Caution Ahead! Updated List Tracks Hazardous Drugs in Elderly

      LOS ANGELES — The American Geriatrics Society (AGS) released a new version of the AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults in early 2019, and care professionals immediately began poring over its updated recommendations — anything but an easy task.
      “The Beers list can be cumbersome and tedious to read. But we need to remember that [medication-related] adverse events are a serious situation,” especially in the geriatric population, said Vanessa J. Mandal, MD, MS, CMD, a geriatrician based near Sacramento, CA.
      Dr. Mandal updated colleagues about the new Beers Criteria (J Am Geriatr Soc 2019;67:674–694) at the annual meeting of the California Association of Long Term Care Medicine, which serves physicians, medical directors, nurses, pharmacists, administrators, and other professionals.
      Researchers estimated that tens of thousands of people in the United States die each year due to adverse medication-related events. The number could be as high as 106,000, making it the nation’s fourth-leading cause of death, the Food and Drug Administration has reported, and that number doesn’t take incidents at nursing homes into account (FDA, “Preventable Adverse Drug Reactions,” Mar. 6, 2018;
      The newly updated Beers Criteria removes 25 medications for various reasons such as lack of current availability or adverse effects that are not unique to older adults (65 and older). Several drugs, however, have been added to the list.
      Dr. Mandal highlighted several drugs and medication classes that should be used with caution.
      Digoxin: Avoid this heart drug as a first-line treatment for atrial fibrillation or heart failure, and beware of multiple potential drug interactions. “If we see this is the only agent on board, it behooves us to contact the cardiologist to ask why this is the case,” Dr. Mandal said. “We also have to avoid doses greater than 0.125 mg. I don’t see it that much, but it still occurs and should be questioned. We need to be cautious not only because of its own effects but because of how it interacts with other medications.”
      Cilostazol: Avoid this vasodilator drug in any type of heart failure. “Generally, I don’t use this medication in older adults anymore,” Dr. Mandal said. “But we see it prescribed in patients from the hospital.”
      Aspirin: Note that the guidelines regarding aspirin’s use as primary protection against cardiovascular disease and colorectal cancer have changed. Now the Beers list says aspirin should be used for these purposes with “extra caution” starting at age 70, not 80.
      H2-receptor antagonists: The Beers list has updated recommendations regarding these drugs and no longer says they should be avoided in patients with dementia or cognitive impairment. But they should still be avoided in the context of delirium.
      Anticholinergics: The Beers Criteria include numerous drugs with anticholinergic properties that should be avoided. Two medications — the antihistamine pyrilamine (also known as mepyramine) and the peptic ulcer drug methscopolamine (Pamine) — are new to the list.
      Alpha blockers: Avoid doxazosin (Cardura), prazosin (Minipress), and terazosin (Hytrin) — all prostate enlargement/blood pressure medications — for hypertension due to risk of reduced blood flow to the brain.
      Antipsychotics: Do not use these drugs to control behavioral problems due to dementia or delirium. Instead, Dr. Mandal suggested, try alternative strategies that don’t involve drugs. Look for ideas, she said, by visiting the Nursing Home Toolkit (, the Hospital Elder Life Program (, and Positive Approach to Care (
      Antidepressants: Avoid amitriptyline (Elavil), amoxapine, clomipramine (Anafranil), desipramine (Norpramin), doxepin (>6 mg/day), imipramine (Tofranil), nortriptyline (Pamelor), paroxetine (Paxil), protriptyline, and trimipramine (Surmontil), which are highly anticholinergic and sedating. Also according to new guidelines, avoid serotonin and norepinephrine reuptake inhibitors (SNRIs) such as duloxetine (Cymbalta) and venlafaxine (Effexor) in patients who have a history of falls or fractures.
      Benzodiazepines and Z drugs: Avoid these drugs except in certain situations because of their risk of dementia and cognitive impairment. On this front, “there’s a lot of awareness [of the risks] of anticholinergics and antipsychotics” Dr. Mandal said, but fewer people know about benzodiazepines and Z drugs such as several common types of sleeping pills.
      Sliding-scale insulin: Avoid the use of “insulin regimens that include only short- or rapid-acting insulin dosed according to current blood glucose levels without concurrent use of basal or long-acting insulin,” according to the new criteria.
      Opioids: Per the FDA’s black-box warning, avoid using opioids concurrently with benzodiazepines and gabapentinoids.
      Although the Beers list doesn’t provide rules, its guidelines are very helpful, Dr. Mandal said. “We can consider it a very useful tool for us to look at potentially avoidable adverse events.”
      Randy Dotinga is a San Diego-based freelance writer.