Beers revised: Drugs not to use in older adults

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The revised 2012 Beers criteria help health professionals determine therapies for older patients.

Older adults are generally characterized as patients who may be at an increased risk for adverse drug events because of altered pharmacokinetics, increased exposure to multiple concomitant medications, and comorbid conditions. In 1991, Mark Beers, MD, and colleagues published criteria listing “potentially inappropriate medications” for older patients. Updates to these criteria were subsequently published in 1997, 2003, and earlier this year in the Journal of the American Geriatrics Society. The revised 2012 version heralds a new partnership between an interdisciplinary panel of experts and the American Geriatrics Society.

Grading the evidence

In all, 2,169 references were reviewed by a panel of experts in the field of geriatric care. The evidence was graded based on the American College of Physicians’ Guideline Grading System. This grading system rates the quality of evidence regarding health outcomes in an appropriate population as high (i.e., consistent results from at least two randomized controlled trials or multiple, consistent observational trials), moderate (i.e., sufficient evidence from at least one high quality trial with more than 100 participants, at least two high quality trials with some inconsistency, at least two lower quality trials with consistent results, or multiple consistent observational trials with flawed methodology), or low (i.e., insufficient evidence based on small or inadequately powered studies, inconsistent results from large trials, or trials with significant methodological flaws).

In addition, the grading system rates the strength of recommendations as strong (i.e., risks plainly outweighs benefits or vice versa), moderate (i.e., risks and benefits are balanced), or weak (i.e., lack of sufficient evidence to establish benefits or risks). The new criteria list both the quality of evidence and strength of the recommendations next to each medication or drug class.

To access the ratings, visit www.americangeriatrics.org/files/documents/beers/2012BeersCriteria_JAGS.pdf.

Categories of medications

The update includes three groups of medications: medications to avoid in older adults regardless of diseases or conditions; medications considered potentially inappropriate when used in older adults with certain diseases or syndromes; and a new, third group of medications that should be used with caution in older adults. This overview will present only some of the medications mentioned in the 2012 Beers criteria; refer to the journal article for complete lists.

Medications to avoid

The revised Beers criteria list 34 potentially inappropriate medications and classes to avoid in older adults. New additions to the criteria include megestrol, glyburide, and sliding-scale insulin. Specific recommendations and rationales are summarized in Table 1.

Table 1. Examples of medications to avoid in older adults regardless of diseases or conditionsa

Drug or drug class Rationale
First-generation antihistamines Highly anticholinergic; greater risk of confusion, dry mouth, and other anticholinergic adverse events
Antispasmodics Highly anticholinergic; questionable effectiveness
Short-acting, oral dipyridamole May cause orthostatic hypotension
Ticlopidine Safer alternatives available
Nitrofurantoin Pulmonary toxicity may occur; lack of efficacy data in those with a CrCl < 60 mL/min
Alpha-1 blockers May cause orthostatic hypotension; do not use as an antihypertensive
Alpha agonists (e.g., clonidine, guanabenz, methyldopa) High risk for CNS adverse events
Class Ia, Ic, and III antiarrhythmics Evidence suggest that rate control yields more benefits than rhythm control in older adults; specific agents associated with numerous
toxicities
Digoxin > 0.125 mg/d Higher doses do not result in additional benefit and risk of toxicity high especially in those with reduced renal function
Immediate-release nifedipine Hypotension and potential risk of precipitating MI
Tertiary TCAs Highly anticholinergic
Antipsychotics, both first and second generation Increased risk of stroke and mortality in those with dementia
Barbiturates High rate of physical dependence; overdose a concern
Benzodiazepines Older adults more sensitive to effects; increases risk of cognitive impairment, delirium, falls, and fractures
Nonbenzodiazepine hypnotics (e.g., zolpidem) Adverse events similar to those observed with benzodiazepines
Estrogens Evidence of carcinogenic potential and lack of cardiovascular or cognitive benefits
Sliding scale insulin Higher risk of hypoglycemia without improving hyperglycemia
Megestrol Minimal effect on weight with accompanying adverse events
Long-acting sulfonylureas (i.e., chlorpropamide, glyburide) Greater risk of prolonged hypoglycemia
Metoclopramide Associated with extrapyramidal adverse events
Meperidine Not effective for pain control and associated with neurotoxic effects
Non-COX selective oral NSAIDs Increased risk of GI bleed and peptic ulcer disease in high-risk groups
Pentazocine CNS adverse events
Skeletal muscle relaxants Poorly tolerated because of anticholinergic effects

Abbreviations used: CrCl, creatinine clearance; CNS, central nervous system; COX, cyclooxygenase; GI, gastrointestinal; NSAID, nonsteroidal anti-inflammatory drug; TCA, tricyclic antidepressant.
Source: American Geriatrics Society updated Beers criteria for potentially inapproporiate medication use in older adults. www.americangeriatrics.org/files/documents/beers/2012BeersCriteria_JAGS.pdf
a This is not a complete list.

Potentially inappropriate medications

In terms of potentially inappropriate medications, many medications may exacerbate underlying conditions. Notable new additions include thiazolidinediones for patients with heart failure, acetylcholinesterase inhibitors in patients with a history of syncope, and selective serotonin reuptake inhibitors in those with a history of falls or fractures. The list of specific diseases/syndromes and medications/drug classes to avoid are summarized in Table 3 of the journal article.

Use with caution

A new addition to the Beers criteria is a list of agents that should be used with caution in this patient population. Specific recommendations and rationales are summarized in Table 2.

Table 2. Potentially inappropriate medications to be used with caution in older adults

Drug or drug class Recommendation Rationale
Aspirin for primary prevention of cardiac events Use with caution in patients ≥ 80 years of age Lack of benefit vs. risk in patients ≥ 80 years of age
Dabigatran (Pradaxa—Boehringer Ingelheim) Use with caution in patients ≥ 75 years of age or in those with CrCl < 30 mL/min Greater risk of bleeding in older adults; lack of evidence for efficacy and safety in those with CrCl < 30 mL/min
Prasugrel (Effient—Daiichi Sankyo, Eli Liily) Use with caution in patients ≥ 75 years of age Greater risk of bleeding in older adults
Antipsychotics, carbamazepine, mirtazapine, SNRIs, SSRIs, TCAs, carboplatin, cisplatin, vincristine) Use with caution May exacerbate syndrome of inappropriate antidiuretic hormone secretion or
hyponatremia
Vasodilators Use with caution May exacerbate episodes of syncope in those with a history of syncope

Abbreviations used: CrCl, creatinine clearance; SNRI, serotonin–norepinephrine reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor; TCA, tricyclic antidepressant.
Source: American Geriatrics Society updated Beers critera for potentially inappropriate medication use in older adults. www.americangeriatrics.org/files/documents/beers/2012BeersCriteria_JAGS/pdf.

Summary

The revised Beers criteria provide a guideline for safer use of medications in older adults. For the first time, the revised version used a validated literature evaluation tool to support the recommendations. The update represents a step forward in the evaluation of drug safety in older patients and is an important tool for health providers who care for this population. The criteria should not serve as a substitute for professional judgment nor should it dictate prescribing for specific patients. The information presented in the criteria should serve only as a guide, with care tailored to each patient’s needs.

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