First developed in 1991 by Dr. Mark Beers, a geriatrician, and colleagues, the report is based on expert panel recommendations and has been updated every three years since 2011.

The Beers Criteria or “Beers List” has become a vital tool in our effort to improve the health of older adults.

By identifying medications that have the potential to harm our elderly patients, we can proactively prevent medication-related harm.

Given that more than 90% of older patients use at least one prescription drug, and more than 66% use three or more drugs, it is crucial that we prevent harm by avoiding those drugs which are inappropriate for use in the geriatric population.  

The Beers Criteria Break Down Their Evidence Into Five Lists Which Describe Certain Medications And Situations:

1.  Potentially Inappropriate Medication Use in Older Adults;
2.  Potentially Inappropriate Medication Use in Older Adults Due to Drug- Disease or Drug-Syndrome Interactions that May Exacerbate the Disease or Syndrome;
3. Drugs to be Used With Caution in Older Adults;
4. Clinically Important Drug Interactions That Should Be Avoided in Older Adults;
5. Medications That Should Be Avoided or Have Their Dosage Reduced With Varying Levels of Kidney Function in Older Adults.

In the 2019 update, 25 medications including ticlopidine, pentazocine, vasodilators, and chemotherapeutic agents were removed based on new evidence.

Histamine Receptor Antagonists (famotidine, ranitidine) were changed from avoiding in all older adults to avoiding in patients with delirium based on limited evidence of adverse effects.

Their use also provides an alternative for proton-pump inhibitors (PPI), which can be problematic having been associated with the risk of fractures, pneumonia, Clostridium difficile diarrhea, hypomagnesemia, vitamin B12 deficiency, chronic kidney disease, and dementia. 

Newly Added Medications Include:

• Tramadol due to hyponatremia;
• Glimepiride due to prolonged hypoglycemia;
• Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) such as venlafaxine, duloxetine, desvenlafaxine, and levomilnacipran, due to the risk of falls;
• Aspirin, when used for primary prevention of cardiovascular events or colon cancer, is now on the list for patients ≥70 years old or who have a creatinine clearance (CrCl) of <30 mL/min. The age break was changed to ≥70 years old from ≥80  years old due to the risk of bleeding;
• Rivaroxaban (Xarelto) now joins dabigatran (Pradaxa) to be avoided in people age ≥75 or CrCl <30 due to GI bleeding risk;
• Trimethoprim-sulfamethoxazole (TMP-SMX) should be used with caution in patients with reduced kidney function due to the risk of hyperkalemia.  This risk is increased when TMP-SMX is used in combination with drugs that can raise potassium levels such as ACE Inhibitors, (lisinopril, benazepril, others);  ARBs (losartan, valsartan, telmisartan, and others); potassium-sparing diuretics (spironolactone);
• Gabapentinoids (pregabalin and gabapentin) which had been on the list to be used in only low doses due to ataxia and falls are now recommended to be avoided in combination with opioids due to sedation, respiratory depression, and death;
• For patients with Parkinson’ disease, the guidelines have changed from avoiding all antipsychotics, to accepting quetiapine, clozapine, and pimavanserin;
• For patients with heart failure, non-dihydropyridine calcium channel blockers (diltiazem, verapamil) should be avoided in older adults with reduced ejection fraction heart failure  In addition, NSAIDs (ibuprofen, naproxen, others), COX-2 inhibitors (celecoxib), thiazolidinediones (pioglitazone) and dronedarone should be used with caution to patients who are asymptomatic and should be avoided in patients who have symptoms;
• Macrolides (excluding azithromycin) or ciprofloxacin should not be used in conjunction with warfarin due to bleeding risk;
• Dextromethorphan/quinidine (Neudexta) should be used with caution due to its limited efficacy and increased risk of falls and drug interactions.    

It is important to remember that the Beers Criteria are recommendations.

As with any such guidelines, they should not be misconstrued as universally unacceptable in all geriatric patient cases or scenarios.

It is always up to the prescriber to weigh the risks versus the benefits while considering the individual patient’s circumstances and goals of care.

The authors of the Beers Criteria have also stressed that the criteria should not be used to restrict access to these medications excessively or unnecessarily.  

How We Can Help:

The dedicated and clinically trained pharmacists at PharmD Live® are well-equipped and uniquely positioned to apply their advanced training and extensive knowledge of drug pharmacology, drug-drug interactions, therapeutic interchanges, informatics, and patient care, to help prescribers provide the best care possible to our older adults. 

PharmD Live®’s solutions include a nationwide network of clinical pharmacists who utilize our innovative medication risk management technology with powerful analytics to identify and mitigate these medication-related risks so as to optimize patients’ medication regimens and ultimately achieve value-based care outcomes.

Additional reading regarding Beers Criteria:

• Anticholinergic Medications 

References:

National Center for Health Statistics. (2018). Table 79. In Health, the United States, 2017. https://www.cdc.gov/nchs/data/hus/2017/079.pdf American Geriatrics Society 2019 https://nicheprogram.org/sites/niche/files/2019-02/Panel-2019-Journal_of_the_American_Geriatrics_Society.pdfSource: American Geriatrics Society 2019 https://nicheprogram.org/sites/niche/files/2019-02/Panel-2019-Journal_of_the_American_Geriatrics_Society.pdfTagged: AGS Beers Criteria 2019, inappropriate medication use in older adults, medication use in older adults

Source:American Geriatrics Society 2019 https://nicheprogram.org/sites/nic

The post AGS Beers Criteria® (2019 Update): Potentially Inappropriate Medication Use In Older Adults appeared first on Pharmdlive.

The Beers Criteria^®1 is a leading source of expert information about potentially inappropriate medications (PIM) in older adults. While these medications are generally harmless in young patients, they can have detrimental effects in older adults. Physicians and pharmacists can easily overlook misuse of these drugs, as many are readily available to patients who purchase over the counter (OTC). As an example, Beers criteria identifies first-generation antihistamines’ ability to block receptors and increase the risks of dementia in older adults. Having Benadryl^® in a household is relatively common—yet, its long-term effects are not usually a consideration. 

Adverse drug events (side effects) such as dry mouth, constipation, dizziness, confusion, depression, and falls have been linked to PIM². Older adults are more susceptible to adverse reactions with anticholinergic medications. This class of medicines acts on muscarinic receptors in the central nervous system and blocks acetylcholine neurotransmission. Acetylcholine is involved in many daily functions, including cognition (thinking and awareness). Attention, learning and memory mechanisms are all affected by acetylcholine. In addition, it is involved in the peripheral nervous system (PNS) actions which are related to urination, intestinal movement and heart rhythm regulation. These drugs may bind exclusively to muscarinic receptors or may also bind with additional receptors causing various adverse effects. Anticholinergic medications may be used in many different disease states, ranging from seasonal allergies, motion sickness, and urinary incontinence to Parkinson’s disease and irritable bowel syndrome. With ®acetylcholine so heavily involved in major functions of the body, it is not surprising that they can lead to adverse effects in older adults.

Despite the known adverse effects of these medicines in older adults, they are still commonly prescribed or the patient purchases OTC and takes them unmonitored. One study showed that in a group of patients with mild cognitive impairment or dementia, 44.7% of the patients were taking anticholinergic drugs. Similarly, 11.7% of these patients were receiving a high anticholinergic load or burden. Although these medications may not cause adverse effects in every older adult, they still carry risk and should be avoided if possible. The table below lists PIM from the Beers Criteria and provides therapeutic alternatives. 

Tips for avoiding anticholinergic adverse effects

Always encourage patients to try non-pharmacological therapy before starting an anticholinergic medication. Secondly, speak with a pharmacist before starting any new medications. Lastly, if starting a new anticholinergic medication, take the smallest effective dose for the shortest time needed. 

PharmD Live® combines a clinical pharmacist-led approach to monitoring patients using AI-driven telehealth technology and predictive analytics to deliver true value-based care and keep patients safe from medication misuse. Having a pharmacist review your patient’s medicines regularly can avoid these kinds of adverse drug events. Contact PharmD Live® to learn about how you can take advantage of this care solution, and set up your patients and practice for success.

Additional reading regarding Beers Criteria:

• 2019 Beers Analysis

References:

1. American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. Journal of the American Geriatrics Society. https://pubmed.ncbi.nlm.nih.gov/30693946/. 
2. López-Álvarez J, Sevilla-Llewellyn-Jones J, Agüera-Ortiz L. Anticholinergic Drugs in Geriatric Psychopharmacology. Front Neurosci. 2019;13:1309. Published 2019 Dec 6. doi:10.3389/fnins.2019.01309

The post Anticholinergic Medications in the Beers Criteria appeared first on Pharmdlive.

The American Geriatrics Society (AGS) Beers Criteria® for Potentially Inappropriate Medication (PIM) Use in Older Adults is a resource for physicians and pharmacists to make careful clinical decisions for their patients. Updated in 2019, using the AGS Beers Criteria® improves medication selection, educates clinicians and patients, reduces adverse drug events, and is valuable for evaluating quality of care, cost, and drug-use patterns in older adults. The safety and clinical efficacy of certain medications are of greater concern in those ages 65 and older. PharmD Live® regards the AGS Beers Criteria as an invaluable resource to provide the safest recommendations to patients and their providers.

In addition to providing medical practices oversight of patient medication, the benefits of applying AGS Beers Criteria through PharmD Live®’s Chronic Care Management and Remote Patient Monitoring solutions are as follows:

Safety and Efficacy

• Our clinical pharmacists identify inappropriate medication use by carefully evaluating the indication, dosage, and duration of each medication the patient is taking. If use is warranted, we will proceed with caution and follow labs to determine safety and efficacy for continuing.  If necessary, dosage adjustments will be made according to the most recent lab values and vitals. 

Highlights Adverse Drug Potential

• The pharmacist will work with the patient to identify any adverse effects, drug-drug interactions, and all other medication concerns the patient may have.

Pharmacist-Patient Monthly Appointments

•  A clinical pharmacist closely monitors and meets monthly with the patient. 

Physician-Pharmacist Review and Planning

• Our pharmacists present recommendations to the patient’s physician for further review and the patient receives a collaborative care plan.

The post 2021 Updated Review of AGS Beers Criteria® appeared first on Pharmdlive.