by Kim Moon, Pharm.D., Blue Cross Blue Shield of Michigan, CSPM Member and Riham Kiston, Pharm.D. Candidate, Blue Cross Blue Shielf of Michigan Intern
The updated 2015 American Geriatrics Society (AGS) Beers Criteria was published to reflect changes made to the existing list of potentially inappropriate medications for patients 65 and older, as well as provide three new components: select drug-drug interactions, renal function dosing adjustments and an alternative medication list. The list is an update to the 2012 Beers criteria, and it aims to address drug related problems and adverse drug events in the geriatric population using new pieces of evidence. It is important to note that these recommendations do not pertain to patients who are receiving hospice or palliative care.
New to the list is the long-term use (greater than eight weeks) of proton-pump inhibitors (PPIs), due to increased risk of C. difficile infections, bone loss and fractures. The Beers criteria recommends avoiding PPI use for more than eight weeks unless the patient is high-risk (chronic use of NSAIDs or oral corticosteroids), has a hyper-secretory condition (erosive esophagitis, Barrett’s esophagus, etc.) or has a demonstrated need for maintenance treatment (trial and failure of H2 blockers, etc.).
Another shift in the criteria is the status change of zolpidem, zaleplon and eszopiclone. The evidence for potential harms of delirium, falls and fractures seems to outweigh the benefit of their use for any duration, in comparison to the 90-day limit previously suggested. If a patient must be on these medications, along with other CNS-active medications (psychiatric medications, opioids, etc.), the recommendation is to reduce the dose and/or frequency and avoid the use of three or more of these drugs concomitantly.
The 2015 Beers update also removes the previous recommendations against use of anti-arrhythmic drug classes Ia, Ic and III as first-line treatment for atrial fibrillation; however, amiodarone and dronedarone are not recommended as first line agents in the treatment of atrial fibrillation and disopyramide is to be avoided altogether. An anti-arrhythmic by another mechanism, digoxin has a few clarifications of its own. Adding to the recommendation of a 0.125mg daily dose maximum, the criteria now also says to avoid digoxin as first line therapy for both atrial fibrillation and heart failure, and to provide renal dose adjustments for stage four or five chronic kidney disease patients.
The following medications have been added to the 2015 Beers list as medications to be avoided due to high anticholinergic activity: dimenhydrinate, meclizine, atropine (excludes ophthalmic), belladonna alkaloids, clidinium-chlordiazepoxide, dicyclomine, hyoscyamine, propantheline, scopolamine, amoxapine, desipramine, nortriptyline, paroxetine and protriptyline.
It is worth noting that trimethobenzamide, an anti-cholinergic traditionally used to treat nausea and vomiting, has been removed from the new Beers criteria. Also, the creatinine clearance below which nitrofurantoin use should be avoided has been loosened from less than 60mL/min to less than 30mL/min. Long-term use of nitrofurantoin is still not recommended.
- The American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2015;63:2227-2246.