TABLE 1.

2019 American Geriatrics Society Beers Criteria® for Potentially Inappropriate

Medication Use in Older Adults

From THE AMERICAN GERIATRICS SOCIETY Organ System, Therapeutic Recommendation, Rationale, Quality of Evidence
Category, Drug(s) (QE), Strength of Recommendation (SR)
A POCKET GUIDE TO THE Anticholinergics *

2019 AGS BEERS CRITERIA

First-generation Avoid
® antihistamines: Highly anticholinergic; clearance reduced with advanced age,
■ Brompheniramine and tolerance develops when used as hypnotic; risk of confusion,
This guide has been developed as a tool to assist healthcare providers in improving ■ Carbinoxamine dry mouth, constipation, and other anticholinergic effects or
■ Chlorpheniramine toxicity
medication safety in older adults. The role of this guide is to inform clinical decision-
■ Clemastine
making, research, training, quality measures and regulations concerning the prescribing of Use of diphenhydramine in situations such as acute treatment of
■ Cyproheptadine
medications for older adults to improve safety and quality of care. It is based on The 2019 severe allergic reaction may be appropriate
■ Dexbrompheniramine
AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. QE = Moderate; SR = Strong
■ Dexchlorpheniramine
Originally conceived of in 1991 by the late Mark Beers, MD, a geriatrician, the Beers ■ Dimenhydrinate
Criteria catalogues medications that cause side effects in the elderly due to the ■ Diphenhydramine (oral)
physiologic changes of aging. In 2011, the AGS sponsored its first update of the criteria, ■ Doxylamine
assembling a team of experts and using an enhanced, evidence-based methodology. ■ Hydroxyzine
Since 2011, the AGS has been the steward of the criteria and has produced updates ■ Meclizine
■ Promethazine
using an evidence-based methodology and rating each Criterion (quality of evidence
■ Pyrilamine
and strength of evidence) using the American College of Physicians’ Guideline Grading
■ Triprolidine
System, which is based on the GRADE scheme developed by Guyatt et al.
Antiparkinsonian agents Avoid
The full document, along with accompanying resources can be found in their entirety ■ Benztropine (oral) Not recommended for prevention of extrapyramidal symptoms
online at [Link]. ■ Trihexyphenidyl with antipsychotics; more effective agents available for
treatment of Parkinson disease
INTENDED USE
QE = Moderate; SR = Strong
The goal of this guide is to improve care of older adults by reducing their exposure to Antispasmodics: Avoid
Potentially Inappropriate Medications (PIMS). ■ Atropine (excludes Highly anticholinergic, uncertain effectiveness
■ This should be viewed as a guideline for identifying medications for which the risks ophthalmic) QE = Moderate; SR = Strong
■ Belladonna alkaloids
of their use in older adults outweigh the benefits.
■ Clidinium-
■ These criteria are not meant to be applied in a punitive manner.
Chlordiazepoxide
■ This list is not meant to supersede clinical judgment or an individual patient’s values
■ Dicyclomine
and needs. Prescribing and managing disease conditions should be individualized ■ Homatropine (excludes
and involve shared decision-making. ophthalmic)
■ These criteria also underscore the importance of using a team approach to ■ Hyoscyamine
prescribing and the use of non-pharmacological approaches and of having ■ Methscopolamine
economic and organizational incentives for this type of model. ■ Propantheline
■ A companion piece that addresses the best way for patients, providers, and health ■ Scopolamine
systems to use (and not use) the AGS Beers Criteria® was also developed. The Antithrombotics
document can be found on [Link].
■ Dipyridamole, oral Avoid
The criteria are not applicable in all circumstances (i.e. patients receiving palliative and short-acting (does not Rationale: May cause orthostatic hypotension; more effective
hospice care). If a provider is not able to find an alternative and chooses to continue to apply to the extended- alternatives available; IV form acceptable for use in cardiac
use a drug on this list in an individual patient, designation of the medication as potentially release combination stress testing
inappropriate can serve as a reminder for close monitoring so that adverse drug effects with aspirin) QE = Moderate; SR = Strong
can be incorporated into the electronic health record and prevented or detected early.

*See also criterion on highly anticholinergic antidepressants

CNS=central nervous system; NSAIDs=nonsteroidal anti-inflammatory drugs; SIADH, syndrome of

AGS THE AMERICAN GERIATRICS SOCIETY

Geriatrics Health Professionals.
inappropriate antidiuretic hormone.
✃

Leading change. Improving care for older adults.

PAGE 1 PAGE 2 Table 1 (continued on page 3)

 Table 1 Continued Table 1 Continued
Organ System, Therapeutic Organ System, Therapeutic
Category, Drug(s) Recommendation, Rationale, QE, SR Category, Drug(s) Recommendation, Rationale, QE, SR
Anti-infective Digoxin for first-line Avoid this rate control agent as first-line therapy for atrial
■ Nitrofurantoin Avoid in individuals with creatinine clearance <30 mL/min or treatment of atrial fibrillation. Avoid as first-line therapy for heart failure. If used
for long-term suppression fibrillation or of heart for atrial fibrillation or heart failure, avoid dosages >0.125 mg/d
Potential for pulmonary toxicity, hepatoxicity, and peripheral failure Use in atrial fibrillation: should not be used as a first-line agent
neuropathy, especially with long-term use; safer alternatives available in atrial fibrillation, because there are safer and more effective
QE = Low; SR = Strong alternatives for rate control supported by high-quality evidence.
Use in heart failure: evidence for benefits and harms of digoxin is
conflicting and of lower quality; most but not all of the evidence
Cardiovascular
concerns use in heart failure with reduced ejection fraction
Peripheral alpha-1 Avoid use as an antihypertensive (HFrEF). There is strong evidence for other agents as first-line
blockers for treatment of High risk of orthostatic hypotension and associated harms, therapy to reduce hospitalizations and mortality in adults wiht
hypertension especially in older adults; not recommended as routine HFrEF. In heart failure, higher dosages are not associated with
■ Doxazosin treatment for hypertension; alternative agents have superior additional benefit and may increase toxicity.
■ Prazosin risk/benefit profile Decreased renal clearance of digoxin may lead to increased
■ Terazosin
QE = Moderate; SR = Strong risk of toxic effects; further dose reduction may be necessary in
Central-alpha agonists Avoid clonidine as first-line antihypertensive. Avoid others CNS those with Stage 4 or 5 chronic kidney disease.
Clonidine for first-line alpha-agonists as listed QE = Atrial fibrillation: low. Heart failure: low.
treatment of hypertension High risk of adverse CNS effects; may cause bradycardia and Dosage >0.125 mg/d: moderate; SR = Atrial fibrillation: strong.
Other CNS alpha-agonists orthostatic hypotension; not recommended as routine treatment Heart failure: strong. Dosage >0.125 mg/d: strong
■ Guanabenz for hypertension Nifedipine, immediate Avoid
■ Guanfacine QE = Low; SR = Strong release Potential for hypotension; risk of precipitating myocardial
■ Methyldopa ischemia
■ Reserpine (>0.1 mg/d)
QE = High; SR = Strong
Disopyramide Avoid
May induce heart failure in older adults because of potent Amiodarone Avoid as first-line therapy for atrial fibrillation unless the patient
negative inotropic action; strongly anticholinergic; other has heart failure or substantial left ventricular hypertrophy
antiarrhythmic drugs preferred
Effective for maintaining sinus rhythm but has greater toxicities
QE = Low; SR = Strong than other antiarrhythmics used in atrial fibrillation; may be
Dronedarone Avoid in individuals with permanent atrial fibrillation or severe reasonable first-line therapy in patients with concomitant heart
or recently decompensated heart failure failure or substantial left ventricular hypertrophy if rhythm
control is preferred over rate control
Worse outcomes have been reported in patients taking
dronedarone who have permanent atrial fibrillation or severe or QE = High; SR = Strong
recently decompensated heart failure Central nervous system
QE = High; SR = Strong Antidepressants, alone or Avoid
in combination: Highly anticholinergic, sedating, and cause orthostatic
■ Amitriptyline hypotension; safety profile of low-dose doxepin (≤6 mg/d)
■ Amoxapine comparable with that of placebo
■ Clomipramine
QE = High; SR = Strong
■ Desipramine
■ Doxepin >6 mg/d
■ Imipramine
■ Nortriptyline
■ Paroxetine
■ Protriptyline
■ Trimipramine
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PAGE 3 Table 1 (continued on page 4) PAGE 4 Table 1 (continued on page 5)

Table 1 Continued Table 1 Continued
Organ System, Therapeutic Organ System, Therapeutic
Category, Drug(s) Recommendation, Rationale, QE, SR Category, Drug(s) Recommendation, Rationale, QE, SR
Antipsychotics, first- Avoid, except for schizophrenia, bipolar disorder, or for short- Ergoloid mesylates Avoid
(conventional) and term use as antiemetic during chemotherapy (dehydrogenated ergot Lack of efficacy
second- (atypical) Increased risk of cerebrovascular accident (stroke) and greater alkaloids) QE = High; SR = Strong
generation rate of cognitive decline and mortality in persons with dementia Isoxsuprine
Avoid antipsychotics for behavioral problems of dementia or Endocrine
delirium unless nonpharmacological options (e.g., behavioral Androgens Avoid unless indicated for confirmed hypogonadism with
interventions) have failed or are not possible and the older adult ■ Methyltestosterone clinical symptoms
is threatening substantial harm to self or others ■ Testosterone Potential for cardiac problems; contraindicated in men with
QE = Moderate; SR = Strong prostate cancer
Barbiturates Avoid QE = Moderate; SR = Weak
■ Amobarbital High rate of physical dependence, tolerance to sleep benefits, Desiccated thyroid Avoid
■ Butabarbital greater risk of overdose at low dosages
■ Butalbital Concerns about cardiac effects; safer alternatives available
QE = High; SR = Strong QE = Low; SR = Strong
■ Mephobarbital
■ Pentobarbital Estrogens with or without Avoid systemic estrogen (eg, oral and topical patch). Vaginal
■ Phenobarbital progestins cream or vaginal tablets: acceptable to use low-dose
■ Secobarbital intravaginal estrogen for management of dyspareunia, recurrent
Benzodiazepines Avoid lower urinary tract infections, and other vaginal symptoms
Short- and intermediate- Older adults have increased sensitivity to benzodiazepines and Evidence of carcinogenic potential (breast and endometrium);
acting: decreased metabolism of long-acting agents; in general, all lack of cardioprotective effect and cognitive protection in older
■ Alprazolam women.
benzodiazepines increase risk of cognitive impairment, delirium,
■ Estazolam
falls, fractures, and motor vehicle crashes in older adults Evidence indicates that vaginal estrogens for the treatment of
■ Lorazepam
May be appropriate for seizure disorders, rapid eye movement vaginal dryness are safe and effective; women with a history of
■ Oxazepam
sleep behavior disorder, benzodiazepine withdrawal, ethanol breast cancer who do not respond to nonhormonal therapies
■ Temazepam
withdrawal, severe generalized anxiety disorder, and are advised to discuss the risk and benefits of low-dose vaginal
■ Triazolam
periprocedural anesthesia estrogen (dosages of estradiol <25 mcg twice weekly) with their
Long-acting: health care provider
■ Chlordiazepoxide (alone
QE = Moderate; SR = Strong
QE = Oral and patch: high. Vaginal cream or tablets: moderate.;
or in combination SR = Oral and patch: strong. Topical vaginal cream or tablets: weak
with amitriptyline or
clidinium) Growth hormone Avoid, except for patients rigorously diagnosed by evidence-based
■ Clonazepam
criteria with growth hormone deficiency due to an established
■ Clorazepate
etiology
■ Diazepam Impact on body composition is small and associated with edema,
■ Flurazepam arthralgia, carpal tunnel syndrome, gynecomastia, impaired fasting
■ Quazepam glucose
Meprobamate Avoid QE = High; SR = Strong
High rate of physical dependence; very sedating Insulin, sliding scale Avoid
(insulin regimens Higher risk of hypoglycemia without improvement in hyperglycemia
QE = Moderate; SR = Strong
containing only short- or management regardless of care setting; Avoid insulin regimens that
Nonbenzodiazepine, Avoid rapid-acting insulin dosed include only short- or rapid-acting insulin dosed according to current
benzodiazepine receptor Nonbenzodiazepine benzodiazepine-receptor agonist hypnotics according to current blood glucose levels without concurrent use of basal or long-acting
agonist hypnotics (ie, “Z drugs”) have adverse events similar to those of blood gluclose levels insulin. This recommendation does not apply to regimens that contain
(ie, “Z-drugs”) benzodiazepines in older adults (e.g., delirium, falls, fractures); without concurrent use basal insulin or long-acting insulin.
■ Eszopiclone increased emergency room visits/hospitalizations; motor vehicle of basal or long-acting
■ Zaleplon
QE = Moderate; SR = Strong
crashes; minimal improvement in sleep latency and duration insulin)
■ Zolpidem
QE = Moderate; SR = Strong Megestrol Avoid
Minimal effect on weight; increases risk of thrombotic events
and possibly death in older adults
QE = Moderate; SR = Strong
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Table 1 Continued Table 1 Continued
Organ System, Therapeutic Organ System, Therapeutic
Category, Drug(s) Recommendation, Rationale, QE, SR Category, Drug(s) Recommendation, Rationale, QE, SR
Sulfonylureas, long-acting Avoid ■ Indomethacin Avoid
■ Chlorpropamide Chlorpropamide: prolonged half-life in older adults; can cause ■ Ketorolac, includes Increased risk of gastrointestinal bleeding/peptic ulcer disease,
■ Glimeperide prolonged hypoglycemia; causes SIADH parenteral and acute kidney injury in older adults
■ Glyburide (also known Indomethacin is more likely than other NSAIDs to have adverse
Glimepiride and Glyburide: higher risk of severe prolonged
as glibenclamide) hypoglycemia in older adults CNS effects. Of all the NSAIDs, indomethacin has the most
adverse effects.
QE = High; SR = Strong QE = Moderate; SR = Strong
Gastrointestinal Skeletal muscle relaxants Avoid
Metoclopramide Avoid, unless for gastroparesis with duration of use not to ■ Carisoprodol Most muscle relaxants poorly tolerated by older adults because
exceed 12 weeks except in rare cases ■ Chlorzoxazone some have anticholinergic adverse effects, sedation, increased
■ Cyclobenzaprine risk of fractures; effectiveness at dosages tolerated by older
Can cause extrapyramidal effects, including tardive dyskinesia; ■ Metaxalone adults questionable
risk may be greater in frail older adults and with prolonged ■ Methocarbamol
exposure ■ Orphenadrine
QE = Moderate; SR = Strong
QE = Moderate; SR = Strong Genitourinary
Mineral oil, given orally Avoid Desmopressin Avoid for treatment of nocturia or nocturnal polyuria
Potential for aspiration and adverse effects; safer alternatives High risk of hyponatremia; safer alternative treatments
available QE = Moderate; SR = Strong
QE = Moderate; SR = Strong
Proton-pump inhibitors Avoid scheduled use for >8 weeks unless for high-risk patients TABLE 2. 2019 American Geriatrics Society Beers Criteria® for Potentially Inappropriate
(e.g., oral corticosteroids or chronic NSAID use), erosive Medication Use in Older Adults Due to Drug–Disease or Drug–Syndrome Interactions That
esophagitis, Barrett’s esophagitis, pathological hypersecretory May Exacerbate the Disease or Syndrome
condition, or demonstrated need for maintenance treatment
(e.g., because of failure of drug discontinuation trial or H2- Recommendation, Rationale,
receptor antagonists Disease or Quality of Evidence (QE), Strength
Risk of C difficile infection and bone loss and fractures Syndrome Drug(s) of Recommendation (SR)
QE = High; SR = Strong Cardiovascular
Pain medications Heart failure Avoid: Cilostazol As noted, avoid or use with caution
Meperidine Avoid Avoid in heart failure with Potential to promote fluid retention and
Oral analgesic not effective in dosages commonly used; may reduced ejection fraction: Non- exacerbate heart failure (NSAIDs and
have higher risk of neurotoxicity, including delirium, than other dihydropyridine CCBs (diltiazem, COX-2 inhibitors, non-dihydropyridine
opioids; safer alternatives available verapamil) CCBs, thiazoildinediones); potential
QE = Moderate; SR = Strong Use with caution in patients with to increase mortality in older adults
Non-cyclooxygenase- Avoid chronic use, unless other alternatives are not effective heart failure who are asymptomatic; with heart failure (cilostazol and
selective NSAIDs, oral: and patient can take gastroprotective agent (proton-pump avoid in patients with symptomatic dronedarone)
■ Aspirin >325 mg/d inhibitor or misoprostol) heart failure: QE = Cilostazol: low Non-
■ Diclofenac Increased risk of gastrointestinal bleeding or peptic ulcer NSAIDs and COX-2 inhibitors dihydropyridine CCBs: moderate
■ Diflunisal disease in high-risk groups, including those aged >75 or taking
■ Etodolac
NSAIDs: moderate COX-2 inhibitors:
oral or parenteral corticosteroids, anticoagulants, or antiplatelet Thiazolidinediones (pioglitazone,
■ Fenoprofen low. Thiazolidinediones: high.
agents; use of proton-pump inhibitor or misoprostol reduces rosiglitazone)
■ Ibuprofen but does not eliminate risk. Upper gastrointestinal ulcers, gross Dronedarone: high; SR = Strong
■ Ketoprofen Dronedarone
bleeding, or perforation caused by NSAIDs occur in ~1% of
■ Meclofenamate patients treated for 3–6 months and in ~2–4% of patients treated
■ Mefenamic acid for 1 year; these trends continue with longer duration of use.
■ Meloxicam Also can increase blood pressure and induce kidney injury. Risks
■ Nabumetone are dose-related. *See Table 7 in full criteria available on [Link].
■ Naproxen
■ Oxaprozin
QE = Moderate; SR = Strong a
May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health conditions but
■ Piroxicam
should be prescribed in the lowest effective dose and shortest possible duration.
■ Sulindac
b
Excludes inhaled and topical forms. Oral and parenteral corticosteroids may be required for conditions such as
■ Tolmetin exacerbation of COPD but should be prescribed in the lowest effective dose and for the shortest possible duration.

CCB=calcium channel blocker; AChEI=acetylcholinesterase inhibitor; CNS=central nervous system;

COX=cyclooxygenase; NSAIDs=nonsteroidal antiinflammatory drug; TCAs=tricyclic antidepressant.
✃

PAGE 7 Table 1 (continued on page 8) PAGE 8 Table 2 (continued on page 9)

Table 2 Continued Table 2 Continued
Disease or Disease or
Syndrome Drug(s) Recommendation, Rationale, QE, SR Syndrome Drug(s) Recommendation, Rationale, QE, SR
Syncope Acetylcholinesterase inhibitors Avoid History of Antiepileptics Avoid unless safer alternatives are
(AChEIs) AChEIs cause bradycardia and should falls or Antipsychoticsa not available; avoid antiepileptics
Non-selective peripheral alpha-1 be avoided in older adults whose fractures Benzodiazepines except for seizure and mood disorders.
blockers (ie, doxazosin, prazosin, syncope may be due to bradycardia. Nonbenzodiazepine, Opioids: avoid except for pain
terazosin) Non-selective peripheral alpha-1 benzodiazepine receptor agonist management in the setting of sever
Tertiary TCAs blockers cause orthostatic blood hypnotics acute pain, eg, recent fractures or joint
Antipsychotics pressure changes and should be ■ Eszopiclone replacement
■ Chlorpromazine avoided in older adults whose syncope ■ Zaleplon May cause ataxia, impaired
■ Thioridazine may be due to orthostatic hypotension. ■ Zolpidem psychomotor function, syncope,
■ Olanzapine Tertiary TCAs and the antipsychotics Antidepressants additional falls; shorter-acting
listed increase the risk of orthostatic ■ TCAs benzodiazepines are not safer than
hypotension or bradycardia. ■ SSRIs long-acting ones
■ SNRIs If one of the drugs must be used,
QE = AChEIs, TCAs and antipsychotics:
high. Non-selective peripheral alpha-1 Opioids consider reducing use of other CNS-
blockers: high; SR = AChEIs, TCAs: active medications that increase risk
strong. Non-selective peripheral of falls and fractures (ie, antiepileptics,
alpha-1 blockers, antipsychotics: weak opioid-receptor agonists, antipsychotics,
antidepressants, nonbenzodiazepine
Central nervous system
and benzodiazepine-receptor agonists,
Delirium Anticholinergics* Avoid other sedatives/hypnotics) and
Antipsychoticsa Avoid in older adults with or at high implement other strategies to reduce
Benzodiazepines risk of delirium because of potential of fall risk. Data for antidepressants are
Corticosteroids (oral and inducing or worsening delirium mixed but no compelling evidence that
parenteral)b Avoid antipsychotics for behavioral certain antidepressants confer less fall
H2-receptor antagonists problems of dementia and/or delirium risk than others.
■ Cimetidine unless nonpharmacological options QE = Opioids: Moderate. All others:
■ Famotidine (e.g., behavioral interventions) have High; SR = Strong
■ Nizatidine failed or are not possible and the Parkinson Antiemetics Avoid
■ Ranitidine older adult is threatening substantial disease ■ Metoclopramide Dopamine-receptor antagonists with
Meperidine harm to self or others. Antipsychotics ■ Prochlorperazine potential to worsen parkinsonian
Nonbenzodiazepine, are associated with greater risk of ■ Promethazine symptoms
benzodiazepine receptor agonist cerebrovascular accident (stroke) and All antipsychotics (except
mortality in persons with dementia Exceptions: Pimavanserin and
hypnotics: eszopiclone, zaleplon, aripiprazole, quetiapine, clozapine) clozapine appear to be less likely to
zolpidem QE = H2-receptor antagonists: Low. precipitate worsening of Parkinson
All others: Moderate; SR = Strong disease. Quetiapine has only been
Dementia Anticholinergics* Avoid studied in low quality clinical trials with
or cognitive Benzodiazepines Avoid because of adverse CNS effects efficacy comparable to that of placebo
impairment in 5 trials and to that of clozapine in
Nonbenzodiazepine, Avoid antipsychotics for behavioral 2 others.
benzodiazepine receptor agonist problems of dementia and/or delirium
hypnotics unless nonpharmacological options QE = Moderate; SR = Strong
■ Eszopiclone (e.g., behavioral interventions) have Gastrointestinal
■ Zaleplon failed or are not possible and the History of Aspirin (>325 mg/d) Avoid unless other alternatives are
■ Zolpidem older adult is threatening substantial gastric or Non-COX-2 selective NSAIDs not effective and patient can take
Antipsychotics, chronic and as- harm to self or others. Antipsychotics duodenal gastroprotective agent (ie, proton-
needed usea are associated with greater risk of ulcers pump inhibitor or misoprostol)
cerebrovascular accident (stroke) and May exacerbate existing ulcers or
mortality in persons with dementia cause new/additional ulcers
QE = Moderate; SR = Strong QE = Moderate; SR = Strong
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PAGE 9 Table 2 (continued on page 10) PAGE 10 Table 2 (continued on page 11)
 Table 2 Continued Table 3 Continued
Disease or Prasugrel Use with caution in adults ≥75 years old
Syndrome Drug(s) Recommendation, Rationale, QE, SR
Increased risk of bleeding in older adults; benefit in highest-risk older
Kidney/Urinary tract adults (e.g., those with prior myocardial infarction or diabetes mellitus)
Chronic NSAIDs (non-COX and COX- Avoid may offset risk when used for its approved indication of acute coronary
kidney selective, oral and parenteral, May increase risk of acute kidney syndrome to be managed with percutaneous coronary intervention
disease Stage nonacetylated salicylates) injury and further decline of renal QE = Moderate; SR = Weak
IV or higher function Antipsychotics Use with caution
(creatinine QE = Moderate; SR = Strong Carbamazepine May exacerbate or cause SIADH or hyponatremia; monitor sodium
clearance <30
Diuretics level closely when starting or changing dosages in older adults
mL/min)
Mirtazapine QE = Moderate; SR = Strong
Oxcarbazepine
Urinary Estrogen oral and transdermal Avoid in women SNRIs
incontinence (excludes intravaginal estrogen) Lack of efficacy (oral estrogen) and SSRIs
(all types) in Peripheral Alpha-1 blockers aggravation of incontinence (alpha-1 TCAs
women ■ Doxazosin blockers) Tramadol
■ Prazosin QE = Estrogen: High. Peripheral alpha-1 Dextromethorphan/ Use with caution
■ Terazosin blockers: Moderate; SR = Estrogen: quinidine Limited efficacy in patients with behavioral symptoms of dementia
Strong. Peripheral alpha-1 blockers: (does not apply to treatment of PBA). May increase risk of falls and
Strong concerns with clinically significant drug interactions. Does not apply to
Lower Strongly anticholinergic drugs, Avoid in men treatment of pseudobulbar affect.
urinary tract except antimuscarinics for urinary May decrease urinary flow and cause QE = Moderate; SR = Strong
symptoms, incontinence.* urinary retention Trimethoprim- Use with caution in patients on ACEI or ARB and decreased creatinine
benign QE = Moderate; SR = Strong sulfamethoxazole clearance.
prostatic
hyperplasia Increased risk of hyperkalemia when used concurrently with an ACEI
or ARB in presence of decreased creatinine clearance.
QE = Low; SR = Strong
TABLE 3. 2019 American Geriatrics Society Beers Criteria® for Potentially Inappropriate
ACEI= angiotensin-converting enzyme inhibitor; ARB=angiotensin receptor blocker; CrCl= creatinine
Medications to Be Used with Caution in Older Adults clearance; SIADH= syndrome of inappropriate antidiuretic hormone secretion; SNRIs = Serotonin-
Recommendation, Rationale, Quality of Evidence (QE), nonrepinephrine reuptake inhitibors; SSRIs = Selective serotonin reuptake inhitibors; TCA=tricyclic
Drug(s) Strength of Recommendation (SR) antidepressant; VTE=venous thromboembolism

Aspirin for primary Use with caution in adults ≥70 years old
prevention of Risk of major bleeding from aspirin increases markedly in older age.
cardiovascular TABLE 4. 2019 American Geriatrics Society Beers Criteria® for Potentially Clinically Important
Several studies suggest lack of net benefit when used for primary Non-anti-infective Drug–Drug Interactions That Should Be Avoided in Older Adults
disease and prevention in older adult with cardiovascular risk factors, but evidence
colorectal cancer is not conclusive. Aspirin is generally indicated for secondary Interacting Drug Recommendation, Risk Rationale, Quality of Evidence
prevention in older adults with established cardiovascular disease. Object Drug and Class and Class (QE), Strength of Recommendation (SR)
QE = Low; SR = Strong RAS inhibitor Another RAS Avoid routine use in those with chronic kidney
(ACEIs, ARBs, inhibitor disease Stage 3a or higher
Dabigatran Use with caution for treatment of VTE or atrial fibrillation in adults ≥75 aliskiren) or (ACEIs, ARBs, Increased risk of hyperkalemia
Rivaroxaban years old potassium-sparing aliskiren) QE = Moderate; SR = Strong
Increased risk of gastrointestinal bleeding compared with warfarin diuretics (amiloride,
and reported rates with other direct oral anticoagulants when used triamterene)
for long-term treatment of venous thromboembolism (VTE) or atrial Opioids Benzo- Avoid
fibrillation in adults ≥75 years old. diazepines Increased risk of overdose
QE = Moderate; SR = Strong QE = Moderate; SR = Strong
✃

PAGE 11 Table 3 (continued on page 12) PAGE 12 Table 4 (continued on page 13)
Table 4 Continued Table 4 Continued
Opioids Gabapentin, Avoid; exceptions are when transitioning from opioid Warfarin Ciprofloxacin Avoid when possible; if used together, monitor INR
pregabalin therapy to gabapentin or pregabalin, or when using closely
gabapentinoids to reduce opioid dose, although Increased risk of bleeding
caution should be used in all circumstances. QE = Moderate; SR = Strong
Increased risk of severe sedation-related adverse Warfarin Macrolides Avoid when possible; if used together, monitor INR
events, including respiratory depression and death (excluding closely
azithromycin) Increased risk of bleeding
QE = Moderate; SR = Strong QE = Moderate; SR = Strong
Anticholinergic Anticholinergic Avoid, minimize number of anticholinergic drugs Warfarin Trimethoprim- Avoid when possible; if used together, monitor INR
Increased risk of cognitive decline sulfamethox- closely
QE = Moderate; SR = Strong azole Increased risk of bleeding
Antidepressants Any Avoid total of ≥3 CNS-active drugsa; minimize number QE = Moderate; SR = Strong
(TCAs, SSRIs, and combination of CNS-active drugs Warfarin NSAIDs Avoid when possible; if used together, monitor closely
SNRIs) of ≥3 of these Increased risk of falls (all) and of fracture for bleeding
Antipsychotics CNS-active (benzodiazepines and nonbenzodiazepine, Increased risk of bleeding
Antiepileptics drugsa benzodiazepine receptor agonist hypnotics) QE = High; SR = Strong
Benzodiazepines QE: Combinations including benzodiazepines and
and nonbenzodiaz- nonbenzodiazepine, benzodiazepine receptor agonist TABLE 5. 2019 American Geriatrics Society Beers Criteria® for Non-Anti-Infective
epine, benzodi- hypnotics or opioids: high. All other combinations:
moderate; SR: Strong Medications That Should Be Avoided or Have Their Dosage Reduced with Varying Levels of
azepine receptor
agonist hypnotics Kidney Function in Older Adults
(ie, “Z-drugs”) Creatinine Clearance,
Opioids Medication Class mL/min, at Which Recommendation, Rationale, Quality of Evidence (QE),
Corticosteroids, NSAIDs Avoid; if not possible, provide gastrointestinal and Medication Action Required Strength of Recommendation (SR)
oral or parenteral protection Anti-infective
Increased risk of peptic ulcer disease or Ciprofloxacin <30 Doses used to treat common infections typically
gastrointestinal bleeding require reduction when CrCl <30 mL/min
QE = Moderate; SR = Strong Increased risk of CNS effects (eg, seizures, confusion)
Lithium ACEIs Avoid, monitor lithium concentrations and tendon rupture
Increased risk of lithium toxicity QE = Moderate; SR = Strong
QE = Moderate; SR = Strong Trimethoprim- <30 CrCl 15-29 mL/min:Reduce Dose
Lithium Loop diuretics Avoid, monitor lithium concentrations sulfamethox- <15 mL/min: Avoid
Increased risk of lithium toxicity azole Increased risk of worsening of renal function and
QE = Moderate; SR = Strong hyperkalemia
Peripheral Loop diuretics Avoid in older women, unless conditions warrant QE = Moderate; SR = Strong
alpha-1 blockers both drugs
Increased risk of urinary incontinence in older women a
Central nervous system (CNS)-active drugs: antiepileptics, antipsychotics; benzodiazepines; nonbenzodiazepine,
QE = Moderate; SR = Strong benzodiazepine receptor agonist hypnotics; tricyclic antidepressants (TCAs); selective serotonin reuptake inhibitors
(SSRIs); serotonin-norepinephrine reuptake inhibitors (SNRIs); and opioids
Phenytoin Trimethoprim- Avoid ACEIs=angiotensin-converting enzyme inhibitors; ARBs=angiotensin receptor blockers;
sulfamethox- Increased risk of phenytoin toxicity NSAIDs=nonsteroidal anti-inflammatory drugs; RAS=renin-angiotensin system
azole QE = Moderate; SR = Strong
Copyright © 2019 by the American Geriatrics Society. All rights reserved. Except where authorized, no part
Theophylline Cimetidine Avoid of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any
Increased risk of theophylline toxicity means, electronic, mechanical, photocopying, recording, or otherwise without written permission of the
QE = Moderate; SR = Strong American Geriatrics Society, 40 Fulton Street, 18th Floor, New York, NY 10038. The Criteria published by The
American Geriatrics Society (AGS) incorporate data obtained from a literature review of the most recent
Theophylline Ciprofloxacin Avoid studies available at the time. As with all clinical reference resources, they reflect the best understanding
Increased risk of theophylline toxicity of the science of medicine at the time of publication, but they should be used with the clear understanding
that continued research may result in new knowledge and recommendations. The Criteria are intended
QE = Moderate; SR = Strong
for general information only, are not medical advice, and do not replace professional medical care and
Warfarin Amiodarone Avoid when possible; if used together, monitor INR physician advice, which always should be sought for any specific condition.
closely
Increased risk of bleeding
QE = Moderate; SR = Strong
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PAGE 13 Table 4 (continued on page 14) PAGE 14 Table 5 (continued on page 15)
Table 5 Continued Table 5 Continued
Creatinine Clearance, Creatinine Clearance,
Medication Class mL/min, at Which Medication Class mL/min, at Which
and Medication Action Required Recommendation, Rationale, QE, SR and Medication Action Required Recommendation, Rationale, QE, SR
Cardiovascular or hemostasis Central nervous system and analgesics
Amiloride <30 Avoid Duloxetine <30 Avoid
Increased potassium and decreased sodium Increased gastrointestinal adverse effects (nausea,
QE = Moderate; SR = Strong diarrhea)
Apixaban <25 Avoid QE = Moderate; SR = Weak
Lack of evidence for efficacy and safety in patients Gabapentin <60 Reduce dose
with a CrCl <25 mL/min CNS adverse effects
QE = Moderate; SR = Strong QE = Moderate; SR = Strong
Dabigatran <30 Avoid; dose adjustment advised when CrCl >30 mL/ Levetiracetam ≤80 Reduce dose
min in the presence of drug-drug interactions CNS adverse effects
Lack of evidence for efficacy and safety in individuals QE = Moderate; SR = Strong
with a CrCl <30 mL/min. Label dose for patients with a Pregabalin <60 Reduce dose
CrCl 15-30 mL/min based on pharmacokinetic data.
CNS adverse effects
QE = Moderate; SR = Strong
QE = Moderate; SR = Strong
Dofetilide <60 CrCl 20-59: Reduce dose
Tramadol <30 Immediate release: Reduce dose
CrCl <20: Avoid Extended release: avoid
QTc prolongation and torsades de pointes CNS adverse effects
QE = Moderate; SR = Strong QE = Low; SR = Weak
Edoxaban 15–50 CrCl 15-50: Reduce dose Gastrointestinal
<15 or >95 CrCl <15 or >95: Avoid
Cimetidine <50 Reduce dose
Lack of evidence of efficacy or safety in patients with
a CrCl <30 mL/min Mental status changes
QE = Moderate; SR = Strong QE = Moderate; SR = Strong
Famotidine <50 Reduce dose
Enoxaparin <30 Reduce dose
Mental status changes
Increased risk of bleeding
QE = Moderate; SR = Strong
QE = Moderate; SR = Strong
Nizatidine <50 Reduce dose
Fondaparinux <30 Avoid
Mental status changes
Increased risk of bleeding
QE = Moderate; SR = Strong
QE = Moderate; SR = Strong
Ranitidine <50 Reduce dose
Rivaroxaban <50 Nonvalvular atrial fibrillation: reduce dose if CrCl
15-50 mL/min; avoid if CrCl <15 mL/min Mental status changes
Venous thromboembolism treatment and for VTE QE = Moderate; SR = Strong
prophylaxis with hip or knee replacement: avoid if Hyperuricemia
CrCl <30 mL/min Colchicine <30 Reduce dose; monitor for adverse effects
Lack of efficacy or safety evidence in patients with a Gastrointestinal, neuromuscular, bone marrow toxicity
CrCl <30 mL/min QE = Moderate; SR = Strong
QE = Moderate; SR = Strong
Probenecid <30 Avoid
Spironolactone <30 Avoid Loss of effectiveness
Increased potassium QE = Moderate; SR = Strong
QE = Moderate; SR = Strong CNS=central nervous system; CrCl=creatinine clearance
Triamterene <30 Avoid
The primary target audience is the practicing clinician. The intentions of the criteria include 1) improving
Increased potassium and decreased sodium the selection of prescription drugs by clinicians and patients; 2) evaluating patterns of drug use within
QE = Moderate; SR = Strong populations; 3) educating clinicians and patients on proper drug usage; and 4) evaluating health-outcome,
quality-of-care, cost, and utilization data.
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PAGE 15 Table 5 (continued on page 16) PAGE 16