- On January 29, 2019 the American Geriatrics Society released a newly updated Beers Criteria outlining medications that should be avoided or used with caution in the geriatric (≥ 65) population. The Beers Criteria lists only potentially inappropriate medications but does not provide medications that should be prescribed for the geriatric population.
- The STOPP (screening tool of older people’s prescriptions) and START (screening tool to alert to the right treatment) criteria were first published in 2008 and updated in 2014. The STOPP/START criteria aim to identify both potentially inappropriate medications and prescribing omissions, making the STOPP/START criteria potentially more comprehensive and clinically prospective than the Beers Criteria.
Noteworthy Additions and Removals to the Beers Criteria1
First published in 1991, the Beers Criteria has been updated five times. The criteria provide a precise list of potentially inappropriate medications that are characteristically best avoided by older adults in most circumstances and in certain situations (i.e. disease states or conditions).
The criteria is used by clinicians, educators, researchers, healthcare administrators, and regulators. Rationale, quality of evidence, and strength of recommendation are provided with each recommendation from the American Geriatrics Society. Summarized below are some of the important removals and additions to the 2019 Beers Criteria.
- Ticlopidine, an anticoagulant, and pentazocine, an opioid analgesic, were removed due to low use and/or no longer being available on the US market.
- Glimepiride, a sulfonylurea commonly used to control diabetes, was added due to severe, prolonged hypoglycemia in older adults. Glimepiride is commonly used due to its long duration of action. If a sulfonylurea cannot be avoided, the best option is to use glipizide. Glipizide is shorter acting and is not included in the Beers Criteria. [Quality: high; Strength: strong]
- Methscopolamine, a medication used to reduce stomach acid secretion, and pyrilamine, a first-generation antihistamine, were added due to strong anticholinergic properties that put older adults at risk of falls and fractures. There is also uncertainty about the effectiveness of methscopalamine. Pyrilamine is also a concern due to reduced clearance with advanced age and tolerance can develop when used as a hypnotic. [Quality: moderate; Strength: strong]
- Rivaroxaban (Xarelto), a direct factor Xa inhibitor used for treating and preventing blood clots, was added due to emerging evidence that there may be an increased risk of gastrointestinal bleeding when used for long term treatment of VTE or atrial fibrillation in adults ≥ 75 years old. Alternative agents, like warfarin or Eliquis, should be considered due to less reported gastrointestinal bleeding. Pradaxa, even though it is not a new addition to the criteria, is still listed in the criteria as a medication to avoid in the older population for the same reason as Xarelto and should only be used if all other options lack success. [Quality: moderate; Strength: strong]
- Tramadol, an opioid analgesic, was added because it may exacerbate or cause SIADH or hyponatremia via stimulation of antidiuretic hormone release. This stimulation is a result of agonist action on morphine receptors and enhanced serotonin release. If tramadol cannot be avoided, serum sodium should be monitored closely when initiating or changing doses in older adults. [Quality: moderate; Strength: strong]
- Trimethoprim-sulfamethoxazole (Bactrim), a sulfonamide antibiotic commonly prescribed for various infections, was added due to increased risk of hyperkalemia when in combination with ACEIs and ARBs in patients with reduced kidney function, which most older patients experience. Hyperkalemia typically manifests as cardiac arrythmias and can be potentially fatal if unnoticed and/or untreated. Bactrim use can be considered with less hesitation in older adults not using an ACEI or ARB without reduced kidney function. [Quality: low; Strength: strong]
Noteworthy Comparisons to STOPP/START Criteria2
The STOPP/START Criteria was first published in 2008 by a European panel of experts, 17 years after the first edition of the Beers Criteria. The most recent update to the criteria occurred in 2014 which expanded the criteria to minimize inappropriate prescribing and encourage filling any prescription omission gaps that can benefit the older patient, the latter characteristic setting the STOPP/START criteria apart from the Beers Criteria. Summarized below are the important comparisons between the latest versions of the STOPP/START and Beers Criteria.
- Glimepiride and tramadol were already recorded as medications to be avoided in older patients in the 2014 STOPP/START. Rationale for the inclusion of glimepiride in the criteria replicates what was stated in the 2019 Beers Criteria, there is a higher risk of prolonged hypoglycemia due to the long duration of action. Tramadol’s rationale is less succinct in STOPP/START, with the recommendation being to avoid tramadol as first line therapy for mild pain.
- Factor Xa inhibitors (i.e. Xarelto) are also listed in the 2014 STOPP/START criteria. However, the rationale for avoiding their use is based on if the patient has any concurrent significant bleeding risk as these drugs increase the risk of bleeding.
- Bactrim is not listed in the STOPP/START criteria. Ticlopidine and pentazocine have not yet been removed from the STOPP/START criteria.
- The START criteria provides a list of medications that should be added in older patients unless omitted for valid clinical reasons. Also included in the START criteria are vaccinations for older patients (i.e. annual influenza and at least one pneumococcal vaccine after the age of 65). The inclusion of the START criteria allows healthcare professionals to maximize the care older patients are receiving and help them get the best quality of life and life expectancy. The Beers Criteria does not include a list of medications or vaccines that should be given to the older population, giving it a clinical disadvantage.
- By the 2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American geriatrics society 2019 updated AGS beers criteria® for potentially inappropriate medication use in older adults: 2019 AGS beers criteria® update expert panel. J Am Geriatr Soc [Internet]. 2019 Jan 29 [cited 2019 Feb 21]; Available from: http://doi.wiley.com/10.1111/jgs.15767
- O’Mahony D, O’Sullivan D, Byrne S, O’Connor MN, Ryan C, Gallagher P. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2014 Oct 16;44(2):213–8