Updated Beers criteria highlight medications that are risky in older patients

Warfarin should be avoided as initial therapy for venous thromboembolism or nonvalvular atrial fibrillation in older adults, unless alternative options (e.g., direct-acting oral anticoagulants) are contraindicated or there are substantial barriers to their use, according to the 2023 American Geriatrics Society (AGS) Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.

The criteria, which were last updated in 2019, are divided into five categories: medications considered potentially inappropriate, medications that are potentially inappropriate in patients with certain diseases or syndromes, medications to be used with caution, potentially inappropriate drug-drug interactions, and medications whose dosages should be adjusted based on renal function.

An interprofessional expert panel reviewed evidence published from June 1, 2017, through May 31, 2022, and used a structured assessment process to develop the 2023 update. The criteria are intended for adults ages 65 years and older in all ambulatory, acute, and institutionalized settings of care in the United States, except hospice and end-of-life care settings. They were published May 4 by the Journal of the American Geriatrics Society.

Warfarin was newly added to the Beers criteria since the 2019 update, independent of diagnosis or condition. For older adults who have been using warfarin long-term, the criteria state that it may be reasonable to continue, particularly among those with well-controlled international normalized ratios (i.e., >70% time in the therapeutic range) and no adverse effects. Other drugs added to the Beers criteria since 2019 include ticagrelor and sodium-glucose cotransporter-2 inhibitors, which are listed in the “use with caution” section, and baclofen, which is listed as a medication that should be avoided or have its dosage reduced with reduced kidney function. New clinically important drug-drug interactions added since 2019 included skeletal muscle relaxants added to central nervous system-active drugs, lithium plus angiotensin receptor blockers and angiotensin receptor/neprilysin inhibitors, and warfarin plus selective serotonin reuptake inhibitors.

The criteria include detailed tables of drugs for each of the five categories, as well as tables listing drugs that have been added, modified, or removed since 2019 and a special box that summarizes criteria for anticoagulants (warfarin, rivaroxaban, and dabigatran). The authors stressed that medications included in the criteria are potentially inappropriate, not definitely inappropriate, and that clinicians should read the rationale and recommendations statements for each criterion, which include important caveats and guidance. Clinicians should understand why medications are included and adjust their approach to those medications accordingly, the statement said.

“‘Avoid’” is not defined as an absolute contraindication unless specified in the medication's label. It is the expert panel's intent that when a PIM [potentially inappropriate medication] is chosen, it is done so through shared decision-making that includes recognition of its potential harms and consideration of the older person's preferences and goals of care,” the authors wrote. The criteria are available on an app and a pocket card at GeriatricsCareOnline.org.