections typically require reduction when CrCl <30 mL/min Moderate, Strong
Trimethoprimsulfamethoxazole <30 Increased risk of worsening of renal function and hyperkalemia Reduce dose if CrCl 15-29 mL/min Avoid if CrCl <15 mL/min Moderate, Strong
Cardiovascular or hemostasis
Amiloride <30 Increased potassium and decreased sodium Avoid Moderate, Strong
Apixaban <25 <25 Lack of evidence for efficacy and safety in patients with a CrCl <25 mL/min Avoid Moderate, Strong
Dabigatran <30 Lack of evidence for efficacy and safety in individuals with a CrCl <30 mL/min. Label dose for patients with a CrCl 15-30 mL/min based on pharmacokinetic data. Avoid; dose adjustment advised when CrCl >30 mL/min in the presence of drug-drug interactions Moderate, Strong
Dofetilide <60 QTc prolongation and torsade de pointes Reduce dose if CrCl 20-59 mL/min
Avoid if CrCl <20 mL/min
Moderate, Strong
Edoxaban 15-50 <15 or >95 Lack of evidence of efficacy or safety in patients with a CrCl <30 mL/min Reduce dose if CrCl 15-50 mL/min
Avoid if CrCl <15 or >95 mL/min
Moderate, Strong
Enoxaparin <30 Increased risk of bleeding Reduce dose Moderate, Strong
Fondaparinux <30 Increased risk of bleeding Avoid Moderate, Strong
Rivaroxaban <50 Lack of efficacy or safety evidence in patients with a CrCl <30 mL/min Nonvalvular atrial fibrillation: reduce dose if CrCl 15-50 mL/min; avoid if CrCl <15 mL/min

Venous thromboembolism treatment and for VTE prophylaxis with hip or knee replacement: avoid if CrCl <30 mL/min
Moderate, Strong
Spironolactone <30 Increased potassium Avoid Moderate, Strong
Triamterene <30 Increased potassium and decreased sodium Avoid Moderate, Strong
Central Nervous System and Analgesics
Duloxetine <30 Increased gastrointestinal adverse effects (nausea, diarrhea) Avoid Moderate, Weak
Gabapentin <60 CNS adverse effects Reduce dose Moderate, Strong
Levetiracetam ≤80 CNS adverse effects Reduce dose Moderate, Strong
Pregabalin <60 CNS adverse effects Reduce dose Moderate, Strong
Tramadol <30 CNS adverse effects Immediate release: reduce dose
Extended release: avoid
Low, Weak
Gastrointestinal
Cimetidine <50 Mental status changes Reduce dose Moderate, Strong
Famotidine <50 Mental status changes Reduce dose Moderate, Strong
Nizatidine <50 Mental status changes Reduce dose Moderate, Strong
Ranitidine <50 Mental status changes Reduce dose Moderate, Strong
Hyperuricemia
Colchicine <30 Gastrointestinal, neuromuscular, bone marrow toxicity Reduce dose; monitor for adverse effects Moderate, Strong
Probenecid <30 Loss of effectiveness Avoid Moderate, Strong

Table 7. Drugs With Strong Anticholinergic Properties

Antiarrhythmic 
  • Disopyramide

Promethazine
  • Pyrilamine
  • Triprolidine

Antidepressants
  • Amitriptyline
  • Amoxapine
  • Clomipramine 
  • Doxepin (>6 mg)
  • Imipramine
  • Nortriptyline 
  • Paroxetine
  • Protriptyline
  • Trimipramine

Antimuscarinics
  • Desipramine (urinary incontinence)
  • Darifenacin
  • Fesoterodine
  • Flavoxate
  • Oxybutynin
  • Solifenacin
  • Tolterodine
  • Trospium

Antiemetics
  • Prochlorperazine 
  • Promethazine

Antiparkinsonian agents
  • Benztropine
  • Trihexyphenidyl

Antihistamines (first generation)
  • Brompheniramine 
  • Carbinoxamine
  • Chlorpheniramine
  • Clemastine
  • Cyproheptadine 
  • Dexbrompheniramine 
  • Dexchlorpheniramine
  • Dimenhydrinate 
  • Diphenhydramine (oral)
  • Doxylamine
  • Hydroxyzine

Antipsychotics
  • Chlorpromazine
  • Clozapine
  • Loxapine
  • Olanzapine
  • Perphenazine
  • Thioridazine
  • Trifluoperazine

Antispasmodics
  • Atropine (excludes ophthalmic)
  • Belladonna alkaloids
  • Scopolamine (excludes ophthalmic)

Meclizine
  • Clidinium-chlordiazepoxide
  • Dicyclomine
  • Homatropine (excludes ophthalmic)
  • Hyoscyamine 
  • Methscopolamine 
  • Propantheline

Skeletal muscle relaxants
  • Cyclobenzaprine
  • Orphenadrine

Table 8. Medications/Criteria Removed Since 2015 American Geriatrics Society Beers Criteria®

Medication/Criterion Reason for Removal
Ticlopidine No longer on US market; low use
Pentazocine Oral no longer on US market
Chronic seizures or epilepsy
Bupropion
Chlorpromazine
Clozapine
Maprotiline
Olanzapine
Thioridazine
Thiothixene
Tramadol
Not unique to older adults
Dementia; H2-receptor antagonists Weak evidence and to avoid overly restricting therapeutic options for older adults with dementia who have gastroesophageal reflux or similar issues (given a coexisting criterion advising against chronic use of PPIs except in specific circumstances)
Insomnia;
Oral decongestants
Phenylephrine
Pseudoephedrine
--
Stimulants
Amphetamine
Armodafinil
Methylphenidate
Modafinil
Theobromines
--
Theophylline
Caffeine
Not unique to older adults
Parkinson disease; Aripiprazole Removed as a preferred antipsychotic in older adults with Parkinson disease because of safety and efficacy concerns
SIADH/hyponatremia;
Carboplatin
Cyclophosphamide
Cisplatin
Vincristine
Highly specialized drugs that fell outside the scope of the criteria
Syncope; Vasodilators Not unique to older adults

Table 9. Medications/Criteria Added Since 2015 American Geriatrics Society Beers Criteria®

Medication/Criterion Reason for Addition
Glimepiride Severe, prolonged hypoglycemia in older adults
Methscopolamine Pyrilamine Strong anticholinergic
History of falls or fractures; SNRI Associated with increased risk in older adults
Parkinson disease; Pimavanserin Unlike most other antipsychotics, the revised criteria consider pimavanserin acceptable for treatment of psychosis in Parkinson disease
Rivaroxaban Emerging evidence of increased risk of serious bleeding compared with other anticoagulant options
Tramadol Risk of SIADH/hyponatremia
Dextromethorphan/quinidine Limited efficacy in treating patients with dementia symptoms disorder in absence of pseudobulbar affect while potentially increasing risk of falls and drug-drug interactions
TMP-SMX Increased risk of hyperkalemia in combination with ACEIs and ARBs in patients with reduced kidney function
Opioids + benzodiazepines Increased risk of overdose
Opioids + gabapentin/pregabalin Increased risk of overdose
Phenytoin + TMP-SMX Increased risk of phenytoin toxicity
Theophylline + ciprofloxacin Increased risk of phenytoin toxicity
Warfarin + ciprofloxacin Increased risk of bleeding
Warfarin + macrolides (excluding azithromycin) Increased risk of bleeding
Warfarin + TMP-SMX Increased risk of bleeding
Ciprofloxacin Increased risk of CNS effects
TMP-SMX Increased risk of worsening of renal function and hyperkalemia

Table 10. Medications/Criterion Modified Since 2015 American Geriatrics Society Beers Criteria®

Medication/Criterion Modification
Peripheral α-1 blockers For treatment of hypertension
Digoxin for atrial fibrillation and heart failure Added wording to Drug column; modified rationale; QE for atrial fibrillation changed to Low
Estrogen with or without progestin Added “recurrent” urinary tract infections
Sliding-scale insulin Clarified definition of sliding-scale insulin
Metoclopramide Added duration of use to recommendation
Meperidine Removed caveat from recommendation
Heart failure Reorganized recommendations; separated COX-2 inhibitors from other NSAIDs; added QE and SR for COX-2 inhibitors; changed recommendation for NSAIDs, COX-2 inhibitors, and thiazolidinediones to use with caution in asymptomatic heart failure and to avoid in symptomatic heart failure; modified rationale
Syncope Specified Specified “nonselective peripheral α-1 blockers”; separated rationales, QE, and SR for AChEIs and nonselective peripheral alpha-1 blockers; modified QE for ACHEIs and antipsychotics
Delirium Changed “Sedative/hypnotics” to Nonbenzodiazepine, benzodiazepine receptor agonist hypnotics; changed QE of H2-receptor antagonists to low
History of fractures and falls Changed SR of opioids to strong
Parkinson disease Added rationale for quetiapine, clozapine, and pimavanserin
Chronic kidney disease and NSAIDs Changed wording (minor) of criterion title
Aspirin as primary prevention Modified age, indication, rationale, and QE
Dabigatran Modified rationale and recommendation
Prasugrel Modified rationale
ACEIs/ARBs and hyperkalemia Dropped “Non–anti-infective”
Combination of three or more CNS agents (antidepressants, antiepileptics, antipsychotics, benzodiazepines, and opioids) Replaced individual criteria with a single criterion
Apixaban, dabigatran, edoxaban, and rivaroxaban Revised CrCl at which action is required, rationale and recommendations to reflect current labeling, and CrCl exclusion parameters in clinical trials

Recommendation Grading

Overview

Title

AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults

Authoring Organization

Publication Month/Year

January 25, 2019

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.

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 2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2019 Apr;67(4):674-694. doi: 10.1111/jgs.15767. Epub 2019 Jan 29. PMID: 30693946.