Beers Criteria Update 2023 - Seven Changes

The American Geriatrics Society (AGS) 2023 updated AGS Beers Criteria® for potentially inappropriate medication (PIM) use in older adults was released during the AGS annual meeting in May 2023.  This is the sixth update to the criteria which are currently designed to identify potentially inappropriate medications (PIMs) that are best avoided in older adults in general or in specific circumstances.  The criteria were first intended to be applied to the nursing home population but were expanded to apply to all adults 65 years old and older (except for end-of-life settings). 

The criteria are arranged into five general categories or situations where medication use should be avoided, questioned, or adjusted.  These categories each have a separate useful

angle when one is performing a detailed review of patients' medications and each section has a useful table. They include:

• Medications considered as potentially inappropriate (e.g., avoid nifedipine immediate release – strong recommendation, high quality evidence)
• Medications potentially inappropriate in patients with certain diseases or syndromes (e.g., avoid dronedarone in heart failure – strong recommendation, high quality evidence)
• Medications to be used with caution (e.g., dabigatran for NVAF, strong recommendation, moderate quality evidence)
• Potentially inappropriate drug interactions (e.g., phenytoin with sulfamethoxazole/trimethoprim – strong recommendation, moderate quality evidence)
• Medications whose dosages should be adjusted based on kidney function (e.g., avoid spironolactone if ClCr < 30 mL/min – strong recommendation, moderate quality evidence)

The 2023 update included a review of the literature since the last guide was published (so it now includes evidence from 2017-2022) to sustain, remove, alter, or add new criteria. The expert panel also graded the strength and quality of evidence and recommendations.

Seven New Changes in the 2023 AGS Beers Criteria

Below are seven new changes to the new update.  It's important to note that when reviewing and using the criteria for clinical purposes, readers should make sure to read the rationales and recommendations for each particular medication or condition as important justifications and caveats are explained.  Situations may not be as simple as "oh I'll avoid this because it's a Beers drug."

Anticoagulation (warfarin and DOACs)

1.  Warfarin has a new status as “avoid” use when initiating therapy for venous thromboembolism (VTE) or nonvalvular atrial fibrillation (NVAF) unless alternatives are unable to be used.  The reason for this is that warfarin has higher risks of major bleeding (namely intracranial bleeding) compared to DOACs while simultaneously having similar or lower effectiveness.  Direct oral anticoagulants (DOACs) include dabigatran, rivaroxaban, apixaban, and edoxaban and some of them have updates in the next points.  The authors do note that for patients that are already using warfarin (so not initiating therapy) and who have well controlled INRs (time in therapeutic range >70%) and no adverse effects, it may be reasonable to continue warfarin.

2.  Rivaroxaban was changed from “use with caution” to “avoid” when used for long term management of VTE and NVAF. The reason for this is that network meta-analyses and observational studies reveal higher major and gastrointestinal bleed rates when comparing it to other DOACs.  One notable role for rivaroxaban might be when a once daily dosing option is highly valued (as several other DOACs are twice daily dosing).

3.  In comparison, dabigatran maintained its “use with caution” status when compared to DOACs like apixaban.  Apixaban is not warned about anywhere in the guideline and the concern for use in reduced renal function was even removed (because of evidence for safe use in end stage renal disease).

Aspirin for primary prevention

4.  Aspirin was changed from “use with caution” to “avoid” when initiating for the primary prevention of cardiovascular disease in the older population. If already in use, steps should be considered to deprescribe it.  This recommendation carries a strength of “strong” and quality of “high” and is in agreement with the 2022 U.S. Preventive Services Task Force recommendation.

SGLT2 inhibitors

5.  Sodium-glucose co-transporter-2 inhibitors (SGLT2 inhibitors) have expanded their roles beyond type 2 diabetes mellitus to now include heart failure and chronic kidney disease.  While having substantial, clinically meaningful value in managing these common chronic conditions, they do cause a number of adverse effects.  Their increased risk of urogenital infections (bacteria or fungi thriving from the increased glucose in the urine) and euglycemic diabetic ketoacidosis has earned them a “use with caution” warning in the current criteria. If using these agents, patients should be monitored early on in treatment.

Anticholinergic burden

6.  Anticholinergic medications are a well known cause of toxicity and harm in the older adult population.  The updated AGS Beers Criteria has an additional description about the anticholinergic toxidrome plus they emphasize the cumulative anticholinergic burden that results from giving combinations of medications that each have anticholinergic side effects. This reminds us that even if we pick the "best" option in a drug class that might have less anticholinergic properties than other drugs in the class, when they are added in combination, toxicity may still occur. This cumulative effect increases the risk of falls, delirium, and dementia (even in younger adults).  

As a reminder, other anticholinergic side effects (and the mnemonic) include:

• flushing (red as a beet)
• anhydrosis / dry mucous membranes (dry as a bone)
• mydriasis = dilated pupil - can cause blurry vision (blind as a bat)
• altered mental status / confusion (mad as a hatter)
• fever (hot as a hare)
• urinary retention (full as a flask) 

What was removed

7.  To improve usability and visibility, the authors removed medications that were very low use in the United States or were no longer on the market.  These medications are still listed in Table 8 as they still have harm (they just took up more valuable space in the other tables).  Here, the über curious can find classics such as disopyramide, pentobarbital, flurazepam, reserpine, and methyldopa.

References:

1. 2023 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023;1‐30. doi:10.1111/jgs.18372

photo by Billy Quinn 1954 (no changes were made)