Transcript BEERS List, An Analysis


Medication-related problems are
common, costly and often preventable
in older adults and lead to poor
outcomes.

Estimates in past studies in ambulatory
and long-term care settings found that
27% of adverse drug events (ADE’s) in
primary care and 42% of ADE’s in longterm care were preventable, with most
problems occurring at the ordering and
monitoring stages of care.

In a study of the 2000/2001 Medical
Expenditure Panel Survey, the total
estimated healthcare expenditures
related to the use of PIM’s was $7.2
billion.

Explicit criteria can identify high-risk drugs
using a list of PIM’s that have been
identified through expert panel review as
having an unfavorable balance of risks
and benefits by themselves and
considering the alternatives available.

A list of PIM’s was developed and
published by Beers and colleagues for
nursing home residents in 1991 and
subsequently expanded and revised in
1997 and 2003 to include all settings of
geriatric care.

The 2012 update continues to categorize
the PIM’s in three categories:
Medications to avoid regardless of
diseases or conditions, medications
considered potentially inappropriate
when used in certain diseases or
syndromes and medications that should
be used with caution.
ANTICHOLINERGICS
(excludes TCA’S)
Rationale
Brompheniramine
Highly anticholinergic; clearance
Carbinoxamine
reduced with advanced age and
Chlorpheniramine
tolerance develops when used as
Clemastine
hypnotic; greater risk of confusion,
Cyproheptadine
dry mouth, constipation and other
Dexbrompheniramine
anticholinergic effects and toxicity.
Dexchlorpheniramine
Use of diphenhydramine in special
Diphenhydramine (oral)
situations such as acute treatment
Doxylamine
of severe allergic reaction may be
Hydroxyzine
appropriate.
Promethazine
Triprolidine
ANTIPARKINSON AGENTS
Rationale
Benztropine (oral)
Not recommended for prevention
Trihexyphenidyl
of extrapyramidal symptoms with
antipsychotics; more effective
agents available for treatment
of Parkinson disease.
ANTISPASMODICS
Rationale
Belladonna alkaloids
Highly anticholinergic, uncertain
Clidinium-chlordiazepoxide
effectiveness.
Dicyclomine
Hyocyamine
Propantheline
Scopolamine
ANTITHROMBOTICS
Rationale
Dipyridamole, oral short acting*
May cause orthostatic
(does not apply to extended
hypotension; more effective
Release combination with aspirin)
alternatives available; intravenous
form acceptable for use in cardiac
stress testing.
Ticlopidine*
Safer effective alternatives
available.
ANTI-INFECTIVES
Rationale
Nitrofurantoin
Potential for pulmonary toxicity;
safer alternatives available; lack
of efficacy in patients with
CrCl under 60ml/min due to
inadequate drug concentration
in the urine.
CARDIOVASCULAR
Rationale
ALPHA-1 BLOCKERS:
High risk of orthostatic
Doxazosin
hypotension; not recommended as
Prazosin
routine treatment for hypertension;
Terazosin
alternative agents have superior
risk benefit profile.
ALPHA AGONISTS, CENTRAL
High risk of adverse CNS effects;
Clonidine
may cause bradycardia and
Guanabenz*
orthostatic hypotension; not
Guanfacine*
recommended as routine
Methyldopa*
treatment for hypertension.
Reserpine (under 0.1 mg/d)*
CARDIOVASCULAR continued
Rationale
Antiarrythmic drugs (Class Ia, IC,
Data suggests that rate control
III)
yields better balance of benefits
Amiodarone
and harms than rhythm control for
Dofetilide
most older adults.
Dronedarone
Amiodarone is associated with
Flecainide
multiple toxicities, including
Ibutilide
thyroid disease, pulmonary
Procainamide
disorders and QT interval
Propafenone
prolongation.
Quinidine
Sotalol
CARDIOVASCULAR, continued
Rationale
Disopyramide*
Disopyramide is a potent negative
inotrope and therefore may
induce
heart failure in older adults;
strongly anticholinergic; other
antiarrhythmic drugs preferred.
Dronedarone
Worse outcomes have been
reported in patients taking
dronedarone with permanent
atrial fibrillation or heart failure. In
general, rate control is preferred
over rhythm control for atrial
fibrillation.
CARDIOVASCULAR, continued
Rationale
Digoxin, above 0.125 mg/d
In heart failure, higher doses
associated with no additional
benefit and may increase risk of
toxicity; slow renal clearance may
lead to risk of toxic effects.
Nifedipine, immediate release*
Potential for hypotension; risk of
precipitating myocardial ischemia.
Spironolactone, above 25mg/d
In heart failure, the risk of
hyperkalemia is higher in older
adults especially if taking
above 25mg/d or taking
concomitant NSAID, angiotensin
converting enzyme inhibitor,
angiotensin receptor blocker, or
potassium supplement.
CENTRAL NERVOUS SYSTEM
Rationale
Tertiary TCA’s, alone or in
Highly anticholinergic, sedating
combination:
and cause orthostatic hypotension;
Amitriptyline
safety profile of low dose doxepin
Chlordiazapoxide-amitriptyline
(below 6mg/d) is comparable with
Clomipramine
that of placebo.
Doxepin, above 6mg/d
Imipramine
Perhenazine-amitriptyline
Trimipramine
CENTRA NERVOUS SYSTEM ,
continued
Rationale
Antipsychotics, first generation
(conventional):
Increased risk of cerebrovascular
Chlorpromazine
accident (stroke) and mortality in
Fluphenazine
persons with dementia.
Haloperidol
Loxapine
Molindone
Perphenazine
Pimozide
Promazine
Thioridazine
Thiothixene
Trifluoperazine
Triflupromazine
CENTRAL NERVOUS SYSTEM,
continued
Rationale
Antipsychotics, second generation
(atypical)
Same as first generation.
Aripiprazole
Asenapine
Clozapine
Iloperidone
Lurasidone
Olanzapine
Paliperidone
Quetiapine
Risperidone
Ziprasidone
CENTRAL NERVOUS SYSTEM,
continued
Rationale
Thioridazine
Highly anticholinergic and risk of
Mesoridazine
QT interval prolongation.
Barbiturates:
High rate of physical dependence;
Amobarbital*
tolerance to sleep benefits; risk of
Butabarbital*
overdose at low dosages.
Butalbital
Mephobarbital*
Pentobarbital*
Phenobarbital
Secobarbital*
CENTRAL NERVOUS SYSTEM,
continued
Rationale
Benzodiazepines
Older adults have increased
Short and intermediate acting:
sensitivity to benzodiazepines and
Alprazolam
slower metabolism of long acting
Estazolam
agents. In general, all
Lorazepam
benzodiazepines increase risk of
Oxazepam
cognitive impairment, delirium,
Temazepam
falls, fractures and motor vehicle
Triazolam
accidents in older adults.
Long acting:
May be appropriate for seizure
Clorazepate
disorders, rapid eye movement
Chlordiazepoxide
sleep disorders, benzodiazepine
Chlordiazepoxide-amitriptyline
withdrawal, ethanol withdrawal,
Clidinium-chlordiazepoxide
severe generalized anxiety
Clonazepam
disorder, periprocedural
Diazepam
anesthesia, end of life care.
Flurazepam
Quazepam
Chloral hydrate*
Tolerance occurs within 10 days,
and risks outweigh benefits in
light of overdose with doses only
3 times the recommended dose.
Meprobamate
High rate of physical dependence;
very sedating.
Nonbenzodiazepine hypnotics
Benzodiazepine receptor agonists
Eszopiclone
that have adverse effects similar to
Zolpidem
those of benzodiazepines in older
Zaleplon
adults (e.g., delirium, falls,
fractures); minimal improvement
in sleep latency and duration.
Ergot mesylates* - Isoxsuprine
Lack of efficacy.
ENDOCRINE: Androgens
Potential for cardiac problems and
Methyltestosterone*
contraindicated in men with
Testosterone
prostate cancer.
Desiccated thyroid
Concerns about cardiac effects;
safer alternatives available.
ENDOCRINE
RATIONALE
Estrogens with or without
Evidence of carcinogenic potential
progestins
(breast and endometrium); lack of
cardioprotective effect and
cognitive protection in older
women.
Evidence that vaginal estrogens
for treatment of vaginal dryness is
safe and effective in women with
breast cancer, especially at
doses of estradiol below 25 ug
twice weekly.
Growth hormone
Effect on body composition is
small and associated with edema,
arthralgia, carpal tunnel syndrome,
gynecomastia, impaired fasting
glucose.
ENDOCRINE
Rationale
Insulin, sliding scale
Higher risk of hypoglycemia
without improvement in
hyperglycemia management
regardless of care setting.
Megestrol
Minimal effect on weight;
increases risk of thrombotic
events and possibly death in older
adults.
Sulfonylureas, long duration
Chlorpropamide: prolonged
Chlorpropamide
half-life in older adults; can cause
Glyburide
prolonged hypoglycemia; causes
syndrome of inappropriate
antidiuretic hormone secretion.
Glyburide: greater risk of severe
prolonged hypoglycemia in older
adults.
GASTROINTESTINAL
RATIONALE
Metoclopramide
Can cause extrapyramidal effects
including tardive dyskinesia; risk
may be even greater in frail older
adults.
Mineral oil, oral
Potential for aspiration and
adverse effects; safer alternatives
available.
Trimethobenzamide
One of the least effective
antiemetic drugs; can cause
extrapyramidal adverse effects.
PAIN
Meperidine
Not an effective oral analgesic in
doses commonly used; may
cause neurotoxicity; safer
alternatives available.
PAIN
RATIONALE
Non-COX selective NSAID’s, oral
Increase risk of GI bleeding and
Aspirin (above 325 mg/d)
peptic ulcer disease in high risk
Diclofenac
groups, including those
Diflunisal
aged above 75 or taking oral or
Etodolac
parental corticosteroids,
Fenoprofen
anticoagulants or antiplatelet
Ibuprofen
agents. Use of proton pump
Ketoprofen
inhibitor or misoprostol reduces
Meclofenamate
but does not eliminate risk. Upper
Mefenamic acid
GI ulcers, gross bleeding or
Meloxicam
perforation caused by NSAID’s
Nabumetone
occur in approximately 1% of
Naproxen
patients treated for 3-6 months
Oxaprozin
and in approximately 2-4% of
Piroxicam
patients treated for 1 year. These
Sulindac
trends continue with longer
Tolmetin
duration of use.
GASTROINTESTINAL
Rationale
Indomethacin
Increases risk of GI bleeding and
Ketrolac, includes parental
peptic ulcer disease in high risk
groups. (See above Non-COX
selective NSAID’s).
Of all the NSAID’s, indomethacin
has most adverse effects.
Pentazocine*
Opiod analgesic that causes CNS
adverse effects, including
confusion and hallucinations, more
commonly than other narcotic
drugs; is also a mixed agonist and
antagonist; safer alternatives
available.
PAIN
Rationale
Skeletal muscle relaxants:
Most muscle relaxants are poorly
Carisoprodol
tolerated by older adults because
Chlorzoxazone
of anticholinergic adverse effects
Cyclobenzaprine
sedation, risk of fracture,
Metaxalone
effectiveness at dosages tolerated
Methocarbamol
by older adults is questionable.
Orphenadrine
DISEASE OR
SYNDROME
DRUG
RATIONALE
NSAID’s and COX-2
inhibitors
Potential to promote
fluid retention and
Nondihydropyridine
CCB’s (avoid -
exacerbate heart
failure.
CARDIOVASCULAR:
Heart Failure
only for for systolic
heart failure):
Diltiazem
Verapamil
Pioglitazone,
rosiglitazone
Cilostazol
Dronedarone
DISEASE OR
SYNDROME
DRUG
RATIONALE
Syncope
AChEls
Increase risk of
Peripheral alpha blockers:
orthostatic
Doxazosin
hypotension
Prazosin
or bradycardia.
Terazosin
Tertiary TCA’s
Chlorpromazine,olanzapine,
thioridazine
Chronic seizures
Bupropion
Lowers seizure
or epilepsy
Chlorpromazine
threshold; may
Clozapine
be acceptable
Maprotiline
in patients with
Olanzapine
well controlled
Thioridazine
seizures in whom
Thiothixene
alternatives are
Tramadol
not effective.
DISEASE OR
SYNDROME
DRUG
RATIONALE
Delirium
All TCA’s
Avoid in older adults
Anticholinergics
with or at high risk of
delirium because of
Benzodiazepines
inducing or worsening
Chlorpromazine
delirium in older adults;
Corticosteroids
if discontinuing drugs
H2-receptor
antagonist
used chronically, taper
to avoid withdrawal
symptoms.
Meperidine
Sedative Hypnotics
Thioridazine
DISEASE OR
SYNDROME
DRUG
RATIONALE
Dementia and
Anticholinergics
Avoid because of
cognitive
Benzodiazepines
adverse CNS effects.
impairment
H2-receptor
antagonists
Avoid antipsychotics
for behavioral
Zolpidem
problems of
Antipsychotics,
chronic
dementia unless
and as-needed use
nonpharmacological
options have failed
and patient is a threat
to themselves or others
Antipsychotics are
associated with an
increased risk of
cerebrovascular
accident (stroke) and
DISEASE OR
SYNDROME
DRUG
RATIONALE
History of
Anticonvulsants
Ability to produce
falls or
Antipsychotics
ataxia, impaired
Fractures
Benzodiazepines
psychomotor function,
Nonbenzodiazepine
hypnotics
syncope, and
additional
Eszopiclone
falls; shorter-acting
Zaleplon
benzodiazepines are
Zolpidem
not safer than long-
TCA’s and selective
serotonin reuptake
inhibitors
acting ones.
DISEASE OR
SYNDROME
DRUG
RATIONALE
Insomnia
Oral decongestants:
CNS stimulant effects
Pseudoephedrine
Phenylephrine
Stimulants:
Amphetamine
Methylphenidate
Pemoline
Theobromines:
Theophylline
Caffiene
DISEASE OR
SYNDROME
DRUG
RATIONALE
Parkinson’s
All antipsychotics
Dopamine receptor
disease
Antiemetics:
antagonists with
Metochlopramide
potential to worsen
Prochlorperzaine
parkinsonion
symptoms.
Promethazine
Quetiapine and
clozapine appear to
be less likely to
precipitate worsening
of Parkinson’s disease.
DISEASE OR
SYNDROME
DRUG
RATIONALE
Chronic
Antimuscarinics for
Can worsen
Constipation
urinary incontinence
constipation; agents
Darfenacin
urinary incontinence:
Fesoterodine
antimuscarinics overall
Oxybutynin (oral)
differ in incidence of
Solifenacin
constipation; response
Tolterodine
variable; consider
Trospium
alternative agent if
Nondihydropyridine
CCB:
Diltiazem
Verapamil
constipation develops.
DISEASE OR
SYNDROME
DRUG
Chronic constipation,
First-generation
antihistamines as
continued
single agent or part of
combination products:
Brompheniramine
Carbinoxamine
Chlorpheniramine
Clemastine
Cyproheptadine
Dexbropheniramine
Dexchlorpheniramine
Diphenhydramine
Doxylamine
Hydroxyzine
Promethazine
Triprolidine
RATIONALE
DISEASE OR
SYNDROME
DRUG
Chronic constipation,
Anticholinergics and
continued
Antispasmotics:
Antipsychotics
Belladonna alkaloids
Clidiniumchlordiazepoxide
Dicyclomine
Hyoscyamine
Propantheline
Scopolamine
Tertiary TCA’s:
Amitriptyline
Clomipramine
Doxepin
Imipramine
Trimipramine
RATIONALE
DISEASE OR
SYNDROME
DRUG
Chronic constipation,
Anticholinergics and
continued
Antispasmotics:
Antipsychotics
Belladonna alkaloids
Clidiniumchlordiazepoxide
Dicylcomine
Hyoscyamine
Propantheline
Scopolamine
Tertiary TCA’s:
Amitriptyline,
Clomipramine,
Doxepin,
Imipramine,
Trimipramine
RATIONALE
DISEASE OR
SYNDROME
DRUG
RATIONALE
History of gastric
Aspirin (above 325 mg) May exacerbate
or duodenal ulcers
Non-COX2 selective
NSAID’s
existing ulcers or cause
new or additional
ulcers.
Chronic kidney
NSAID’s
May increase risk of
disease, Stages IV or V
Triamterene (alone or
kidney injury.
in combination)
Urinary
Estrogen oral and
Aggravation of
Incontinence
transdermal (excludes
incontinence.
(all types)
intravaginal estrogen)
in women
Aspirin
Lack of evidence of
Use with caution in
for primary prevention
benefit versus risk in
adults over 80.
of cardiac events
individuals over 80
Dabigatran
Greater risk of
Use with caution in
bleeding than with
adults aged above 75
warfarin in adults aged or if CrCl below
above 75; lack of
30mL/min.
evidence for efficacy
and safety in
individuals with CrCl
Below 30 mL/min
Pasugrel
Greater risk of
Use with caution in
bleeding in older
adults above 75.
adults; risk may be
offset by benefit in
highest risk older adults
(e.g., with prior
myocardial infarction
or diabetes mellitus
DIEASE OR SYNDROME
DRUG
RATIONALE
Lower urinary tract
symptoms,
Inhaled anicholinergic
agents
May decrease urinary
flow and cause
benign prostatic
hyperplasia
Strongly
anitcholinergic drugs
urinary retention.
except
antimusscarinics for
urinary incontinence
Stress or mixed
urinary incontinence
Alpha blockers:
Doxazosin
Prazosin
Terazosin
Aggravation of
incontinence.
DRUG
RATIONALE
RECOMMENDATION
Aspirin, for primary
prevention
Lack of evidence of
benefit versus risk in
Use with caution in
adults over age 80.
of cardiac events
individuals over age 80
Dabigatran
Greater risk of
Use with caution in
bleeding than with
adults over age 75 or
warfarin in adults aged If CrCl less than 30mL
above 75; lack of
/min.
evidence for efficacy
and safety in
individuals with CrCl
less than 30mL/min
Prasugrel
Greater risk of
Use with caution in
bleeding (may benefit
adults above age 75.
higher risk adults with
prior myocardial injury
or diabetes mellitus
DRUG
RATIONALE
RECOMMENDATION
Antipsychotics
May exacerbate or
Use with caution.
Carbamazepine
cause syndrome of
Carboplatin
inappropriate
Cisplatin
antidiuretic hormone
Mirtazapine
secretion or
Serotoninnorepinephrine
hyponatremia;
need to
reuptake inhibitor
monitor sodium level
Selective serotonin
closely when starting
reuptake inhibitor
or changing dosages
Tricyclic
antidepressants
in older adults due to
increased risk
Vincristine
Vasodilators
May exacerbate
episodes of syncope
in individuals
with history of syncope
Use with caution.

Previously, as many as 40% of older
adults received one or more of the
medications on this list, depending on
the care setting.

These criteria have some limitations:
Older adults are often underrepresented
in drug trials, The criteria does not
address other types of PIM’s that are not
unique to aging and Hospice and
palliative care patients needs (symptom
control being paramount) are not
completely addressed.

Finally, these criteria are not meant to
supersede clinical judgment or an
individual’s values and needs.
Prescribing and managing disease
conditions should be individualized and
involve shared decision making.

The American Geriatric Society 2012
Beers Criteria Update Expert Panel.
American Geriatrics Society Updated
Beers Criteria for Potentially
Inappropriate Medication Use in Older
Adults. JAGS 2012:1-16.
Victor J. Sobolewski, III, D.O.
Visiting Physicians
West Allis, WI
262-949-1893