2019 Beers Criteria for Drug Use in the Elderly, Updated

J Am Geriatr Soc. Published online January 29, 2019.

Study Highlights

• The Beers Criteria are designed for use by practicing clinicians. The authors encourage their application for teaching and measuring quality of care, but not as a punitive measure.
• The authors acknowledge that drugs on their list are not always inappropriate for a given patient. Clinical rationale and shared decision-making are the most important elements for safe prescribing.
• A multidisciplinary team of 13 healthcare providers assessed 377 articles published between 2015 and 2017 to create the current update.
• H2-receptor antagonists were removed from the "avoid" list among adults with dementia or cognitive impairment. The degree of evidence that these drugs cause negative cognitive effects is weak. Use of H2-receptor antagonists is not recommended in patients with delirium and remain on the "avoid" list for this indication.
• Glimepiride was added to the list of sulfonylureas, which can increase the risk for severe prolonged hypoglycemia.
• Serotonin-norepinephrine reuptake inhibitors were added to the list of drugs to avoid among adults with a history of falls or fractures.
• Although most antipsychotic medications should be avoided among patients with Parkinson disease, quetiapine, clozapine, and pimavanserin may be preferred in this setting.
• Nondihydropyridine calcium channel blockers should not be used among patients with heart failure. Nonsteroidal anti-inflammatory drugs and thiazolidinediones should be used with caution in cases of heart failure.
• The age limit for the safe use of aspirin as primary prophylaxis against cardiovascular disease and colorectal cancer was lowered from 80 to 70 years.
• Rivaroxaban was added to dabigatran as increasing the risk for gastrointestinal bleeding compared with warfarin and other direct oral anticoagulants among adults at age 75 years and older.
• Dextromethorphan/quinidine is deemed inappropriate in the treatment of the behavioral symptoms of dementia. This drug has limited evidence of efficacy and may increase the risk for falls and drug interactions. This recommendation did not apply to the treatment of pseudobulbar affect.
• Multiple drugs should be avoided because of their associated risk for hyponatremia and syndrome of inappropriate diuretic hormone, including carbamazepine, diuretics, tramadol, and multiple forms of antidepressants.
• Trimethoprim-sulfamethoxazole was cited for its associated risk for hyperkalemia when used with a renin-angiotensin inhibitor in the setting of reduced creatinine clearance. Trimethoprim-sulfamethoxazole can also increase the risk for phenytoin toxicity and bleeding among patients treated with warfarin. Finally, trimethoprim-sulfamethoxazole was added to the warning list among older adults with renal dysfunction.
• Nonsteroidal anti-inflammatory drugs should be avoided if possible among older adults, especially for prolonged periods of treatment. The authors note that indomethacin is associated with the highest rate of adverse effects of all nonsteroidal anti-inflammatory drugs.
• Ciprofloxacin can cause neurological adverse effects among adults with reduced renal function, and it can promote a higher risk for tendon rupture among these patients.

Clinical Implications

• A previous study found that more than half of older adults used at least 1 PIM, and participants were exposed to a PIM during more than 10% of the study period. Nonsteroidal anti-inflammatory drugs were the most common class of PIM. Use of a PIM was independently associated with a higher risk for hospitalization.
• The current update to the Beers Criteria includes warnings regarding glimepiride, trimethoprim-sulfamethoxazole, ciprofloxacin, rivaroxaban and nonsteroidal anti-inflammatory drugs; as well as the deletion of multiple drugs from the list due to availability. There is a clear warning for the avoidance of dextromethorphan/quinidine in the treatment of behavioral symptoms of dementia.
• Implications for the Healthcare Team: The healthcare team should proactively reconcile medications for older adults and eliminate PIMs when possible. Health care professionals should engage in active communication with each other and across care transitions to enable appropriate selection of medication for the elderly. The beers guideline should be utilized as an essential tool to identify and improve medication appropriateness and safety

https://www.medscape.org/viewarticle/909799

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Benjamin Hidalgo-Matlock
Skin Care Physicians of Costa Rica

Clinica Victoria en San Pedro: 4000-1054
Momentum Escazu: 2101-9574

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