With almost a decade since the previous release, the American Geriatrics Society (AGS) recently updated their Alternative Treatments to Selected Medications guidelines to reflect the evolving landscape of geriatric healthcare and medicine. Based on the recommendations in the 2023 AGS Beers Criteria, this 2025 update follows the 2015 release of the previous version (which was based on the then-current 2012 AGS Beers Criteria).
The AGS designates the primary audience of this effort to be front-line clinicians caring for older adults who require pharmacological alternatives or non-pharmacologic management tactics. The AGS encourages clinical judgement at the discretion of the clinician and does not provide a prioritized list nor does it consider this to be a comprehensive list. However, where there is a clear consensus based on clinical practice guidelines, comments and a preferred order of alternatives are noted.
Because the two guidelines were formatted differently, and steps were taken to make the latest update far more helpful to clinicians, making direct comparisons between the two are not ideal. The clinical insights provided in the 2025 update eclipse the guidance in the previous version, not to mention the latest guideline contains the lasted available information. Outlined below are some of the elements that appeared in both guidelines.
Comparison of Suggestions for Alternatives Between the Guidelines
| Topic | 2015 Guideline | 2025 Guideline |
|---|---|---|
| Tricyclic Antidepressant | For depression: SSRI (except paroxetine), SNRI, bupropion. For neuropathic pain: SNRI, gabapentin, capsaicin topical, pregabalin, lidocaine patch | For neuropathic pain: Instead of tricyclic antidepressants, consider the following: SNRIs, gabapentinoids, other topical agents including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments), lidocaine. |
| High Blood Pressure | Thiazide-type diuretic, ACEI, ARB, long-acting dihydropyridine CCB In black patients—thiazide-type diuretic, CCB For heart failure, diabetes mellitus, chronic kidney disease—ACEI or ARB preferred | First-line drug therapies for hypertension include thiazide diuretics, calcium channel blockers, ACEIs, and ARBs. Beta blockers may be indicated in some cases (e.g., recent MI or acute coronary syndrome, HFrEF, AF, or angina). Alternatives to immediate-release nifedipine include other calcium channel blockers, (e.g., amlodipine, felodipine, nifedipine ER). Additional agents for use in patients with resistant hypertension include spironolactone and hydralzazine, after considering other causes of resistant hypertension (e.g., medication non-adherence, hyperaldosteronism). |
| Atrial Fibrillation | For rate control: nondihydropyridine CCB (e.g., diltiazem), beta-blocker For rhythm control: dofetilide flecainide, propafenone Long-acting dihydropyridine CCB (e.g., amlodipine) | Consider other DOACs (e.g., apixaban, edoxaban). For many older adults seeking rhythm control, dofetilide and sotalol are preferred antiarrhythmic agents. |
| Insomnia | Nonpharmacological options are recommended to treat insomnia initially, including sleep hygiene combined with behavioral interventions | Medications which may be safer (but not completely safe) and have evidence of effectiveness for insomnia in older adults include low-dose doxepin (up to 6 mg), dual orexin receptor antagonists (e.g., daridorexant, lemborexant, suvorexant), and remelteon, all for short-term use. However, formal, evidence-based guidelines addressing efficacy and/or safety of these medications in older adults are not available. There is insufficient evidence to recommend trazodone, mirtazapine, melatonin, and other medications commonly prescribed for adults with insomnia disorder. Guidelines do not recommend these drugs for insomnia disorder in adults of any age. |
| Anxiety | For anxiety: buspirone, SSRI, SNRI | If pharmacologic therapy is indicated, consider agents with a safer adverse effect profile for older adults, including the following. Note that the AGS Beers Criteria cautions use of SSRIs and SNRIs in older adults with a history of falls, due to increased fall risk. Generalized Anxiety Disorder: escitalopram, sertraline, venlafaxine, duloxetine, buspirone, pregabalin Panic Disorder: sertraline, escitalopram, venlafaxine Social Anxiety Disorder: escitalopram, sertaline, venlafaxine, (also: beta-blocker, e.g., propranolol, for performance-only anxiety) PTSD global symptoms: sertraline, venlafaxine PTSD nightmares: prazosin |
| Pain | For neuropathic pain: SNRI, gabapentin, capsaicin topical, pregabalin, lidocaine patch. For acute mild or moderate pain—acetaminophen, nonacetylated salicylate (e.g., salsalate), propionic acid derivatives (e.g., ibuprofen, naproxen) if no heart failure or eGFR>30 mL/min and given with PPI for gastroprotection if used for >7 days. For mild or moderate chronic pain—acetaminophen, nonacetylated salicylate (e.g., salsalate), propionic acid derivatives (e.g., ibuprofen, naproxen) if no heart failure or eGFR >30 mL/min and given with PPI for gastroprotection. For acute moderate to severe pain—tramadol, morphine, oxycodone immediate release with acetaminophen. For chronic moderate to severe pain: all the above; avoid long-duration, sustained-release dosage forms in opioid-naïve individuals; see neuropathic pain alternatives above under tertiary tricyclic antidepressant alternatives. | For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: short-term use of NSAIDs, topical NSAIDs (e.g., diclofenac gel), COX-2 selective inhibitors; other topical agents including capsaicin, rubefacients, and related agents (e.g., menthol-containing ointments); lidocaine, acetaminophen, and intra-articular corticosteroids. For neuropathic pain: Instead of TCAs chonsider the following: SNRIs, gabapentinoids, other topical agents including capsaicin, rubefacients and related ageints (e.g., menthol-containing ointments), lidocaine. |
The 2025 update comes with supportive notations and commentary that clinicians can review for additional insights and perspectives. Consult the full-text version of the 2025 update for a complete look at the latest recommendations from AGS.
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