Nurs-6521 assignment wk1

  

Assignment

: Ethical and Legal Implications of Prescribing Drugs

What type of drug should you prescribe based on your patient’s diagnosis? How much of the drug should the patient receive? How often should the drug be administered? When should the drug not be prescribed? Are there individual patient factors that could create complications when taking the drug? Should you be prescribing drugs to this patient? How might different state regulations affect the prescribing of this drug to this patient?

These are some of the questions you might consider when selecting a treatment plan for a patient. 

As an advanced practice nurse prescribing drugs, you are held accountable for people’s lives every day. Patients and their families will often place trust in you because of your position. With this trust comes power and responsibility, as well as an ethical and legal obligation to “do no harm.” It is important that you are aware of current professional, legal, and ethical standards for advanced practice nurses with prescriptive authority. Additionally, it is important to ensure that the treatment plans and administration/prescribing of drugs is in accordance with the regulations of the state in which you practice. Understanding how these regulations may affect the prescribing of certain drugs in different states may have a significant impact on your patient’s treatment plan. In this Assignment, you explore ethical and legal implications of scenarios and consider how to appropriately respond.

To Prepare

Review the Resources for this module and consider the legal and ethical implications of prescribing prescription drugs, disclosure, and nondisclosure.

https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?CFRPart=1300

https://www.deadiversion.usdoj.gov/drugreg/practioners/index.html

https://oce.ovid.com/article/01741002-201705000-00005/HTML

Review the scenario assigned by your Instructor for this Assignment.

Search specific laws and standards for prescribing prescription drugs and for addressing medication errors for your state or region and reflect on these as you review the scenario assigned by your Instructor.

The Scenario for this week’s assignments is:

You see another nurse practitioner writing a prescription for her husband, who is not a patient of the nurse practitioner. The prescription is for a narcotic. You can’t decide whether or not to report the incident.

Consider the ethical and legal implications of the scenario for all stakeholders involved, such as the prescriber, pharmacist, patient, and patient’s family.

Think about two strategies that you, as an advanced practice nurse, would use to guide your ethically and legally responsible decision-making in this scenario, including whether you would disclose any medication errors.

Assignment

Write a 2- to 3-page that addresses the following:

Explain the ethical and legal implications of the scenario you selected on all stakeholders involved, such as the prescriber, pharmacist, patient, and patient’s family.

Describe strategies to address disclosure and nondisclosure as identified in the scenario you selected. Be sure to reference laws specific to your state.

Explain two strategies that you, as an advanced practice nurse, would use to guide your decision making in this scenario, including whether you would disclose your error. Be sure to justify your explanation. 

Explain the process of writing prescriptions, including strategies to minimize medication errors

CLINICAL INVESTIGATION

American Geriatrics Society 2019 Updated AGS Beers Criteria®

for Potentially Inappropriate Medication Use in Older Adult

s

By the 2019 American Geriatrics Society Beers Criteria® Update Expert Panel*

The American Geriatrics Society (AGS) Beers Criteria®

(AGS Beers Criteria®) for Potentially Inappropriate Medica-
tion (PIM) Use in Older Adults are widely used by clini-
cians, educators, researchers, healthcare administrators, and
regulators. Since 2011, the AGS has been the steward of the
criteria and has produced updates on a 3-year cycle. The
AGS Beers Criteria® is an explicit list of PIMs that are typi-
cally best avoided by older adults in most circumstances or
under specific situations, such as in certain diseases or con-
ditions. For the 2019 update, an interdisciplinary expert
panel reviewed the evidence published since the last update
(2015) to determine if new criteria should be added or if
existing criteria should be removed or undergo changes to
their recommendation, rationale, level of evidence, or
strength of recommendation. J Am Geriatr Soc 00:1–
21, 2019

.

Key words: medications; drugs; older adults; Beers list;
Beers Criteria

The American Geriatrics Society (AGS) Beers Criteria
®

(AGS Beers Criteria®) for Potentially Inappropriate
Medication (PIM) Use in Older Adults are widely used by
clinicians, educators, researchers, healthcare administrators,
and regulators. Since 2011, the AGS has been the steward
of the criteria and has produced updates on a 3-year cycle
that began in 2012.1,2 The AGS Beers Criteria® are a

n

explicit list of PIMs that are typically best avoided by older
adults in most circumstances or under specific situations,
such as in certain diseases or condition

s.

For the 2019 update, an interdisciplinary expert pane

l

reviewed the evidence published since the last update
(2015) to determine if new criteria should be added or if
existing criteria should be removed or undergo changes to
their recommendation, rationale, level of evidence, or
strength of recommendation. Each of the five types of cri-
teria in the 2015 update were retained in this 2019 update:
medications that are potentially inappropriate in most older
adults, those that should typically be avoided in older
adults with certain conditions, drugs to use with caution,
drug-drug interactions, and drug dose adjustment based on
kidney function.

OBJECTIVES

The specific aim was to update the 2015 AGS Beers Criteria®

using a comprehensive, systematic review and grading of the
evidence on drug-related problems and adverse events in
older adults. The strategies to achieve this aim were to:

• Incorporate new evidence on PIMs included in the 2015 AGS
Beers Criteria® and evidence regarding new criteria or modifi-
cations of existing criteria being considered for the 2019
update.

• Grade the strength and quality of each PIM statement based on
the level of evidence and strength of recommendation.

• Convene an interdisciplinary panel of 13 experts in geriatric
care and pharmacotherapy who would apply a modified Delphi
method, informed by the systematic review and grading, to
reach consensus on the 2019 update.

• Incorporate exceptions in the AGS Beers Criteria® that the
panel deemed clinically appropriate. These exceptions would
be designed to make the criteria more individualized to clinical
practice and be more relevant across settings of care.

INTENT OF CRITERIA

The primary target audience for the AGS Beers Criteria®

is practicing clinicians. The criteria are intended for use in
adults 65 years and older in all ambulatory, acute, and
institutionalized settings of care, except for the hospice
and palliative care settings. Consumers, researchers, phar-
macy benefits managers, regulators, and policymakers also
widely use the AGS Beers Criteria®. The intention of the
AGS Beers Criteria® is to improve medication selection;

From the *American Geriatrics Society, New York, New York.

Address correspondence to Mary Jordan Samuel, American Geriatrics
Society, 40 Fulton St, 18th Floor, New York, NY 10038.
E-mail: mjsamuel@americangeriatrics.org

See related editorial by Michael Steinman et al.

DOI: 10.1111/jgs.15767

JAGS 00:1–21, 2019
© 2019 The American Geriatrics Society 0002-8614/18/$15.00

mailto:mjsamuel@americangeriatrics.org

https://doi.org/10.1111/jgs.15766

educate clinicians and patients; reduce adverse drug events;
and serve as a tool for evaluating quality of care, cost, and
patterns of drug use of older adults.

As with previously published AGS Beers Criteria®, the
goal of the 2019 update continues to be improving the
care of older adults by reducing their exposure to PIMs that
have an unfavorable balance of benefits and harms com-
pared with alternative treatment options. This is accom-
plished by using the AGS Beers Criteria® as both an
educational tool and a quality measure—two uses that a

re

not always in agreement—and the panel considered and
vigorously deliberated both. The AGS Beers Criteria® are
not meant to be applied in a punitive manner. Prescribi

ng

decisions are not always clear-cut, and clinicians must con-
sider multiple factors, including discontinuation of medica-
tions no longer indicated. Quality measures must be clearly
defined, easily applied, and measured with limited informa-
tion and, thus, although useful, cannot perfectly distinguish
appropriate from inappropriate care. The panel’s review of
evidence at times identified subgroups of individuals who
should be exempt from a given criterion or to whom a spe-
cific criterion should apply. Such a criterion may not be eas-
ily applied as a quality measure, particularly when such
subgroups cannot be easily identified through structured
and readily accessible electronic health data. As an exam-
ple, the panel thought that a criterion should not be
expanded to include all adults 65 years and older when
only certain subgroups have an adverse balance of benefits
vs harms for the medication, or conversely when a sizable
subgroup of older adults may be appropriate candidates for
a medication that is otherwise problematic.

Despite past and current efforts to translate the cri-
teria into practice, some controversy and myths about
their use in practice and policy continue to prevail. The
panel addressed these concerns and myths by writing a
companion article to the 2015 update of the AGS Bee

rs

Criteria® and an updated 2019 short piece, which remains
the best way to advise patients, providers, and health sys-
tems on how to use (and not use) the 2019 AGS Beers
Criteria®.3

METHODS

Methods used for the 2019 update of the AGS Beers Criteria®

were similar to those used in the 2015 update, with additional
emphasis on extending the rigor of the evidence review and
synthesis process.2 These methods were based on the Grading
of Recommendations Assessment, Development and Evalua-
tion (GRADE) guidelines for clinical practice guideline devel-
opment and are consistent with recommendations from the
National Academy of Medicine.4,5

Panel Composition

The AGS Beers Criteria® expert update panel comprised
13 clinicians and included physicians, pharmacists, and
nurses, each of whom had participated in the 2015 update.
Panelists had experience in different practice settings,
including ambulatory care, home care, acute hospital care,
skilled-nursing facility, and long-term care. In addition,
the panel included ex-officio representatives from the Cen-
ters for Medicare and Medicaid Services, the National

Committee for Quality Assurance, and the Pharmacy
Quality Alliance. Potential conflicts of interest were dis-
closed at the beginning of the process and before each full
panel call and are listed in the disclosures section of this
article. Panelists were recused from discussion in areas in
which they had a potential conflict of interest.

Literature Review

Literature searches were conducted in PubMed and the
Cochrane Library from January 1, 2015, to September
30, 2017. Search terms for each criterion included individ-
ual drugs, drug classes, specific conditions, and combina-
tions thereof, each with a focus on “adverse drug events”
and “adverse drug reactions.” Medications believed to have
low utilizations (eg, meprobamate and central α-agonist
antihypertensives other than clonidine) or no longer avail-
able in the United States were excluded from the literature
search. Searches targeted controlled clinical trials, observa-
tional studies, and systematic reviews and meta-analyses,
with filters for human participants, 65 years and older, and
English language. Clinical reviews and guidelines were also
included to provide context. Case reports, case series, letters
to the editor, and editorials were excluded.

Searches identified 17,627 references; 5403 abstracts
were sent to panelists for review, of which 1422 references
were selected for full-text review. Among these, 377 articles
were abstracted into evidence tables, including 67 systematic
reviews and/or meta-analyses, 29 controlled clinical trials,
and 281 observational studies.

Development Process

Between February 2016 and May 2018, the full panel con-
vened for a series of conference calls and 1 full-day, in-
person meeting. In addition, the panel divided into four
work groups, each assigned a subset of the criteria. Each
work group led the review and synthesis of evidence for its
subset of the criteria, convening via conference calls and
electronically via e-mail.

The development process began by soliciting ideas from
the panelists about criteria that should be explored for addi-
tion, modification, or removal. Suggestions from others
were also welcomed. To guide the evidence selection,
review, and synthesis process, each work group then under-
took an exercise to identify a priori which clinical out-
comes, indications, and comparison groups were most
relevant when considering evidence for each criterion
(ie, the “desired evidence” for reviewing each criterion).
These discussions were not considered binding but provided
guidance for keeping the evidence review and synthesis
focused on what was most clinically relevant.

Each work group reviewed abstracts from the literature
searches for the criteria in its purview and collectively
selected a subset for full-text review. This selection process
considered the methodologic quality of each study, its rele-
vance to older adults, and its concordance with the desired
evidence noted above. After reviewing the full text of each
selected article, the work group then decided by consensus
which articles represented the best available evidence, based
on a balance of these same three key criteria (methodologic
quality, relevance to older adults, and concordance with

2 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL MONTH 2019–VOL. 00, NO. 00 JAGS

desired evidence). Special emphasis was placed on selecting
systematic reviews and meta-analyses when available,
because resource constraints precluded the panel from con-
ducting these types of comprehensive analyses. In general, a
study was considered relevant to older adults if the mean or
median age of participants was older than 65 years, and
especially relevant if most or all participants were older
than this age threshold.

Articles comprising the best available evidence were
abstracted by AGS staff into evidence tables. These tables
summarized the design, population, and findings of each
study, and identified markers of methodologic quality
highlighted by the GRADE criteria for clinical trials and
observational studies and by A MeaSurement Tool to
Assess Systematic Reviews (AMSTAR).6–8 Each work group
then synthesized evidence for each criterion from the 2015
to 2017 literature reviews based on GRADE guidelines and
the American College of Physicians’ evidence grading
framework (Table 1).6,9

Using evidence from the 2015 to 2017 literature
review, evidence findings from previous updates in 2012
and 2015, and clinical judgment, each work group pre-
sented to the full panel its findings and suggestions for
changes (or no change) to the criteria, with ensuing discus-
sion. For most criteria, a consensus emerged, to leave an
existing criterion from the 2015 update unchanged, to mod-
ify it, to remove it entirely, or to add a new criterion. Poten-
tial modifications included the drug(s) included in the
criterion, the recommendation, the rationale, the quality of
evidence, and the strength of recommendation. As noted in
the GRADE guidelines, strength of recommendation ratings
incorporate a variety of considerations, including expert
opinion and clinical judgment and context, and thus do not
always align with quality of evidence ratings.

After discussion of proposed changes, an anonymous Del-
phi process was used to ascertain panel consensus, using a
five-point Likert scale with anchors of “strongly disagree” and
“strongly agree.” As a general rule, criteria receiving “agree”
or strongly agree ratings from more than 90% of panelists
were included. The remainder were brought back for group
discussion, with final decisions resolved through consensus.

In addition to changes made on the basis of evidence,
the panel decided on several modifications to improve clar-
ity and usability of the AGS Beers Criteria®. These included
removing a number of medications that are used only
rarely. These removals should not be interpreted as condon-
ing use of these medications but rather are intended to
“declutter” the AGS Beers Criteria® and not distract from
information on more commonly used medications. In
selected cases, the panel changed the wording of certain cri-
teria, recommendations, and rationale statements to
improve clarity and avoid potential misinterpretations.

The final set of criteria was reviewed by the AGS Exec-
utive Committee and Clinical Practice and Models of Care
Committee and subsequently released for public comment.
Comments were solicited from the general public and sent
to 39 organizations. Comments were accepted over a
3-week period from August 13, 2018, until September
4, 2018. A total of 244 comments were received from
47 individuals (79 comments), 6 pharmaceutical companies
(10 comments), and 22 peer organizations (155 comments).
All comments were reviewed and discussed by the panel

cochairs. All comments along with proposed changes to the
criteria were shared with the entire panel for final approval.

RESULTS

Noteworthy Changes to PIMs for Older Adults

Tables 2 through 6 show the 2019 criteria. Table 7 lists
those drugs with strong anticholinergic properties that are
sometimes referenced in Tables 2 through 6. Compared
with the 2015 criteria, several drugs were removed from
Table 2 (medications that are potentially inappropriate in
most older adults), Table 3 (medications that are potentially
inappropriate in older adults with certain conditions), and
Table 4 (medications that should be used with caution).
These removals are summarized in Table 8 and include
removal of drugs no longer available in the United States
(ticlopidine, oral pentazocine). In other cases, the recom-
mendation was removed entirely because the panel decided
the drug-related problem was not sufficiently unique to
older adults (eg, using stimulating medications in patients
with insomnia or avoiding medications that can lower the
seizure threshold in patients with a seizure disorder). The

se

removals do not imply that these medications are now con-
sidered safe for older adults; rather, they were made to help
keep the AGS Beers Criteria® streamlined and focused on
medications particularly problematic for older adults.

The H2-receptor antagonists were removed from the
“avoid” list in patients with dementia or cognitive impair-
ment. This is because evidence for adverse cognitive effects
in these conditions is weak, and because the panel
expressed concern that the intersection of this criterion with
another criterion that discourages chronic use of proton-
pump inhibitors in the absence of strong indications would
overly restrict therapeutic options for older adults with
dementia who have gastroesophageal reflux or similar
issues. However, H2-receptor antagonists remain on the cri-
teria as “avoid” in patients with delirium. In addition,
wording of this criterion was modified to affirm that non-
benzodiazepine, benzodiazepine receptor agonist hypnotics
(ie, the “Z drugs”: zolpidem, eszopiclone, and zaleplon

)

should be avoided in older adults with delirium.

Two drugs with strong anticholinergic properties, pyri-
lamine and methscopolamine, were added to the list of anti-
cholinergic drugs to avoid. Changes to criteria on
cardiovascular drugs include minor updates to the rationale
and a minor change to clarify the recommendation for
avoiding digoxin as first-line therapy for atrial fibrillation
and heart failure (Table 2). The rationale to avoid sliding-
scale insulin has been revised to clarify its meaning and
intent (Table 2). Glimepiride has been added to the list of
sulfonylureas with a greater risk of severe prolonged hypo-
glycemia (Table 2). The duration of use of metoclopramide
has been added to be consistent with US Food and Drug
Administration labeling (Table 2).

The serotonin-norepinephrine reuptake inhibitors
(SNRIs) have been added to the list of drugs to avoid in
patients with a history of falls or fractures (Table 3). Fol-
lowing a principle that applies to all criteria, the panel rec-
ognizes there may be situations when SNRIs, other
antidepressants, and other medications listed in this crite-
rion may be appropriate for people with a history of falls

JAGS MONTH 2019–VOL. 00, NO. 00 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL 3

or fractures, based on potential benefits and the lack of
availability of safer alternatives. After reviewing and dis-
cussing the evidence on antipsychotics to treat psychosis in
patients with Parkinson disease, the panel decided to
remove aripiprazole as preferred and add pimavanserin.
Thus, the 2019 AGS Beers Criteria® recognize quetiapine,
clozapine, and pimavanserin as exceptions to the general
recommendation to avoid all antipsychotics in older adults
with Parkinson disease (Table 3). However, none of these
three excepted drugs is close to ideal in either efficacy or
safety, each having its own limitations and concerns.

The criteria on drugs to avoid in older adults with heart fail-
ure were reorganized to add clinical nuance based on evidence,
other guideline recommendations, and clinical considerations.
The updated recommendations are that nondihydropyridine cal-
cium channel blockers should be avoided in older adults who
have heart failure with reduced ejection fraction; that nonsteroi-
dal anti-inflammatory drug (NSAIDs), cyclooxygenase-2 inhibi-
tors, thiazolidinediones (“glitazones”), and dronedarone should

be used with caution in older adults with heart failure who are
asymptomatic (ie, excellent control of heart failure signs and
symptoms, with or without use of medications) and avoided in
older adults who are symptomatic; and that cilostazol should
continue to be avoided in older adults with heart failure of
any type.

Drugs To Be Used With Caution

Table 4 contains drugs to be used with caution in older
adults. The purpose of this table is to identify drugs for
which there is some cause for concern, but for which the
evidence and/or clinical context is as of yet insufficient to
merit inclusion in the main tables. Compared with the pre-
vious update, the following changes and additions
were made:

• The age threshold beyond which extra caution is advised for
using aspirin for primary prevention of cardiovascular disease

Table 1. Designations of Quality of Evidence and Strength of Recommendationsa

Quality of Evidence
Quality of evidence ratings for each criterion are based on synthetic assessment of two complementary approaches to evaluating the
quality of evidence.

ACP-based approach9 GRADE-based approach4

High-quality evidence “Evidence…obtained from 1 or more well-
designed and well-executed randomized,
controlled trials (RCTs) that yield consistent and
directly applicable results. This also means that
further research is very unlikely to change our
confidence in the estimate of effect.”

Consider the following five factors for the studies
that comprise the best-available evidence for a
given criterion:
1. Risk of bias: Severity of threats to studies’

internal validity (eg, randomized vs
observational design, potential for
confounding, bias in measurement)

2. Inconsistency: Do different studies provide
similar or different estimates of effect size

3. Indirectness: How relevant are the studies to
the clinical question at hand (eg, nature of
study of population, comparison group, type
of outcomes measured)

4. Imprecision: Precision of estimates of effect
5. Publication bias: Risk of bias due to selective

publication of results

Moderate-quality evidence “Evidence…obtained from RCTs with important
limitations…. In addition, evidence from well-
designed controlled trials without randomization,
well-designed cohort or case-control analytic
studies, and multiple time series with or without
intervention are in this category. Moderate-
quality evidence also means that further
research will probably have an important effect
on our confidence in the estimate of effect and
may change the estimate.”

Low-quality evidence “Evidence obtained from observational studies
would typically be rated as low quality because
of the risk for bias. Low-quality evidence means
that further research is very likely to have an
important effect on our confidence in the
estimate of effect and will probably change the
estimate. However, the quality of evidence may
be rated as moderate or even high, depending
on circumstances under which evidence is
obtained from observational studies.”

# # # # #
Overall quality of evidence that supports a given criterion: high, moderate, low

Strength of Evidence
Strength of evidence ratings for each criterion are based on synthetic integration of the quality of evidence, the frequency and severity
of potential adverse events and relationship to potential benefits, and clinical judgment.
Strong Harms, adverse events, and risks clearly outweigh benefits.
Weak Harms, adverse events, and risks may not outweigh benefits.

Abbreviations: ACP, American College of Physicians; GRADE, Grading of Recommendations Assessment, Development and Evaluation.
aAdapted from: Qaseem A, Snow V, Owens DK, et al. The development of clinical practice guidelines and guidance statements of the American College of
Physicians: summary of methods. Ann Intern Med. 2010;153:194-–199. Guyatt G, Oxman AD, Sultan S, et al. GRADE guidelines,: 11.: making an overall
rating of confidence in effect estimates for a single outcome and for all outcomes. J Clin Epidemiol. 2013;66(2):151-–157. Andrews JC, Schünemann HJ,
Oxman AD, et al. GRADE guidelines,: 15.: going from evidence to recommendation-determinants of a recommendation’s direction and strength. J Clin Epi-
demiol. 2013;66(7):726–735.

4 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL MONTH 2019–VOL. 00, NO. 00 JAGS

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s;

m
o
re

e
ff
e
ct
iv
e

a
g

e
n
ts

a
va

ila
b
le

fo
r
tr
e
a
tm

e
n
t
o
f

P
a
rk
in
so

n

d
is
e
a
se

A
vo
id

M
o
d
e
ra
te

S
tr
o
n
g

A
n
tis
p
a
sm

o
d
ic
s

A
tr
o

p
in
e

(e
xc
lu
d
e
s
o
p
h
th
a
lm

ic
)

B
e
lla
d
o
n
n
a
a
lk
a
lo
id
s

C
lid
in

iu
m

-c
h
lo
r

d
ia
ze

p
o
xi
d
e

D
ic
yc
lo
m
in
e
H
o
m
a
tr
o
p
in
e

(e
xc
lu
d
e
s
o
p
th
a
lm

ic
)

H
yo

sc
ya

m
in
e

M
e
th
sc
o

p
o
la
m
in
e

P
ro
p
a
n
th
e
lin
e

S
co

p
o
la
m
in
e

H
ig
h
ly

a
n
tic
h
o
lin
e
rg
ic
,
u
n
ce

rt
a
in

e
ff
e
ct
iv
e
n
e
ss

A
vo

id
M
o
d
e
ra
te

S
tr
o
n
g

A
n
tit
h
ro
m

b
o

tic
s

D
ip
yr
id
a
m
o
le
,
o
ra
ls

h
o
rt
a
ct

in
g

(d
o
e
s

n
o
t

a
p
p
ly

to
th
e
e
xt
e
n
d
e
d
-r
e
le
a
se

co

m
b
in
a
tio

n
w
ith

a
sp

ir
in

)

M
a
y
ca

u
se

o
rt
h
o
st
a
tic

h
yp

o
te
n
si
o
n
;
m
o
re

e
ff
e
ct
iv
e

a
lte

rn
a
tiv
e
s

a
va

ila
b
le
;
IV

fo
rm

a
cc
e
p
ta
b
le

fo
r
u
se

i

n
ca

rd
ia
c
st
re
ss

te
st
in
g

A
vo
id
M
o
d
e
ra
te
S
tr
o
n
g

A
n
ti-
in
fe
ct
iv
e

N
itr
o
fu
ra
n
to
in

P
o
te
n
tia

lf
o
r

p
u
lm

o
n
a
ry

to
xi
ci
ty
,
h
e
p
a
to
xi
ci
ty
,
a
n
d

p
e

ri
p
h
e
ra
ln

e
u
ro
p
a
th
y,

e
sp

e
ci
a
lly

w
ith

lo
n
g
-t

e
rm

u
se

;
sa

fe
r
a
lte

rn
a
tiv
e
s
a
va

ila
b
le
A
vo
id
in

in
d
iv
id
u
a
ls

w
ith

cr
e
a
tin

in
e
cl
e
a
ra
n
ce

< 3 0 m L /m

in
o
r
fo
r
lo
n
g
-t
e
rm

su
p
p
re
ss
io
n

L
o
w

S
tr
o
n
g

C
a
rd
io
va

sc
u
la
r

P
e
ri
p

h
e
ra
la

lp
h
a
-1

b
lo
ck
e
rs

fo
r
tr
e
a
tm
e
n
t

o
f
h
yp

e
rt
e
n
si
o
n

D
o
xa

zo

si
n

P
ra
zo

si
n

T
e
ra
zo

si
n

H
ig
h
ri
sk

o
f
o
rt
h
o
st
a
tic

h
yp

o
te
n
si
o
n
a
n
d

a
ss
o
ci
a
te
d

h
a
rm

s,
e
sp

e
ci
a
lly

in
o
ld
e
r

a
d
u
lts

;
n
o
t

re
co

m
m
e
n
d
e
d
a
s

ro
u
tin

e
tr
e
a
tm

e
n
t
fo
r
h
yp

e
rt
e
n
si
o
n
;
a
lte

rn
a
tiv
e
a
g
e
n
ts

h
a
ve

su
p
e
ri
o
r
ri
sk
/b
e
n
e
fi
t

p
ro
fi
le

A
vo

id
u
se

a
s
a
n
a
n
tih

yp
e
rt
e
n
si
ve

M
o
d
e
ra
te
S
tr
o
n
g

(C
o
n
ti
n
u
ed

)

JAGS MONTH 2019–VOL. 00, NO. 00 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL 5

T
ab

le
2
(C

o
n
td
.)

O
rg
an
Sy
st
em
,
Th
er
ap
eu
tic
Ca
te
go
ry
,
D
ru
g(
s)

R
at
io
na
le

R
ec
om
m
en
da
tio
n
Q
ua
lit
y
of

Ev
id
en
ce

St
re
ng
th
of
R
ec
om
m
en
da
tio
n

C
e
n
tr
a
la

lp
h
a
-a
g
o

n
is

ts

C
lo
n
id
in
e
fo
r
fi
rs
t-
lin
e
tr
e
a
tm

e
n
t
o
f
h
yp
e
rt
e
n
si
o
n

O
th
e
r
C
N
S
a
lp
h
a
-a
g
o
n
is
ts

G
u
a
n
a
b
e
n
z

G
u
a
n
fa

ci
n

e

M
e
th
yl
d
o
p
a

R
e
se

rp
in
e
(>
0
.1

m
g
/d
a
y)

H
ig
h
ri
sk

o
f

a
d
ve

rs
e

C
N
S
e
ff
e
ct
s;

m
a
y
ca

u
se

b
ra
d
yc
a
rd
ia

a
n
d
o
rt
h
o
st
a
tic

h
yp

o
te
n
si
o
n
;
n
o
t
re
co

m
m
e
n
d
e
d
a
s
ro
u
tin

e
tr
e
a
tm
e
n
t
fo
r
h
yp
e
rt
e
n
si
o
n
A
vo

id
a
s
fi
rs
t-
lin
e
a
n
tih

yp
e
rt
e
n
si
ve
A
vo

id

o
th
e
r

C
N
S
a
lp
h
a
-a
g
o
n
is
ts

a
s

lis
te
d

L
o
w
L
o
w
S
tr
o
n
g
S
tr
o
n
g

D
is
o
p
yr
a
m
id
e

M
a
y
in
d
u
ce

h
e
a
rt

fa
ilu
re

in

o
ld
e
r
a
d
u
lts

b

e
ca

u
se

o
f
p
o
te
n
t

n
e
g
a
tiv
e
in
o
tr
o
p
ic

a
ct
io
n
;

st
ro
n
g

ly

a
n
tic
h
o
lin
e
rg
ic
;
o
th
e
r

a
n
tia

rr
h
yt
h
m
ic

d

ru
g

s
p
re
fe
rr
e
d

A
vo

id
L
o
w

S
tr
o
n
g

D
r

o
n
e

d
a
ro
n
e

W
o
rs
e
o
u
tc
o
m
e
s
h
a
ve

b
e
e
n
re
p
o
rt
e
d
in

p
a
tie

n
ts

ta
ki
n
g

d
ro
n
e
d
a
ro
n
e
w
h
o
h
a
ve

p
e
rm

a
n
e
n
t

a
tr
ia
lfi

b
ri
lla
tio

n
o
r

se
ve

re

o
r

re
ce

n
tly

d
e
co

m
p
e
n
sa

te
d

h
e
a
rt
fa
ilu
re

.

A
vo
id
in
in
d
iv
id
u
a
ls
w
ith
p
e
rm
a
n
e
n
t
a
tr
ia
lfi
b
ri
lla
tio

n
o
r
se

ve
re
o
r
re
ce
n
tly
d
e
co
m
p
e
n
sa
te
d
h
e
a
rt
fa
ilu
re
H
ig
h
S
tr
o
n
g

D
ig
o
xi
n
fo
r
fi
rs
t-
lin
e
tr
e
a
tm

e
n
t
o
f

a
tr
i

a
l

fi
b
ri
lla
tio

n
o
r
o
f
h
e
a
rt
fa
ilu
re

U
se

in
a
tr
ia
lfi

b
ri
lla
tio

n
:

sh

o
u
ld

n
o
t
b

e
u
se

d
a
s
a
fi
rs
t-
lin
e

a
g
e
n
t
in

a
tr
ia
lfi
b
ri
lla
tio

n
,

b
e
ca

u
se

th
e
re

a
re

sa
fe

r
a
n
d

m
o
re

e
ff
e
ct
iv
e
a
lte

rn
a
tiv
e
s
fo

r
ra
te

co
n
tr
o
ls

u
p
p
o
rt
e
d
b
y

h
ig
h

-q
u
a
lit
y

e
vi
d

e
n
ce

.
U
se

in

h
e
a
rt
fa
ilu
re
:

e
vi
d
e
n
ce

fo
r
b
e
n
e
fi
ts

a
n
d
h
a
rm

s
o
f

d
ig
o
xi
n
is

co
n
fl
ic
tin

g
a
n
d
o
f

lo
w

e
r
q
u
a
lit
y;

m
o
st

b
u
t
n
o
t

a
ll

o
f
th
e
e
vi
d
e
n
ce

co
n
ce

rn
s
u
se

in
H
F
rE
F
.
T
h
e
re

is
st
ro
n
g

e
vi
d
e
n
ce

fo
r
o
th
e
r
a
g
e
n
ts

a
s
fi
rs
t-
lin
e

th
e
ra
p
y

to

re
d
u
ce

h
o
sp

ita
liz
a
tio

n
s
a
n
d
m
o
rt
a
lit
y
in

a
d
u
lts
w
ith

H
F
rE
F
.
In

h
e
a
rt
fa
ilu
re
,
h
ig
h
e
r

d
o
sa

g
e
s

a
re

n
o
t
a
ss
o
ci
a
te
d
w
ith

a
d
d
iti
o
n
a
lb

e
n
e
fi
t
a
n
d
m
a
y

in
cr
e
a
se

ri
sk

o
f
to
xi
ci
ty
.

D
e
cr
e
a
se

d
re
n
a
lc

le
a
ra
n
ce

o
f
d
ig
o
xi
n
m
a
y
le
a

d
to

in
cr
e
a
se

d
ri
sk

o
f
to
xi
c
e
ff
e
ct
s;

fu
rt
h
e
r

d
o
se

re
d
u
ct
io
n
m
a
y

b
e
n
e
ce

ss
a
ry

in

th
o
se

w
ith

st
a
g
e

4
o
r

5
ch

ro
n
ic

ki
d
n
e
y

d
is
e
a
se
.
A
vo

id
th
is

ra
te

co
n
tr
o
la

g
e
n
t
a
s
fi
rs
t-

lin
e
th
e
ra
p
y
fo
r
a
tr
ia
lfi

b
ri
lla
tio
n
A
vo

id
a
s
fi
rs
t-
lin
e
th
e
ra
p
y
fo
r
h
e
a
rt

fa
ilu
re

If
u
se

d
fo
r
a
tr
ia
lfi

b
ri
lla
tio

n
o
r
h
e
a
rt

fa
ilu
re
,

a
vo

id
d
o
sa

g
e
s
>
0
.1
2
5
m
g
/d
a
y

A
tr
ia
lfi

b
ri
lla
tio
n
:
lo
w

H
e
a
rt
fa
ilu
re

:

lo
w

D
o
sa

g
e

>
0
.1
2
5
m
g
/d
a
y:

m
o
d
e
ra
te

A
tr
ia
lfi
b
ril
la
tio
n
:

st
ro
n
g
H
e
a
rt
fa
ilu
re
:
st
ro
n
g
D
o
sa
g
e
>
0
.1
2
5
m
g
/d
a
y:
st
ro
n
g

N
ife

d
ip
i

n
e
,

im

m

e
d
ia
te

re
le
a
se

P
o
te
n
tia

lf
o
r
h
yp

o
te
n
si
o
n
;
ri
sk

o
f
p
re
ci
p
ita

tin
g
m
yo

ca
rd
ia
l

is
ch

e

m
ia

A
vo

id
H
ig
h

S
tr
o
n
g

A
m
io
d
a
ro
n
e

E
ff
e
ct
iv
e
fo
r
m
a
i

n
ta
in

in
g
si
n
u
s
rh
yt
h
m

b
u
t
h
a
s
g
re
a
te
r

to
xi
ci
tie

s
th
a
n
o
th
e
r
a
n
tia

rr
h
yt
h
m
ic
s
u
se

d
in
a
tr
ia
l
fi
b
ri
lla
tio

n
;
m
a
y
b
e
re
a
so

n
a
b
le

fi
rs
t-
lin
e
th
e
ra
p
y
in

p
a
tie
n
ts
w
ith

co
n
co

m
ita

n
t
h
e
a
rt
fa
ilu
re

o
r
su

b
st
a
n
tia

ll
e
ft

ve

n
tr
ic
u
la
r

h
yp

e
rt
ro
p
h
y

if
rh
yt
h
m

co
n
tr
o
li
s
p
re
fe
rr
e
d
o
ve

r
ra
te

co
n
tr
o
l

A
vo

id
a
s
fi
rs
t-
lin
e
th
e
ra
p
y
fo
r
a
tr
ia
l

fi
b
ri
lla
tio

n

u

n

le
ss

p
a
tie

n
t
h
a
s
h
e
a
rt

fa
ilu
re
o
r
su
b
st
a
n
tia

ll
e
ft
ve

n
tr
ic
u
la
r
h
yp
e
rt
ro
p
h
y
H
ig
h
S
tr
o
n
g

C
e
n
tr
a
ln

e
rv
o
u
s
sy
st
e
m

A
n
tid

e
p
re
ss
a
n
ts

,
a

lo
n
e

o
r
in

co
m
b
in
a
tio

n
A
m
itr
ip
ty
lin
e

A
m
o
xa

p
in
e

C
lo
m
ip
ra
m
in
e

D
e
si
p
ra
m
in
e

D
o
xe

p
in

>
6
m
g
/d
a
y

Im
ip
ra
m
in
e

H
ig
h
ly

a
n
tic
h
o
lin
e
rg
ic
,
se

d
a
tin

g
,

a
n
d
ca

u
se
o
rt
h
o
st
a
tic
h
yp

o
te
n
si
o
n
;
sa

fe
ty

p
ro
fi
le

o
f

lo
w
-d
o
se

d
o
xe

p
in

(≤
6
m
g
/d
a
y)

co

m
p
a
ra
b
le

to
th

a
t

o
f
p
la
ce

b
o
A
vo
id
H
ig
h
S
tr
o
n
g

6 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL MONTH 2019–VOL. 00, NO. 00 JAGS

T
ab
le
2
(C
o
n
td
.)
O
rg
an
Sy
st
em
,
Th
er
ap
eu
tic
Ca
te
go
ry
,
D
ru
g(
s)
R
at
io
na
le
R
ec
om
m
en
da
tio
n
Q
ua
lit
y
of
Ev
id
en
ce
St
re
ng
th
of
R
ec
om
m
en
da
tio
n

N
o
rt
ri
p
ty
lin
e

P
a
ro
xe

tin
e

P
ro
tr
ip
ty
lin
e

T
ri
m
ip
ra
m
in
e

A
n
tip
sy
ch

o
tic
s,

fi
rs
t
(c
o
n
ve

n
tio

n
a
l

)
a
n
d

se
co

n
d
(a
ty
p
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a
l)
g
e
n
e
ra
tio

n

In
cr
e
a
se

d
ri
sk

o
f
ce

re
b
ro
va

sc
u
la
r

a
cc
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(s
tr
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)
a
n
d

g
re
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r
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o
f
co

g
n
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ve

d
e
cl
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a
n
d
m
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a
lit
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in

p
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o
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s

w
ith

d

e
m
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n
tia

A
vo

id

a
n
tip
sy
ch

o
tic
s

fo
r
b
e
h
a
vi
o
ra
lp
ro
b
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m
s

o
fd

e
m
e
n
tia
o
r

d
e
lir
iu
m

u
n
le
ss

n
o
n
p
h
a
rm

a
co

lo
g
ic
a
lo

p
tio

n
s
(e
g
,b

e
h
a
vi
o

ra
l

in
te
rv
e
n
tio

n
s)

h
a
ve

fa
ile
d
o
r

a
re

n
o
tp

o
ss
ib
le
a
n
d
th
e
o
ld
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r

a
d
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lt
is
th
re
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te

n
in

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su

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n
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lh
a
rm

to
se

lf
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r
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e
rs

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vo

id
,

e
xc
e
p
t

in

sc
h
iz
o
p
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re
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o
r

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r
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r
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sh

o
rt
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se

a
s
a
n
tie

m
e
tic

d
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n
g
ch

e
m
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th
e
ra
p
y

M
o
d
e
ra
te
S
tr
o
n
g

B
a
rb
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ra
te
s

A
m
o

b
a
rb
ita

l
B
u
ta
b
a
rb
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l
B
u
ta
lb
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l
M
e
p
h
o
b
a
rb
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l
P
e
n
to
b
a
rb
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l
P
h
e
n
o
b
a
rb
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l
S
e
co

b
a
rb
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l

H
ig
h
ra
te

o
f
p
h
ys
ic
a
ld

e
p
e
n
d
e
n
ce

,
to
le
ra
n
ce

to
sl
e
e
p

b
e
n
e
fi

ts
,

g
re
a
te
r
ri
sk

o
f
o
ve

rd
o
se

a
t
lo
w

d
o
sa
g
e
s
A
vo
id
H
ig
h
S
tr
o
n
g

B

e
n
zo

d
ia
ze

p
in
e
s

S
h
o
rt
a
n
d
in
te
rm

e
d
ia
te

a
c
tin

g
:

A
lp
ra
zo

la
m

E
st
a
zo

la
m

L
o
ra
ze

p
a
m

O
xa

ze
p
a
m

T
e
m
a
ze

p
a
m

T
ri
a
zo

la
m

L
o
n
g
a
c
tin

g
:

C
h
lo
rd
ia
ze

p
o
xi
d
e
(a
lo
n
e
o
r
in

co
m
b
in
a
tio
n
w
ith

a
m
itr
ip
ty
lin
e
o
r
cl
id
in
iu
m
)

C
lo
n
a
ze

p
a
m

C
lo
ra
ze

p
a
te

D
ia
ze

p
a
m

F
lu
ra
ze

p
a
m

Q
u
a
ze

p
a
m

O
ld
e
r
a
d
u
lts

h
a
ve
in
cr
e
a
se

d
se

n
si
tiv
ity

to

b
e
n
zo

d
ia
ze

p
in
e
s
a
n
d

d
e
cr
e
a
se

d
m
e
ta
b
o
lis
m

o
f
lo
n
g
–

a
ct
in
g
a
g
e
n
ts
;
in

g
e
n
e
ra
l,
a
ll
b
e
n
zo

d
ia
ze

p
in

e
s
in

cr
e
a
se

ri
sk
o
f
co
g
n
iti
ve

im
p
a
ir
m
e
n
t,
d
e
lir
iu

m
,

fa
lls
,
fr
a
ct
u
re
s,

a
n
d

m
o

to
r

ve

h
ic
le

cr
a
sh

e
s
in
o
ld
e
r
a
d
u
lts

M
a
y
b
e
a
p
p
ro
p
ri
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te

fo
r
se

iz
u
re

d
is
o
rd
e
rs

,
ra
p
id

e
ye

m
o
ve

m
e
n
t
sl
e
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p
b
e
h
a
vi
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r
d
is
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rd
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r,
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zo

d
ia
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p
in
e
w
ith

d
ra
w
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e
th
a
n
o
lw

ith
d
ra
w
a
l,
se

ve
re

g
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n
e
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l

iz
e

d

a
n
xi
e
ty

d
is
o
rd
e
r,
a
n
d
p
e
ri
p
ro
ce

d
u
ra
la

n
e
st
h
e
si
a

A
vo
id
M
o
d
e
ra
te
S
tr
o
n
g

M
e
p
ro
b
a
m
a
te

H
ig
h
ra
te
o
f
p
h
ys
ic
a
ld
e
p
e
n
d
e
n
ce

;
se

d
a
tin

g
A
vo

id
M
o
d
e
ra
te
S
tr
o
n
g

N
o
n
b
e
n
zo

d
ia
ze

p
in
e
,

b
e
n
zo

d
ia
ze
p
in
e
re
ce

p
to
r

a
g
o
n
is
t

h
yp

n
o
tic
s

(i
e
,
“Z
-d
ru
g
s”
)

E
sz
o
p
ic
lo
n
e

Z
a
le
p
lo
n

Z
o

lp
id
e
m

N
o
n
b
e
n
zo
d
ia
ze

p
in
e
b
e
n
zo

d
ia
ze

p
in
e
re
ce

p
to
r
a
g
o
n
is
t
h
yp

n
o
tic
s
(i
e
,
Z
d
ru
g
s)

h
a
ve
a
d
ve

rs
e
e
ve

n
ts

si
m
ila
r
to

th
o
se

o
fb

e
n
zo
d
ia
ze

p
in
e
s
in

o
ld
e
r
a
d
u
lts

(e
g
,
d
e
lir
iu
m
,

fa
lls
,
fr
a
ct
u
re
s)
;
in
cr
e
a
se

d
e
m
e
rg
e
n
cy

ro
o
m

vi
si
ts
/

h
o
sp
ita
liz
a
tio

n
s;

m
o
to
r
ve
h
ic
le
cr
a
sh

e
s;

m
in
im

a
l

im

p
ro
ve

m
e
n
t
in

sl
e
e
p
la
te
n
cy

a
n
d
d
u
ra
tio

n
A
vo
id
M
o
d
e
ra
te
S
tr
o
n
g

E
rg
o
lo
id

m
e
sy
la
te
s

(d
e
h
yd

ro
g
e
n
a
te
d
e
rg
o
t
a
lk
a
lo
id
s)

Is
o
xs
u

p
ri
n
e

L
a
ck

o
f

e
ffi
ca

cy
A
vo

id
H
ig
h
S
tr
o
n
g
(C
o
n
ti
n
u
ed
)

JAGS MONTH 2019–VOL. 00, NO. 00 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL 7

T
ab
le
2
(C
o
n
td
.)
O
rg
an
Sy
st
em
,
Th
er
ap
eu
tic
Ca
te
go
ry
,
D
ru
g(
s)
R
at
io
na
le
R
ec
om
m
en
da
tio
n
Q
ua
lit
y
of
Ev
id
en
ce
St
re
ng
th
of
R
ec
om
m
en
da
tio
n

E
n
d
o
cr
in
e

A
n
d
ro
g

e
n
s

M
e
th
yl
te
st
o
st
e
ro
n
e

T
e
st
o
st
e
ro
n
e

P
o
te
n
tia

lf
o
r
ca

rd
ia
c
p
ro
b
le
m
s;

co
n
tr
a
in
d
ic
a
te
d
in

m
e
n
w
ith

p
ro
st
a
te

ca
n
ce

r
A
vo

id
u
n
le
ss

in
d
ic
a
te
d
f

o
r
co

n
fi
rm

e
d
h
yp

o
g
o
n
a
d
is
m

w
ith

cl
in
ic
a
ls

ym
p
to
m
s
M
o
d
e
ra
te

W
e
a
k

D
e
si
cc
a
te
d
th
yr
o
id

C
o
n
ce

rn
s
a
b
o
u
t
ca

rd
ia
c
e
ff
e
ct
s;

sa
fe
r

a
lte

rn
a
tiv
e
s
a
va
ila
b
le
A
vo
id
L
o
w
S
tr
o
n
g

E
st
ro
g
e
n
s
w
ith

o
r
w
ith

o
u
t
p
ro
g
e
st
in
s

E
vi
d
e
n
ce

o
f
ca

rc
in
o
g
e
n
ic

p
o
te
n
tia

l(
b

re
a
st

a
n
d

e
n
d
o
m
e
tr
iu
m
);
la
ck

o
f
ca

rd
io
p
ro
te
ct
iv
e
e
ff
e
ct

a
n
d

co
g
n
iti
ve

p

ro
te
ct
io
n

in

o
ld
e
r

w
o
m
e
n

E
vi
d
e
n
ce

in
d
ic
a
te
s
th
a
tv

a

g
in
a
le

st
ro
g
e
n
s
fo
r
th
e
tr
e
a
tm

e
n
t

o
fv

a
g
in
a
ld

ry
n
e
ss

a
re
sa
fe

a
n
d
e
ff
e
ct
iv
e
;w

o
m
e
n
w
ith

a
h
i

s
to

ry

o
fb
re
a
st
ca
n
ce

r
w
h
o
d
o
n
o
tr
e
sp

o
n
d
to

n
o
n

h
o
rm

o
n
a
lt
h
e
ra
p
ie
s
a
re

a
d
vi
se

d
to

d
is
cu

ss
th
e
ri
sk
s
a
n
d

b
e
n
e
fi
ts
o

fl
o
w

-d
o
se

va
g
in
a
le

st
ro
g
e
n
(d
o
sa

g
e
s
o
fe

st
ra
d
io
l

< 2 5 μg

tw
ic
e
w
e
e
kl
y)

w
ith

th
e
ir
h
e
a
lth

ca
re

p
ro
vi
d
e
r

A
vo

id
sy
st
e
m
ic

e
st
ro
g
e
n
(e
g
,

o
ra
la

n
d

to
p
ic
a
lp

a
tc
h
)

V
a
g
in
a
lc

re
a
m

o
r
va

g
in
a
lt
a
b
le
ts
:

a
cc
e
p
ta
b
le

to
u
se

lo
w
-d
o
se

in
tr
a
va

g
in
a
l

e
st
ro
g
e
n
fo
r
m
a
n
a
g
e
m
e
n
t

o
f
d
ys
p
a
re
u
n
ia
,
re
cu

rr
e
n
t
lo
w
e
r

u
ri
n
a
ry

tr
a
ct

in
fe
ct
io
n
s,

a
n
d
o
th
e
r

va
g
in
a
ls

ym
p
to
m
s

O
ra
la

n
d
p
a
tc
h
:

h
ig
h
V
a
g
in
a
lc
re
a
m
o
r
va
g
in
a
l

ta
b
le
ts
:

m
o
d
e
ra
te
O
ra
la
n
d
p
a
tc
h
:
st
ro
n
g

T
o
p
ic
a
lv

a
g
in
a
l

cr
e
a
m

o
r
ta
b
le
ts
:

w
e
a
k

G
ro
w
th

h
o
rm
o
n
e

Im
p
a
ct

o
n
b
o
d
y
co

m
p
o
si
tio

n
is

sm
a
ll
a
n
d
a
ss
o
ci
a
te
d
w
ith

e
d
e
m
a
,
a
rt
h
ra
lg
ia
,
ca

rp
a
lt
u
n
n
e
ls

y

n
d
ro
m
e

,

g
yn

e
co

m
a
st
ia
,
im

p
a
ir
e
d
fa
st
in
g
g
lu
co

se
A
vo

id
,
e
xc
e
p
t
fo
r
p
a
tie
n
ts

rig
o
ro
u
sl
y

d
ia
g
n
o
se

d
b
y
e
vi
d
e
n
ce

-b
a
se

d

cr
ite

ria

w
ith

g
ro
w
th

h
o
rm

o
n
e
d
e
fi
ci
e
n
cy

d
u
e
to

a
n
e
st
a
b
lis
h
e
d
e
tio
lo
g
y

H
ig
h
S
tr
o
n
g

In
su

lin
,
sl
id
in
g
sc
a
le

(i
n
su

lin
re
g
im

e
n
s

co
n
ta
in
in
g

o
n
ly

sh
o
rt
–
o
r
ra
p
id
–

a
ct
in
g

in
su

lin
d
o
se

d
a
cc
o
rd
in
g
to

cu
rr
e
n
t
b
lo
o
d
g
lu
co

se
le
ve

ls
w
ith

o
u
t
co

n
cu

rr
e
n
t
u
se

o
f

b
a
sa

lo
r

lo
n
g
-a
ct
in
g
in
su

l

in
)

H
ig
h
e
r
ri
sk

o
f
h
yp

o
g
ly
ce

m
ia
w
ith

o
u
t
im

p
ro
ve
m
e
n
t
in
h
yp

e
rg
ly
ce

m
ia

m
a
n
a
g
e
m
e
n
t
re
g
a
rd
le
ss

o
f
ca

re
se

tt
in
g
.

A
vo

id
in
su

lin
re
g
im

e
n
s
th
a
t
in
cl
u
d
e
o
n
ly

sh
o
rt
–
o
r
ra
p
id
–

a
ct
in
g
in
su
lin
d
o
se
d
a
cc
o
rd
in
g
to
cu
rr
e
n
t
b
lo
o
d
g
lu
co
se
le
ve
ls
w
ith
o
u
t
co
n
cu
rr
e
n
t
u
se
o
f
b
a
sa

lo
r
lo
n
g
-a
ct
in
g

in
su

lin
.

T
h
is

re
co

m
m
e
n
d
a
tio

n
d
o
e
s
n
o
t
a
p
p
ly

to
re
g
im

e
n
s

th
a
t
co

n
ta
in
b
a
sa

li
n
su

lin
o
r
lo
n
g
-a
ct
in
g
in
su

lin
.
A
vo
id
M
o
d
e
ra
te
S
tr
o
n
g

M
e
g
e
st
ro
l

M
in
im

a
le
ff
e
ct

o
n
w
e
ig
h
t;
in
cr
e
a
se

s
ri
sk

o
f
th
ro
m
b
o
tic

e
ve
n
ts

a
n
d
p
o
ss
ib
ly

d
e
a
th

in
o
ld
e
r
a
d
u
lts

A
vo
id
M
o
d
e
ra
te
S
tr
o
n
g

S
u
lfo

n
yl
u
re
a
s,

lo
n
g
a
ct
in
g

C
h
lo
rp
ro
p
a
m
id
e

G
lim

e
p
ir
id
e

G
ly
b
u
ri
d
e
(a
ls
o
kn

o
w
n
a
s
g
lib
e
n
cl
a
m
id
e
)

C
h
lo
rp
ro
p
a
m
id
e
:
p
ro
lo
n
g
e
d
h
a
lf-
lif
e
in

o
ld
e
r
a
d
u
lts
;
ca

n
ca
u
se

p
ro
lo
n
g
e
d
h
yp

o
g
ly
ce

m
ia
;
ca

u
se

s
S
IA
D
H

G
lim

e
p
ir
id
e
a
n
d
g
ly
b
u
ri
d
e
:

h
ig
h
e
r
ri
sk

o
f
se

ve
re
p
ro
lo
n
g
e
d
h
yp
o
g
ly
ce
m
ia
in
o
ld
e
r
a
d
u
lts
A
vo
id
H
ig
h
S
tr
o
n
g

G
a
st
ro
in
te
st
in
a
l

M
e
to
cl
o
p
ra
m
id
e

C
a
n
ca

u
se

e
xt
ra
p
yr
a
m
id
a
le

ff
e
ct
s,

in
cl
u
d
in
g
ta
rd
iv
e

d
ys
ki
n
e
si
a
;
ri
sk

m
a
y
b
e
g
re
a
te
r
in

fr
a
il
o
ld
e
r
a
d
u
lts

a
n
d
w
ith

p
ro
lo
n
g
e
d
e
xp

o
su

re
A
vo

id
,u

n
le
ss

fo
r
g
a
st
ro
p
a
re
si
s
w
ith

d
u
ra
tio
n
o
fu

se
n
o
tt
o
e
xc
e
e
d
1
2
w
e
e
ks

e
xc
e
p
ti
n
ra
re

ca
se

s
M
o
d
e
ra
te
S
tr
o
n
g

M
in
e
ra
lo

il,
g
iv
e
n
o
ra
lly

P
o
te
n
tia

lf
o
r
a
sp

ir
a
tio

n
a
n
d
a
d
ve

rs
e
e
ff
e
ct
s;

sa
fe
r
a
lte
rn
a
tiv
e
s
a
va
ila
b
le
A
vo
id
M
o
d
e
ra
te
S
tr
o
n
g

P
ro
to
n
-p
u
m
p

in
h
ib
ito

rs
R
is
k
o
f
C
lo
st
ri
d
iu
m

d
iffi
c
ile

in
fe
ct
io
n
a
n
d
b
o
n
e
lo
ss

a
n
d

fr
a
ct
u
re
s

A
vo

id
sc
h
e
d
u
le
d
u
se

fo
r
>
8
w
e
e
ks

u
n
le
ss

fo
r
h
ig
h
-r
is
k
p
a
tie
n
ts
(e
g
,o

ra
l

co
rt
ic
o
st
e
ro
id
s
o
r
ch

ro
n
ic
N
S
A
ID

u
se

),
e
ro
si
ve

e
so

p
h
a
g
iti
s,

B
a
rr
e
tt
e
so

p
h
a
g
iti
s,

p
a
th
o
lo
g
ic
a
lh
yp

e
rs
e
cr
e
to
ry
co

n
d
iti
o
n
,o

r
d
e
m
o
n
st
ra
te
d
n
e
e
d
fo
r
m
a
in
te
n
a
n
ce

tr
e
a
tm

e
n
t(
e
g
,b

e
ca
u
se

o
ff
a
ilu
re

o
fd
ru
g

d
is
co

n
tin

u
a
tio
n
tr
ia
lo
r

H
2
-r
e
ce

p
to
r

a
n
ta
g
o
n
is
ts
)

H
ig
h
S
tr
o
n
g

8 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL MONTH 2019–VOL. 00, NO. 00 JAGS

T
ab
le
2
(C
o
n
td
.)
O
rg
an
Sy
st
em
,
Th
er
ap
eu
tic
Ca
te
go
ry
,
D
ru
g(
s)
R
at
io
na
le
R
ec
om
m
en
da
tio
n
Q
ua
lit
y
of
Ev
id
en
ce
St
re
ng
th
of
R
ec
om
m
en
da
tio
n

P
a
in

m
e
d
ic
a
tio

n
s

M
e
p
e
ri
d
in
e

O
ra
la

n
a
lg
e
si
c
n
o
t
e
ff
e
ct
iv
e
in

d
o
sa

g
e
s
co

m
m
o
n
ly

u
se

d
;

m
a
y
h
a
ve

h
ig
h
e
r
ri
sk

o
f
n
e
u
ro
to
xi
ci
ty
,
in
cl
u
d
in
g
d
e
lir
iu
m
,

th
a
n
o
th
e
r

o
p
io
id

s;

sa
fe
r
a
lte

rn
a
tiv
e
s
a
va
ila
b
le
A
vo
id
M
o
d
e
ra
te
S
tr
o
n
g

N
o
n
–
cy
cl
o
o
xy
g
e
n
a
se
-s
e

le
ct
iv
e

N
S
A
ID
s,
o
ra
l:

A
sp

ir
in

>
3
2
5
m
g
/d
a
y

D
ic
lo
fe
n
a
c

D
ifl
u
n
is
a
l

E
to
d
o
la
c

F
e
n
o
p
ro
fe
n

Ib
u
p
ro
fe
n

K
e
to
p
ro
fe
n

M
e
cl
o
fe
n
a
m
a
te

M
e
fe
n
a
m
ic

a
ci
d

M
e
lo
xi
ca

m
N
a
b
u
m
e
to
n
e

N
a
p
ro
xe

n
O
xa

p
ro
zi
n

P
ir
o
xi
ca

m
S
u
lin
d
a
c

T
o
lm

e
tin

In
cr
e
a
se
d
ri
sk

o
f
g
a
st
ro
in
te
st
in
a
lb

le
e
d
in
g
o
r
p
e
p
tic

u
lc
e
r

d
is
e
a
se

in
h
ig
h
-r
is
k
g
ro
u
p
s,

in
cl
u
d
in
g
th
o
se

>
7
5
ye

a
rs

o
r

ta
ki
n
g

o
ra
lo

r
p
a
re
n
te
ra
lc

o
rt
ic
o
st
e
ro
id
s,

a
n
tic
o
a
g
u
la
n
ts
,

o
r
a
n
tip

la
te
le
t
a
g
e
n
ts
;
u
se

o
f
p
ro
to
n
-p
u
m
p
in
h
ib
ito

r
o
r

m
is
o
p
ro
st
o
l
re
d
u
ce

s
b
u
t
d
o
e
s
n
o
t
e
lim

in
a
te

ri
sk
.
U
p
p
e
r

g
a
st
ro
in
te
st
in
a
lu

lc
e
rs

,
g
ro
ss

b
le
e
d
in
g

,
o
r
p
e
rf
o
ra
tio

n
ca
u
se

d
b
y

N
S
A
ID
s

o
cc
u
r
in

~
1
%

o
f
p
a
tie

n
ts

tr
e
a
te
d
fo
r

3
-6

m
o
n
th
s
a
n
d
in

~
2
%
-4
%

o
f
p
a
tie
n
ts

tr
e
a
te
d
fo
r
1
ye

a
r;

th
e
se

tr
e
n
d
s
co

n
tin

u
e
w
ith

lo
n
g
e
r
d
u
ra
tio

n
o
f
u
se

.
A
ls
o

ca
n
in
cr
e
a
se

b
lo
o
d
p
re
ss
u
re

a
n
d
in
d
u
ce

ki
d
n
e
y

in
ju
ry

.

R
is
ks

a
re
d
o
se

re
la
te
d
.

A
vo

id
ch

ro
n
ic
u
se

,
u
n
le
ss

o
th
e
r
a
lte

rn
a
tiv
e
s
a
re

n
o
t
e
ff
e
ct
iv
e
a
n
d

p
a
tie

n
t
ca

n
ta
ke

g
a
st
ro
p
ro
te
ct
iv
e

a
g
e
n
t
(p
ro
to
n
-p
u
m
p
in
h
ib
ito

r
o
r

m
is
o
p
ro
st
o
l)

M
o
d
e
ra
te
S
tr
o
n
g

In
d
o
m
e
th
a
ci
n

K
e
to
ro
la
c,

in
cl
u
d
e
s
p
a
re
n
te
ra
l

In
c
re
a
se

d
ri
s
k
o
f
g
a
st
ro
in
te
s
ti
n
a
l
b
le
e
d
in
g
/p
e
p
ti
c
u
lc
e
r

d
is
e
a
s
e

a
n
d

a
c
u
te

k
id
n
e
y
in
ju
ry

in
o
ld
e
r
a
d
u
lt
s

In
d
o
m
e
th
a
ci
n
is

m
o
re

lik
e
ly

th
a
n
o
th
e
r
N
S
A
ID

s
to
h
a
ve
a
d
ve

rs
e
C
N
S
e
ff
e
ct
s

.
O
f
a
ll
th
e
N
S
A
ID

s
,
in
d
o
m
e
th
a
ci
n

h
a
s
th
e
m
o
st

a
d
ve

rs
e
e
ff
e
ct
s.

A
vo
id
M
o
d
e
ra
te
S
tr
o
n
g

S
ke

le
ta
lm

u
sc
le

re
la
xa

n
ts

C
a
ri
so

p
ro
d
o
l

C
h
lo
rz
o
xa

zo
n
e

C
yc

lo
b
e
n
za

p
ri
n
e

M
e
ta
xa

lo
n
e

M
e
th
o
ca

rb
a
m
o
l

O
rp
h
e
n
a
d
ri
n
e

M
o
st

m
u
sc
le

re
la
xa
n
ts

p
o
o
rl
y
to
le
ra
te
d
b
y
o
ld
e
r
a
d
u
lts

b
e
ca
u
se

so
m
e
h
a
ve

a
n
tic
h
o
lin
e
rg
ic
a
d
ve

rs
e
e
ff
e
ct
s,

se
d
a
tio

n
,
in
cr
e
a
se

d
ri
sk

o
f
fr
a
ct
u
re

s;

e
ff
e
ct
iv
e
n
e
ss
a
t
d
o
sa

g
e
s
to
le
ra
te
d
b
y
o
ld
e
r
a
d
u
lts

q
u
e
st
io
n
a
b
le

A
vo
id
M
o
d
e
ra
te
S
tr
o
n
g

G
e
n
ito

u
ri
n
a
ry

D
e
sm

o
p
re
ss
in

H
ig
h
ri
sk
o
f
h
yp

o
n
a
tr
e
m
ia
;
sa

fe
r
a
lte

rn
a
tiv
e
tr
e
a
tm

e
n
ts
A
vo

id
fo
r
tr
e
a
tm

e
n
t
o
f
n
o
ct
u
ri
a
o
r

n
o
ct
u
rn
a
lp

o
ly
u
ri
a

M
o
d
e
ra
te
S
tr
o
n
g

A
b
b
re
vi
at
io

n
s:

C
N
S,

ce
n
tr
al

n
er
vo

u
s
sy
st
em

;
H
F
rE
F
,
h
ea
rt

fa
il
u
re

w
it
h
re
d
u
ce
d
ej
ec
ti
o
n
fr
ac
ti
o
n
;

N
SA

ID
,
n
o
n
st
er
o
id
al

an
ti
-i
n
fl
am

m
at
o
ry

d
ru
g;

SI
A
D
H
,
sy
n
d
ro
m
e
o
f
in
ap

p
ro
p
ri
at
e
an

ti
d
iu
re
ti
c
h
o
rm

o
n
e
se
cr
et
io
n
.

a
T
h
e
p
ri
m
ar
y
ta
rg
et

au
d
ie
n
ce

is
th
e
p
ra
ct
ic
in
g
cl
in
ic
ia
n
.
T
h
e
in
te
n
ti
o
n
s
o
f
th
e
cr
it
er
ia

in
cl
u
d
e
(1
)
im

p
ro
vi
n
g
th
e
se
le
ct
io
n
o
f
p
re
sc
ri
p
ti
o
n
d
ru
gs

b
y
cl
in
ic
ia
n

s
an

d
p
at
ie
n
ts

;
(2
)
ev
al
u
at
in
g
p
at
te
rn
s
o
f
d
ru
g
u
se

w
it
h
in

p
o
p
u
la
ti
o
n
s;
(3
)
ed
u
ca
ti
n
g
cl
in
ic
ia
n
s
an

d
p
at
ie
n
ts

o
n
p
ro
p
er

d
ru
g
u
sa
ge
;
an

d
(4
)
ev
al
u
at
in
g
h
ea
lt
h
-o
u
tc
o
m
e,

q
u
al
it
y-
o
f-
ca
re
,
co
st
,
an

d
u
ti
li
za
ti
o
n
d
at
a.

b
Se
e
al
so

cr
it
er
io
n
o
n
h
ig
h
ly

an
ti
ch
o
li
n
er
gi
c
an

ti
d
ep

re
ss
an

ts
.

JAGS MONTH 2019–VOL. 00, NO. 00 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL 9

T
ab

le
3
.
2
0
1
9
A
m
er
ic
an

G
er
ia
tr
ic
s
So
ci
et
y
B
ee
rs
C
ri
te
ri
a®

fo
r
P
o
te
n
ti
al
ly

In
ap
p
ro
p
ri
at
e
M

ed
ic
at
io
n
U
se

in
O
ld
er

A
d
u
lt
s

D
u
e
to

D
ru
g-

D
is
ea
se

o
r
D
ru
g-
Sy

n
d
ro
m
e

In
te
ra
ct
io
n
s
T
h
at

M
ay

E
x
ac
er
b
at
e
th
e
D
is
ea
se

o
r
Sy

n
d
ro
m
ea

D
is
ea
se

or
Sy
nd
ro
m
e

D
ru
g(
s)
R
at
io
na
le
R
ec
om
m
en
da
tio
n
Q
ua
lit
y
of
Ev
id
en
ce
St
re
ng
th
of
R
ec
om
m
en
da
tio
n
C
a
rd
io
va
sc
u
la
r
H
e
a
rt
fa
ilu
re
A
vo

id
:

C
ilo
st
a
zo

l
A
vo
id
in
h
e
a
rt
fa
ilu
re
w
ith
re
d
u
ce

d
e
je
ct
io
n
fr
a
ct
io
n
:

N

o
n
d
ih
yd

ro
p
yr
id
in
e

C
C
B
s
(d
ilt
ia
ze

m
,

ve
ra
p
a
m
il)

U
se
w
ith

ca
u
tio

n
in
p
a
tie
n
ts
w
ith
h
e
a
rt
fa
ilu
re

w
h
o
a
re

a

sy
m
p
to
m
a
tic

;
a
vo

id
in
p
a
tie
n
ts
w
ith
sy
m
p
to
m
a
tic
h
e
a
rt
fa
ilu
re
:

N
S
A
ID
s

a
n
d

C
O
X
-2

in
h
ib
ito
rs

T
h
ia
zo

lid
in
e
d
io
n
e
s
(p
io
g
lit
a
zo

n
e
,

ro
si
g
lit
a
zo

n
e
)

D
ro
n
e
d
a
ro
n
e

P
o
te
n
tia

l
to

p
ro
m
o
te

fl
u
id

re
te
n
tio

n
a
n
d
/o
r
e
xa

ce
rb
a
te

h
e
a
rt
fa
ilu
re

(N
S
A
ID
s

a
n
d
C
O
X
-2

in
h
ib
ito
rs
,n

o
n
d
ih
yd
ro
p
yr
id
in
e

C
C
B
s,
th
ia
zo

lid
in
e
d
io
n
e
s)
;p

o
te
n
tia
lt
o

in
cr
e
a
se

m
o
rt
a
lit
y
in
o
ld
e
r
a
d
u
lts

w
ith
h
e
a
rt
fa
ilu
re

(c
ilo
st
a
zo

la
n
d

d
ro
n
e
d
a
ro
n
e
)

A
s
n
o
te
d
,
a
vo

id
o
r
u
se

w
ith
ca
u
tio

n
C
ilo
st
a
zo

l:
lo
w

N
o
n
d
ih
yd

ro
p
yr
id
in
e

C
C
B
s:

m
o
d
e
ra
te

N
S
A
ID
s:

m
o
d
e
ra
te
C
O
X
-2
in
h
ib
ito

rs
:
lo
w

T
h
ia
zo

lid
in
e
d
io
n
e
s:

h
ig
h

D
ro
n
e
d
a
ro
n
e
:
h
ig
h

C
ilo
st
a
zo

l:
st
ro
n
g

N
o
n
d
ih
yd
ro
p
yr
id
in
e
C
C
B
s:
st
ro
n
g
N
S
A
ID
s:
st
ro
n
g
C
O
X
-2

in
hi
bi
to
rs
:s
tro

ng
T
h
ia
zo
lid
in
e
d
io
n
e
s:
st
ro
n
g

D
ro
n
e
d
a
ro
n
e
:
st
ro
n
g

S
yn

co
p
e

A
C
h
E
Is

N
o

n
se

le
ct
iv
e

p
e
ri
p
h
e
ra
la

lp
h
a
-1
b
lo
ck
e
rs

(i
e
,
d
o
xa

zo
si
n

,
p
ra
zo

si
n
,
te
ra
zo

si
n
)

T
e
rt
ia
ry

T
C
A
s

A
n
tip
sy
ch

o
tic
s:

C
h
lo
rp
ro
m
a
zi
n
e

T
h
io
ri
d
a
zi
n
e

O
la
n
za

p
in
e
A
C
h
E
Is

ca
u
se

b
ra
d
yc
a
rd
ia

a
n
d
sh

o
u
ld
b
e
a
vo

id
e
d
in

o
ld
e
r
a
d
u
lts

w
h
o
se

sy
n
co

p
e

m
a
y
b
e
d
u
e
to

b
ra
d
yc
a
rd
ia
.
N
o
n
se

le
ct
iv
e

p
e
rip

h
e
ra
la
lp
h
a
-1
b
lo
ck
e
rs
ca
u
se
o
rt
h
o
st
a
tic
b
lo
o
d
p
re
ss
u
re

ch
a
n
g
e
s
a
n
d

sh
o
u
ld

b
e
a
vo

id
e
d
in
o
ld
e
r
a
d
u
lts
w
h
o
se
sy
n
co

p
e
m
a
y
b
e
d
u
e
to

o
rt
h
o
st
a
tic
h
yp

o
te
n
si
o
n
.
T
e
rt
ia
ry

T
C
A
s
a
n
d
th
e

a
n
tip
sy
ch

o
tic
s
lis
te
d
in
cr
e
a
se

th
e
ris
k
o
f

o
rt
h
o
st
a
tic
h
yp

o
te
n
si
o
n
o
r
b
ra
d
yc
a
rd
ia
.

A
vo

id
A
C
h
E
Is
,
T
C
A
s,

a
n
d
a
n
tip
sy
ch
o
tic
s:
h
ig
h
N
o
n
se

le
ct
iv
e
p
e
ri
p
h
e
ra
l

a
lp
h
a
-1

b
lo
ck
e
rs
:
h
ig
h

A
C
h
E
Is

a
n
d
T
C
A
s:

st
ro
n
g
N
o
n
se
le
ct
iv
e
p
e
ri
p
h
e
ra
la
lp
h
a
-1
b
lo
ck
e
rs
a
n
d
a
n
tip
sy
ch
o
tic
s:
w
e
a
k
C
e
n
tr
a
ln
e
rv
o
u
s
sy
st
e
m

D
e
lir
iu
m

A
n
tic
h
o
lin
e
rg
ic

s

(s
e
e
T
a
b
le

7
a
n
d
fu
ll

cr
ite

ri
a
a
va

ila
b
le

o
n
w
w
w
.

g
e
ri
a
tr
ic
sc
a
re
o
n
lin
e
.o
rg
.)

A
n
tip
sy
ch

o
tic
sb

B
e
n
zo

d
ia
ze
p
in
e
s

C
o
rt
ic
o
st
e
ro
id
s
(o
ra
la

n
d
p
a
re
n
te
ra
l)
c

H
2
-r
e
ce

p
to
r
a
n
ta
g
o
n
is
ts

C
im

e
tid

in
e

F
a
m
o
tid

in
e

N
iz
a
tid

in
e

R
a
n
iti
d
in
e

M
e
p
e
ri
d
in
e
N
o
n
b
e
n
zo
d
ia
ze

p
in
e
,
b
e
n
zo

d
ia
ze
p
in
e
re
ce

p
to
r

a
g
o
n
is
t
h
yp

n
o
tic
s:

e
sz
o
p
ic
lo
n
e
,
za

le
p
lo
n
,
zo

lp
id
e
m
A
vo
id
in
o
ld
e
r
a
d
u
lts
w
ith

o
r
a
t
h
ig
h
ri
sk

o
f
d
e
lir
iu
m

b
e
ca
u
se

o
f
p
o
te
n
tia

lo
f

in
d
u
ci
n
g
o
r
w
o
rs
e
n
in
g
d
e
lir
iu
m

A
vo

id
a
n
tip

sy
ch

o
tic
s
fo
r
b
e
h
a
vi
o
ra
l

p
ro
b
le
m
s
o
f

d
e
m
e
n
tia

a
n
d
/o
r
d
e
lir
iu
m

u
n
le
ss
n
o
n
p
h
a
rm
a
co
lo
g
ic
a
lo
p
tio

n
s
(e
g
,

b
e
h
a
vi
o
ra
li
n
te
rv
e
n
tio

n
s)
h
a
ve
fa
ile
d
o
r
a
re

n
o
t
p
o
ss
ib
le

a
n
d
th
e
o
ld
e
r
a
d
u
lt
is

th
re
a
te
n
in
g
su

b
st
a
n
tia
lh
a
rm
to
se
lf
o
r

o
th
e

rs
.

A
n
tip

sy
ch

o
tic
s
a
re

a
ss
o
ci
a
te
d
w
ith
g
re
a
te
r
ri
sk
o
f
ce
re
b
ro
va
sc
u
la
r
a
cc
id
e
n
t
(s
tr
o
ke

)
a
n
d
m
o
rt
a
lit
y
in

p
e
rs
o
n
s
w
ith

d
e
m
e
n
tia
.
A
vo

id
H
2
-r
e
ce

p
to
r
a
n
ta
g
o
n
is
ts
:

lo
w

A
ll
o
th
e
rs
:
m
o
d
e
ra
te

S
tr
o
n
g

D
e
m
e
n
tia

o
r
co
g
n
iti
ve

im
p
a
ir
m
e
n
t

A
n
tic
h
o
lin
e
rg
ic
s
(s
e
e
T
a
b
le
7
a
n
d
fu
ll
cr
ite
ri
a
a
va
ila
b
le
o
n
w
w
w
.

g
e
ri
a
tr
ic
sc
a
re
o
n
lin
e
.o
rg
)

B
e
n
zo
d
ia
ze
p
in
e
s
N
o
n
b
e
n
zo
d
ia
ze
p
in
e
,
b
e
n
zo
d
ia
ze
p
in
e
re
ce
p
to
r
a
g
o
n
is
t
h
yp
n
o
tic
s
E
sz
o
p
ic
lo
n
e
A
vo

id
b
e
ca

u
se

o
f
a
d
ve

rs
e
C
N
S
e
ff
e
ct
s
A
vo
id
a
n
tip
sy
ch
o
tic
s
fo
r
b
e
h
a
vi
o
ra
l

p
ro
b
le
m
s
o
f
d
e
m
e
n
tia

a
n
d
/o
r
d
e
lir
iu
m
u
n
le
ss
n
o
n
p
h
a
rm
a
co
lo
g
ic
a
lo
p
tio
n
s
(e
g
,
b
e
h
a
vi
o
ra
li
n
te
rv
e
n
tio
n
s)
h
a
ve
fa
ile
d
o
r
a
re
n
o
t
p
o
ss
ib
le
a
n
d
th
e
o
ld
e
r
a
d
u
lt
is
th
re
a
te
n
in
g
su
b
st
a
n
tia
lh
a
rm
to
se
lf
o
r
A
vo
id
M
o
d
e
ra
te
S
tr
o
n
g

10 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL MONTH 2019–VOL. 00, NO. 00 JAGS

http://www.geriatricscareonline.org

http://www.geriatricscareonline.org

http://www.geriatricscareonline.org

http://www.geriatricscareonline.org

T
ab

le

3
(C

o
n
td
.)
D
is
ea
se
or
Sy
nd
ro
m
e
D
ru
g(
s)
R
at
io
na
le
R
ec
om
m
en
da
tio
n
Q
ua
lit
y
of
Ev
id
en
ce
St
re
ng
th
of
R
ec
om
m
en
da
tio
n
Z
a
le
p
lo
n

Z
o
lp
id
e
m

A
n
tip
sy
ch
o
tic
s,

ch
ro
n
ic

a
n
d
a
s-
n
e
e
d
e
d

u
se
b
o
th
e
rs
.
A
n
tip
sy
ch
o
tic
s
a
re
a
ss
o
ci
a
te
d
w
ith
g
re
a
te
r
ri
sk
o
f
ce
re
b
ro
va
sc
u
la
r
a
cc
id
e
n
t
(s
tr
o
ke
)
a
n
d
m
o
rt
a
lit
y
in
p
e
rs
o
n
s
w
ith
d
e
m
e
n
tia

.

H
is
to
ry

o
f
fa
lls

o
r
fr
a
ct
u
re
s

A
n
tie

p
ile
p
tic
s

A
n
tip
sy
ch
o
tic
sb
B
e
n
zo
d
ia
ze
p
in
e
s
N
o
n
b
e
n
zo
d
ia
ze
p
in
e
,
b
e
n
zo
d
ia
ze
p
in
e
re
ce
p
to
r
a
g
o
n
is
t
h
yp
n
o
tic
s
E
sz
o
p
ic
lo
n
e
Z
a
le
p
lo
n
Z
o
lp
id
e
m
A
n
tid
e
p
re
ss
a
n
ts
T
C
A
s

S
S
R
Is

S
N
R
Is

O
p
io
id
s

M
a
y
ca
u
se

a
ta
xi
a
,i
m
p
a
ire

d
p
sy
ch

o
m
o
to
r

fu
n
ct
io
n
,s
yn

co
p
e
,a

d
d
iti
o
n
a
lf
a
lls
;s
h
o
rt
e
r-

a
ct
in
g
b
e
n
zo

d
ia
ze

p
in
e
s
a
re

n
o
ts
a
fe
r
th
a
n

lo
n
g
-a
ct
in
g
o
n
e
s.

If
on

e
of
th
e
dr
ug

s
m
us
tb
e
us
ed

,c
on

si
de

r
re
du

ci
ng

us
e
of

ot
he

r
C
N
S
-a
ct
iv
e

m
ed

ic
at
io
ns

th
at
in
cr
ea

se
ris
k
of
fa
lls

an
d

fra
ct
ur
es

(ie
,a
nt
ie
pi
le
pt
ic
s,
op

io
id
-r
ec
ep

to
r

ag
on

is
ts
,a
nt
ip
sy
ch
ot
ic
s,
an

tid
ep

re
ss
an
ts
,

no
nb

en

zo
di
az
ep

in
e
an

d
be

nz
od

ia
ze
pi
ne

re
ce
pt
or

ag
on

is
th
yp
no

tic
s,
ot
he

r
se
da

tiv
es
/h
yp
no

tic
s)
an

d
im
pl
em

en
to
th
er

st
ra
te
gi
es

to
re
du

ce
fa
ll
ris
k.
D
at
a
fo
r

an
tid
ep

re
ss
an

ts
ar
e
m
ix
ed

bu
tn
o
co
m
pe

lli
ng

ev
id
en

ce
th
at
ce
rta

in
an

tid
ep
re
ss
an

ts
co
nf
er

le
ss

fa
ll
ris
k
th
an

ot
he
rs
.
A
vo
id
u
n
le
ss
sa
fe
r
a
lte
rn
a
tiv
e
s
a
re
n
o
t
a
va

ila
b
le
;
a
vo

id
a
n
tie

p
ile
p
tic
s
e
xc
e
p
t
fo
r

se
iz
u
re

a
n
d
m
o
o
d

d
is
o
rd
e
rs

O
p
io
id
s:

a
vo

id
e
xc
e
p
t
fo
r

p
a
in

m
a
n
a
g
e
m
e
n
t
in

th
e

se
tt
in
g
o
f
se

ve
re
a
cu

te
p
a
in

(e
g
,
re
ce

n
t
fr
a
ct
u
re
s

o
r
jo
in
t
re
p
la
ce

m
e
n
t)

O
p
io
id
s:
m
o
d
e
ra
te

A
ll
o
th
e
rs
:
h
ig
h

S
tr
o
n
g
P
a
rk
in
so

n
d
is
e
a
se

A
n
tie

m
e
tic
s

M
e
to
cl
o
p
ra
m
id
e

P
ro
ch

lo
rp
e
ra
zi
n
e

P
ro
m
e
th
a
zi
n
e

A
ll
a
n
tip

sy
ch

o
tic
s
(e
xc
e
p
t
q
u
e
tia

p
in
e
,

cl
o
za

p
in
e
,
p
im

a
va
n
se

ri
n
)

D
op
am

in
e-
re
ce
pt
or

an
ta
go
ni
st
s
w
ith

po
te
nt
ia
lt
o
w
or
se
n
pa
rk
in
so
ni
an

sy
m
pt
om

s

E
xc
e
p
tio

n
s:

P
im

a
va
n
se

ri
n
a
n
d
cl
o
za

p
in
e
a
p
p
e
a
r
to

b
e
le
ss

lik
e
ly

to
p
re
ci
p
ita

te
w
o
rs
e
n
in
g

o
f
P
a
rk
in
so

n
d
is
e
a
se

.
Q
u
e
tia

p
in
e
h
a
s

o
n
ly

b
e
e
n
st
u
d
ie
d
in

lo
w
-q
u
a
lit
y
cl
in
ic
a
l

tr
ia
ls

w
ith
e
ffi
ca

cy
co

m
p
a
ra
b
le

to
th
a
t

o
f
p
la
ce

b
o
in

fi
ve

tr
ia
ls

a
n
d
to

th
a
t
o
f

cl
o
za

p
in
e
in

tw
o
o
th
e
rs
.

A
vo
id
M
o
d
e
ra
te
S
tr
o
n
g
G
a
st
ro
in
te
st
in
a
l
H
is
to
ry

o
f
g
a
st
ri
c
o
r

d
u
o
d
e
n
a
lu

lc
e
rs
A
sp
ir
in
>
3
2
5
m
g
/d
a
y

N
o
n
–
C
O
X
-2
–
se

le
ct
iv
e
N
S
A
ID
s

M
a
y
e
xa

ce
rb
a
te

e
xi
st
in
g
u
lc
e
rs

o
r
ca
u
se

n
e
w
/a
d
d
iti
o
n
a
lu

lc
e
rs
A
vo
id
u
n
le
ss
o
th
e
r
a
lte
rn
a
tiv
e
s
a
re
n
o
t

e
ff
e
ct
iv
e
a
n
d
p
a
tie

n
t
ca
n
ta
ke
g
a
st
ro
p
ro
te
ct
iv
e

a
g
e
n
t
(i
e
,
p
ro
to
n
-p
u
m
p

in
h
ib
ito

r
o
r
m
is
o
p
ro
st
o
l)

M
o
d
e
ra
te
S
tr
o
n
g

K
id
n
e
y/
u
ri
n
a
ry

tr
a
ct

C
h
ro
n
ic

ki
d
n
e
y
d
is
e
a
se
st
a
g
e
4
o
r

h
ig
h
e
r
(c
re
a
tin

in
e
cl
e
a
ra
n
ce
< 3 0 m L /m in )

N
S
A
ID
s
(n
o
n
-C

O
X
a
n
d
C
O
X
se

le
ct
iv
e
,

o
ra
la

n
d
p
a
re
n
te
ra
l,
n
o
n
a
ce

ty
la
te
d

sa
lic
yl
a
te
s)

M
a
y
in
cr
e
a
se

ri
sk

o
f
a
cu

te
ki
d
n
e
y

in
ju
ry

a
n
d
fu
rt
h
e
r
d
e
cl
in
e
o
f
re
n
a
lf
u
n
ct
io
n

A
vo
id
M
o
d
e
ra
te
S
tr
o
n
g
(C
o
n
ti
n
u
ed
)

JAGS MONTH 2019–VOL. 00, NO. 00 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL 11

was lowered to 70 years or older from 80 years or older. This
criterion was also expanded to cover use of aspirin as primary
prevention of colorectal cancer. Note that this criterion does
not apply to use of aspirin for secondary prevention of either
disease.

• In addition to the existing caution about dabigatran, the
updated criteria highlight caution about use of rivaroxaban for
treatment of venous thromboembolism or atrial fibrillation in
adults 75 years or older.

• Tramadol was added to the list of drugs associated with
hyponatremia or syndrome of inappropriate antidiuretic hor-
mone secretion. The chemotherapeutic agents carboplatin, cyclo-
phosphamide, cisplatin, and vincristine were removed from this
list because the panel thought the prescribing of these highly spe-
cialized drugs fell outside the scope of the criteria.

• Vasodilators were removed, because syncope is not unique to
older adults.

• The combination dextromethorphan/quinidine was added to
the “use with caution” table on the basis of limited efficacy in
patients with behavioral symptoms of dementia without pseu-
dobulbar affect while potentially increasing the risk of falls and
drug-drug interactions.

• The combination trimethoprim-sulfamethoxazole (TMP-SMX)
should be used with caution by patients with reduced kidney
function and taking an angiotensin-converting enzyme inhibi-
tor (ACEI) or angiotensin receptor blocker (ARB) because of
an increased risk of hyperkalemia.

Drug-Drug Interactions

Table 5 contains potentially clinically important drug-drug
interactions to be avoided in older adults. New recommen-
dations include avoiding use of opioids concurrently with
benzodiazepines and avoiding use of opioids concurrently
with gabapentinoids (except when transitioning from the
former to the latter). Other additions to the table are inter-
actions involving TMP-SMX, macrolide antibiotics, and
ciprofloxacin. TMP-SMX in combination with phenytoin
or warfarin increases the risk of phenytoin toxicity and
bleeding, respectively. Macrolides, excluding azithromycin,
or ciprofloxacin in combination with warfarin increases
bleeding risk. Ciprofloxacin in combination with theophyl-
line increases risk of theophylline toxicity. The concurrent
use of a combination of three or more central nervous sys-
tem (CNS) agents (antidepressants, antipsychotics, benzodi-
azepines, nonbenzodiazepine benzodiazepine receptor
agonist hypnotics, antiepileptics, and opioids) and increased
fall risk have been collapsed into one recommendation
instead of separate recommendations for each drug class.
The recommendation on avoiding concurrent use of medi-
cations that increase serum potassium has been expanded
to encompass a broader range of these medications.

PIMs Based on Kidney Function

Table 6 contains a list of medications that should be
avoided or have their dosage reduced based on kidney func-
tion. Two antibiotics have been added, ciprofloxacin and
TMP-SMX, over concerns of increased CNS effects and ten-
don rupture, and worsening renal function and hyperkale-
mia, respectively. Dofetilide was also added because of
concerns of corrected QT interval prolongation and torsade
de pointes. The creatinine clearance lower limit at which to
avoid edoxaban has been reduced to less than 15 mL/min.T

ab
le

3
(C
o
n
td
.)
D
is
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or
Sy
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m
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s)
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lit
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id
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re
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st
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sy
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ly

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e
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ll
cr
ite

ri
a
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w
w
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u
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se
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id
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ra
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tr
o
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A
b
b
re
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at
io
n
s:

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h
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ac
et
yl
ch
o
li
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ra
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in
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it
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lc
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ch
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b
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ce
n
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em

;
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SA
ID
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ti
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se
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–

n
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it
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k
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it
o
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t.
a
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rg
et

au
d
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th
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ra
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ic
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)
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p
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p
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)
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at
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se

w
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ca
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at
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p
er
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g
u
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ge
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d
(4
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at
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lt
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tc
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m
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q
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al
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o
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ca
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st
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M
ay

b
e
re
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u
ir
ed

to
tr
ea
t
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n
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rr
en
t
sc
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iz
o
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re
n
ia
,
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ip
o
la
r
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is
o
rd
er
,
an

d
o
th
er

se
le
ct
ed

m
en
ta
l
h
ea
lt
h
co
n
d
it
io
n
s

b
u
t
sh
o
u
ld

b
e
p
re
sc
ri
b
ed

in
th
e
lo
w
es
t
ef
fe
ct
iv
e

d
o
se

an
d
sh
o
rt
es
t
p
o
ss
ib
le

d
u
ra
ti
o
n
.

c E
x
cl
u
d
es

in
h
al
ed

an
d
to
p
ic
al

fo
rm

s.
O
ra
l
an

d
p
ar
en
te
ra
l
co
rt
ic
o
st
er
o
id
s
m
ay

b
e
re
q
u
ir
ed

fo
r
co
n
d
it
io
n
s
su
ch

as
ex
ac
er
b
at
io
n
o
f
ch
ro
n
ic

o
b
st
ru
ct
iv
e
p
u
lm

o
n
ar
y
d
is
ea
se

b
u
t
sh
o
u
ld
b
e
p
re
sc
ri
b
ed
in
th
e
lo
w
es
t
ef
fe
ct
iv
e
d
o
se

an
d
fo
r
th
e
sh
o
rt
es
t
p
o
ss
ib
le

d
u
ra
ti
o
n
.

12 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL MONTH 2019–VOL. 00, NO. 00 JAGS

http://www.geriatricscareonline.org

DISCUSSION

The 2019 AGS Beers Criteria® update contributes to the
critically important evidence base and discussion of medica-
tions to avoid in older adults and the need to improve medi-
cation use in older adults. The 2019 AGS Beers Criteria®

include 30 individual criteria of medications or medication
classes to be avoided in older adults (Table 2) and 16 cri-
teria specific to more than 40 medications or medication
classes that should be used with caution or avoided in cer-
tain diseases or conditions (Tables 3 and 4). As in past

updates, there were several changes to the 2019 AGS Beers
Criteria®, including criteria that were modified or dropped,
a few new criteria, and some changes in the level of evi-
dence grading and clarifications in language and rationale
(Tables 8–10).

The 2019 AGS Beers Criteria® is the third such update
by the AGS and the fifth update of the AGS Beers Criteria®

since their original release.1,2,10–12 The criteria was first
published almost 30 years ago in 1991, making them the
longest running criteria for PIMs in older adults.

Table 4. 2019 American Geriatrics Society Beers Criteria® for Potentially Inappropriate Medications: Drugs To Be
Used With Caution in Older Adultsa

Drug(s) Rationale Recommendation

Quality of
Evidence

Strength of
Recommendation

Aspirin for primary prevention
of cardiovascular disease
and colorectal cancer

Risk of major bleeding from aspirin
increases markedly in older age. Several
studies suggest lack of net benefit when
used for primary prevention in older adult
with cardiovascular risk factors, but evidence
is not conclusive. Aspirin is generally
indicated for secondary prevention in older
adults with established cardiovascular
disease.

Use with caution in
adults ≥70 years

Moderate Strong

Dabigatran
Rivaroxaban

Increased risk of gastrointestinal bleeding
compared with warfarin and reported rates
with other direct oral anticoagulants when
used for long-term treatment of VTE or atrial
fibrillation in adults ≥75 years.

Use with caution
for treatment of
VTE or atrial
fibrillation in adults
≥75 years

Moderate Strong

Prasugrel Increased risk of bleeding in older adults;
benefit in highest-risk older adults (eg, those
with prior myocardial infarction or diabetes
mellitus) may offset risk when used for its
approved indication of acute coronary
syndrome to be managed with percutaneous
coronary intervention.

Use with caution in
adults ≥75 years

Moderate Weak

Antipsychotics
Carbamazepine
Diuretics
Mirtazapine
Oxcarbazepine
SNRIs
SSRIs
TCAs
Tramadol

May exacerbate or cause SIADH or
hyponatremia; monitor sodium level closely
when starting or changing dosages in older
adults

Use with caution Moderate Strong

Dextromethorphan/
quinidine

Limited efficacy in patients with behavioral
symptoms of dementia (does not apply to
treatment of PBA). May increase risk of falls
and concerns with clinically significant drug
interactions. Does not apply to treatment of
pseudobulbar affect.

Use with caution Moderate Strong

Trimethoprim-
sulfamethoxazole

Increased risk of hyperkalemia when used
concurrently with an ACEI or ARB in
presence of decreased creatinine clearance

Use with caution in
patients on ACEI
or ARB and
decreased
creatinine
clearance

Low Strong

Abbreviations: ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; PBA, pseudobulbar affect; SIADH, syndrome of inappro-
priate antidiuretic hormone secretion; SNRI, serotonin-norepinephrine reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor; TCA, tricyclic antide-
pressant; VTE, venous thromboembolism.
aThe primary target audience is the practicing clinician. The intentions of the criteria include (1) improving the selection of prescription drugs by clinicians
and patients; (2) evaluating patterns of drug use within populations; (3) educating clinicians and patients on proper drug usage; and (4) evaluating health-
outcome, quality-of-care, cost, and utilization data.

JAGS MONTH 2019–VOL. 00, NO. 00 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL 13

T
ab

le
5
.
2
0
1
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m
er
ic
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er
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ee
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in
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cr
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a
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d
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a
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7
)

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A
nt
id
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if
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r,
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cl
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se
ly
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d
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ra
te
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tr
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n
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a
rf
a
ri
n

M
a
cr
o
lid
e
s
(e
xc
lu
d
in
g

a
zi
th
ro
m
yc
in
)

In
cr
e
a
se
d
ri
sk
o
f
b
le
e
d
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w
h
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n
p
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ss
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le
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if
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se
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th
e
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r
IN
R
cl
o
se
ly
M
o
d
e
ra
te
S
tr
o
n
g

14 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL MONTH 2019–VOL. 00, NO. 00 JAGS

The 2019 update has a similar number of changes to
the 2015 update but fewer changes than the 2012 update.
This is likely because, with the support of the AGS and the
expert panel, the criteria have been regularly updated about
every 3 years since 2012. In 2019, 25 medications or medi-
cation classes to be avoided outright or in a disease condi-
tion were dropped from the AGS Beers Criteria® (Table 8).
A few were also moved to a new table category or modified
(Table 10). For medications to be removed from the AGS
Beers Criteria®, the panel had to have new evidence or a
strong rationale, for reasons such as the literature showed a
change in evidence that cast new doubt on their “avoid”
status. Finally, some drugs or drug-disease combinations
were omitted because they are not disproportionately rele-
vant to the older adult population; this included the criteria
on drugs to avoid in adults with chronic seizures or epilepsy
and in adults with insomnia.

Four new medications or medication classes were
added to the list of drugs to be used with caution (Table 4;
additions are also summarized in Table 9). Dextromethor-
phan/quinidine was added because of its limited efficacy,
concerns for clinically significant drug interactions, and
potentially increased risk of falls in older adults. TMP-SMX
was placed in the “use with caution table” because of
increased risk of hyperkalemia when used concurrently with
an ACEI or ARB in the presence of decreased creatinine
clearance.13,14 Rivaroxaban was also added to the use with
caution table for adults 75 years or older. Other important
changes in the use with caution table included lowering the
age threshold in the aspirin for primary prevention recom-
mendation from 80 years or younger to 70 years or youn-
ger on the basis of emerging evidence of a major increase in
the risk of bleeding at a lower age.15 The Aspirin in Reduc-
ing Events in the Elderly (ASPREE) trial, which was pub-
lished outside the window of our literature search, found
that low-dose aspirin used for primary prevention in older
adults did not confer a reduction in mortality, disability-free
survival, or cardiovascular events.16,17 In a few instances,
the level of evidence was revised based on new literature and
the improved modified grading method. For instance,
H2-receptor antagonists were removed from the list of drugs
to avoid in dementia, and the evidence level for H2-receptor
antagonists was decreased to low (from moderate in 2015)
for drugs to avoid in delirium.18 Again in 2019, the panel
clarified the language for sliding-scale insulin because this
continued to be an area of confusion for clinicians.

Importantly, several drugs were added to the drug-
disease and drug-drug interactions tables (Tables 3 and 5).
Notably, SNRIs were added to the list of antidepressant
drug classes to avoid in persons with a history of falls or
fractures.19,20 For this criterion, the level of evidence for
opioids was changed to “moderate”; all other drugs remain
at high. Two new drug-drug interactions involving opioids
were added, reflecting evidence of substantial harms that
can occur when opioids are used concurrently with benzodi-
azepines or gabapentinoids. Though these drug interactions
involving opioids are problematic in all persons, they are
growing increasingly common and may lead to greater harm
in vulnerable older adults. These concerns need to be balanced
with the need to treat chronic pain. A recent review of deaths
from opioids concluded that the burden of opioid overdose in
older adults requires special attention, noting the largestT

ab
le

5
(C

o
n
td
.)
O
bj
ec
t
D
ru
g
an
d
Cl
as
s
In
te
ra
ct
in
g
D
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g
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d
Cl
as
s
R
is
k
R
at
io
na
le
R
ec
om
m
en
da
tio
n
Q
ua
lit
y
of
Ev
id
en
ce
St
re
ng
th
of
R
ec
om
m
en
da
tio
n
W
a
rf
a
ri
n
T
ri
m
e
th
o
p
ri
m
-s
u
lfa
m
e
th
o
xa
zo
le
In
cr
e
a
se
d
ri
sk
o
f
b
le
e
d
in
g
A
vo
id
w
h
e
n
p
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ss
ib
le
;
if
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se
d
to
g
e
th
e
r,
m
o
n
ito
r
IN
R
cl
o
se
ly
M
o
d
e
ra
te
S
tr
o
n
g
W
a
rf
a
ri
n
N
S
A
ID
s
In
cr
e
a
se
d
ri
sk
o
f
b
le
e
d
in
g
A
vo
id
w
h
e
n
p
o
ss
ib
le
;
if
u
se
d
to
g
e
th
e
r,
m
o
n
ito

r
cl
o
se

ly
fo
r

b
le
e
d
in
g
H
ig
h
S
tr
o
n
g
A
b
b
re
vi
at
io
n
s:

A
C
E
I,
an

gi
o
te
n
si
n
-c
o
n
ve
rt
in
g
en
zy
m
e
in
h
ib
it
o
r;

A
R
B
,
an

gi
o
te
n
si
n
re
ce
p
to
r
b
lo
ck
er
;
C
N
S,

ce
n
tr
al
n
er
vo
u
s
sy
st
em

;
IN

R
,
in
te
rn
at
io
n
al

n
o
rm

al
iz
ed

ra
ti
o
;
N
SA

ID
,
n
o
n
st
er
o
id
al
an
ti
-i
n
fl
am
m
at
o
ry
d
ru
g;

R
A
S,

re
n
in
-a
n
gi
o
te
n
si
n
sy
st
em

;
SN

R
I,
se
ro
to
n
in
–
n
o
re
p
in
ep
h
ri
n
e
re
u
p
ta
k
e
in
h
ib
it
o
r;
SS
R
I,
se
le
ct
iv
e
se
ro
to
n
in

re
u
p
ta
k
e
in
h
ib
it
o
r;
T
C
A
,
tr
ic
yc
li
c
an
ti
d
ep
re
ss
an

t.
a
C
N
S-
ac
ti
ve

d
ru
gs
:
an

ti
ep
il
ep
ti
cs
;
an

ti
p
sy
ch
o
ti
cs
;
b
en
zo
d
ia
ze
p
in
es
;
n
o
n
b
en
zo
d
ia
ze
p
in
e,

b
en
zo
d
ia
ze
p
in
e
re
ce
p
to
r
ag
o
n
is
t
h
yp

n
o
ti
cs
;
T
C
A
s;
SS
R
Is
;
SN

R
Is
;
an

d
o
p
io
id
s.

JAGS MONTH 2019–VOL. 00, NO. 00 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL 15

Table 6. 2019 American Geriatrics Society Beers Criteria® for Medications That Should Be Avoided or Have Their
Dosage Reduced With Varying Levels of Kidney Function in Older Adults

Medication Class
and Medication

Creatinine Clearance
at Which Action
Required, mL/min Rationale Recommendation

Quality of
Evidence
Strength of
Recommendation

Anti-infective
Ciprofloxacin <30 Increased risk of CNS effects

(eg, seizures, confusion) and
tendon rupture

Doses used to treat common
infections typically require
reduction when CrCl
<30 mL/min

Moderate Strong
Trimethoprim-
sulfamethoxazole

<30 Increased risk of worsening of

renal function and hyperkalemia

Reduce dose if CrCl
15-29 mL/min
Avoid if CrCl <15 mL/min

Moderate Strong

Cardiovascular
or hemostasis

Amiloride <30 Increased potassium and decreased sodium

Avoid Moderate Strong

Apixaban <25 Lack of evidence for efficacy and safety in patients with a CrCl <25 mL/min

Avoid Moderate Strong

Dabigatran <30 Lack of evidence for efficacy and safety in individuals with a CrCl <30 mL/min. Label dose for patients with a CrCl 15-30 mL/min based on pharmacokinetic data.

Avoid; dose adjustment advised
when CrCl >30 mL/min in the
presence of drug-drug
interactions

Moderate Strong

Dofetilide <60 QTc prolongation and torsade de pointes

Reduce dose if CrCl
20-59 mL/min
Avoid if CrCl <20 mL/min

Moderate Strong

Edoxaban 15-50
<15 or >95

Lack of evidence of efficacy or
safety in patients with a CrCl
<30 mL/min

Reduce dose if CrCl
15-50 mL/min
Avoid if CrCl <15 or >95 mL/min

Moderate Strong

Enoxaparin <30 Increased risk of bleeding Reduce dose Moderate Strong Fondaparinux <30 Increased risk of bleeding Avoid Moderate Strong Rivaroxaban <50 Lack of efficacy or safety

evidence in patients with a CrCl
<30 mL/min

Nonvalvular atrial fibrillation:
reduce dose if CrCl
15-50 mL/min; avoid if CrCl
<15 mL/min Venous thromboembolism treatment and for VTE prophylaxis with hip or knee replacement: avoid if CrCl <30 mL/min

Moderate Strong

Spironolactone <30 Increased potassium Avoid Moderate Strong Triamterene <30 Increased potassium and

decreased sodium
Avoid Moderate Strong

Central nervous system
and analgesics

Duloxetine <30 Increased gastrointestinal adverse effects (nausea, diarrhea)

Avoid Moderate Weak

Gabapentin <60 CNS adverse effects Reduce dose Moderate Strong Levetiracetam ≤80 CNS adverse effects Reduce dose Moderate Strong Pregabalin <60 CNS adverse effects Reduce dose Moderate Strong Tramadol <30 CNS adverse effects Immediate release: reduce

dose
Extended release: avoid

Low Weak

Gastrointestinal
Cimetidine <50 Mental status changes Reduce dose Moderate Strong Famotidine <50 Mental status changes Reduce dose Moderate Strong Nizatidine <50 Mental status changes Reduce dose Moderate Strong Ranitidine <50 Mental status changes Reduce dose Moderate Strong

16 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL MONTH 2019–VOL. 00, NO. 00 JAGS

relative increase in opioids occurred in persons 55 to
64 (754% increase from 0.2% to 1.7%) and 65 years and
older and the absolute number of deaths in this group is
moderate.21,22

Several drug-drug interactions involving antimicrobial
agents were also added to Table 5, and the recommendation
to avoid concurrent use of three or more CNS-active

medications was reformatted to clarify and bring further
attention to the increased risk of falls and other harms that
can occur when multiple CNS-active medications are
combined.23

PIM use continues to be a serious problem in older
adults and especially in vulnerable older adults with multi-
ple chronic conditions. Thus, the AGS Beers Criteria® con-
tinue to be useful and necessary as a clinical tool, as an
educational tool at the bedside, and as a public health tool
to improve medication safety in older adults. The AGS
Beers Criteria® can increase awareness of polypharmacy
and aid decision making when choosing drugs to avoid in
older adults. In a 2017 study using medical expenditure
data (n = 16,588) in adults 65 years and older, poor health
status was associated with increased PIM use. In another
study, the use of PIMs, as measured by the 2015 criteria, in
persons with dementia was 11% higher after diagnosis than
in the year of diagnosis.24,25 Benzodiazepine use remains
common in older adults, especially in older women, despite
the fact that older adults are highly vulnerable to harms
associated with use of these drugs.26 The challenge of
decreasing PIM use and improving the overall quality of
medication prescribing in older adults remains, and the
AGS Beers Criteria® are one part of the solution.

The AGS Beers Criteria® are an essential evidence-
based tool that should be used as a guide for drugs to avoid
in older adults. However, they are not meant to supplant
clinical judgment or an individual patient’s preferences,
values, care goals, and needs, nor should they be used puni-
tively or to excessively restrict access to medications. These
criteria were developed to be used in conjunction with a
person-centered team approach (physicians, nurses, phar-
macists, other clinicians, the older adult, family, and others)
to prescribing and monitoring adverse effects.27 A compan-
ion article published to the 2015 updated AGS Beers
Criteria®, entitled “How to Use the Beers Criteria: A Guide
for Patients, Clinicians, Health Systems, and Payors,”
remains an important guide for using the AGS Beers
Criteria®. It reminds clinicians that medications listed in the
Criteria are potentially inappropriate, rather than definitely
inappropriate for all older adults, and encourages users to
read the rationale and recommendation statements for each
medication to avoid because these statements provide
important guidance.3 Moreover, the criteria should not be
interpreted as giving license to steer patients away from
PIMs to even worse choices. For example, the recommenda-
tion to avoid chronic, regular use of NSAIDs should not be

Table 6 (Contd.)

Medication Class
and Medication
Creatinine Clearance
at Which Action
Required, mL/min Rationale Recommendation
Quality of
Evidence
Strength of
Recommendation

Hyperuricemia
Colchicine <30 Gastrointestinal,

neuromuscular, bone marrow
toxicity

Reduce dose; monitor for
adverse effects

Moderate Strong

Probenecid <30 Loss of effectiveness Avoid Moderate Strong

Abbreviations: CNS, central nervous system; CrCl, creatinine clearance; QTc, corrected QT interval; VTE, venous thromboembolism.

Table 7. Drugs With Strong Anticholinergic Properties
Antiarrhythmic Promethazine

Disopyramide Pyrilamine
Triprolidine

Antidepressants
Amitriptyline
Amoxapine
Clomipramine Antimuscarinics
Desipramine (urinary incontinence)
Doxepin (>6 mg) Darifenacin
Imipramine Fesoterodine
Nortriptyline Flavoxate
Paroxetine Oxybutynin
Protriptyline Solifenacin
Trimipramine Tolterodine

Trospium
Antiemetics

Prochlorperazine Antiparkinsonian agents
Promethazine Benztropine

Trihexyphenidyl
Antihistamines (first generation)

Brompheniramine Antipsychotics
Carbinoxamine Chlorpromazine
Chlorpheniramine Clozapine
Clemastine Loxapine
Cyproheptadine Olanzapine
Dexbrompheniramine Perphenazine
Dexchlorpheniramine Thioridazine
Dimenhydrinate Trifluoperazine
Diphenhydramine (oral)
Doxylamine Antispasmodics
Hydroxyzine Atropine (excludes

ophthalmic)
Meclizine Belladonna alkaloids
Clidinium-chlordiazepoxide Scopolamine (excludes

ophthalmic)
Dicyclomine
Homatropine
(excludes ophthalmic)

Skeletal muscle relaxants

Hyoscyamine Cyclobenzaprine
Methscopolamine Orphenadrine
Propantheline

JAGS MONTH 2019–VOL. 00, NO. 00 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL 17

interpreted as an invitation to prescribe opioids in their
place. For further reference, a 2012 article provides a case
example on how nurses can use the criteria to improve
medication use in older adults.28

As in previous years, the panel recognizes the need to
offer older adults and their clinicians pharmacological and
nonpharmacological alternatives to medications included in
the AGS Beers Criteria®. Alternatives to some of the most
commonly implicated medications listed in the 2015 update

were published in a companion article that accompanied
that update. Readers are encouraged to review these sugges-
tions, although we acknowledge that further work needs to
be done to keep pace with updates to the criteria and the
changing landscape of drug and nondrug therapies. We also
encourage readers to research the safety and effectiveness of
potential alternatives to drugs included in this document.
Deprescribing is a concept to eliminate unsafe or unneces-
sary drugs from a patient’s regimen. One source for online

Table 8. Medications/Criteria Removed Since 2015
American Geriatrics Society Beers Criteria®

Medication/Criterion Reason for Removal

Independent of Diagnosis or Condition (Table 2)
Ticlopidine No longer on US market; low

use
Pentazocine Oral no longer on US market
Considering Disease and Syndrome Interactions (Table 3)
Chronic seizures or epilepsy

Bupropion
Chlorpromazine
Clozapine
Maprotiline
Olanzapine
Thioridazine
Thiothixene
Tramadol

Not unique to older adults

Dementia
H2-receptor antagonists

Weak evidence and to avoid
overly restricting therapeutic
options for older adults with
dementia who have
gastroesophageal reflux or
similar issues (given a
coexisting criterion advising
against chronic use of PPIs
except in specific
circumstances)

Insomnia
Oral decongestants

Phenylephrine
Pseudoephedrine

Stimulants
Amphetamine
Armodafinil
Methylphenidate
Modafinil

Theobromines
Theophylline
Caffeine

Not unique to older adults

Parkinson disease
Aripiprazole

Removed as a preferred
antipsychotic in older adults
with Parkinson disease
because of safety and efficacy
concerns

Use With Caution (Table 4)
SIADH/hyponatremia

Carboplatin
Cyclophosphamide
Cisplatin
Vincristine

Highly specialized drugs that
fell outside the scope of the
criteria

Syncope
Vasodilators

Not unique to older adults

Abbreviations: PPI, proton-pump inhibitor; SIADH, syndrome of inappro-
priate antidiuretic hormone secretion.

Table 9. Medications/Criteria Added Since 2015 Ameri-
can Geriatrics Society Beers Criteria®

Medication/Criterion Reason for Addition

Independent of Diagnosis or Condition (Table 2)
Glimepiride Severe, prolonged

hypoglycemia in older adults
Methscopolamine
Pyrilamine

Strong anticholinergic

Considering Disease and Syndrome Interactions (Table 3)
History of falls or fractures
SNRI

Associated with increased risk
in older adults

Parkinson disease
Pimavanserin

Unlike most other
antipsychotics, the revised
criteria consider pimavanserin
acceptable for treatment of
psychosis in Parkinson disease

Use With Caution (Table 4)
Rivaroxaban Emerging evidence of

increased risk of serious
bleeding compared with other
anticoagulant options

Tramadol Risk of SIADH/hyponatremia
Dextromethorphan/quinidine Limited efficacy in treating

patients with dementia
symptoms disorder in absence
of pseudobulbar affect while
potentially increasing risk of
falls and drug-drug interactions

TMP-SMX Increased risk of hyperkalemia
in combination with ACEIs and
ARBs in patients with reduced
kidney function

Clinically Important Drug-Drug Interactions (Table 5)
Opioids + benzodiazepines

Increased risk of overdose

Opioids +
gabapentin/pregabalin

Increased risk of overdose

Phenytoin + TMP-SMX Increased risk of phenytoin
toxicity

Theophylline + ciprofloxacin Increased risk of theophylline
toxicity

Warfarin + ciprofloxacin

Increased risk of bleeding

Warfarin + macrolides
(excluding azithromycin)

Increased risk of bleeding

Warfarin + TMP-SMX Increased risk of bleeding
Medications That Should Be Avoided or Have Their Dosage
Reduced With Decreased Kidney Function (Table 6)
Ciprofloxacin Increased risk of CNS effects
TMP-SMX Increased risk of worsening of

renal function and hyperkalemia

Abbreviations: ACEI, angiotensin-converting enzyme inhibitor;
ARB, angiotensin receptor blocker; CNS, central nervous system;
SIADH, syndrome of inappropriate antidiuretic hormone secretion;
SNRI, serotonin-norepinephrine reuptake inhibitor; TMP-SMX,
trimethoprim-sulfamethoxazole.

18 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL MONTH 2019–VOL. 00, NO. 00 JAGS

deprescribing resources for many medications included in
the 2019 AGS Beers Criteria® is https://deprescribing.org.

Of particular note is the potential role for nonpharmacolo-
gical approaches to manage common conditions in older adults.
The evidence base for specific nonpharmacological approaches
with a person-centered approach to care is small but
growing.29–32 One example of the growing evidence for non-
drug alternatives is in the area of care for persons with dementia
and delirium. Scales and colleagues published a 2019 compre-
hensive review of evidence-based nonpharmacological
approaches for behavioral and psychological symptoms of
dementia. They evaluated 197 articles that included sensory
practices (eg, massage, light therapy), psychosocial practices (eg,
music, pet therapy, reminiscence), and structured care protocols
(eg, mouth care, bathing). Though they had recommendations
for improving the evidence base, they concluded most practices
were acceptable to patients, had no harmful effects, and required
minimal to moderate investment.33 Online resources for some of

these approaches can be found at www.nursinghometoolkit.
com and www.hospitalelderlifeprogram.org.

While the AGS Beers Criteria® can be a valuable tool,
it should be viewed within the larger context of tools and
strategies for improving pharmacological care for older
adults. Specifically, the AGS Beers Criteria® is one compo-
nent of what should be a comprehensive approach to medi-
cation use in older adults, and it should be used in
conjunction with other tools and management strategies for
improving medication safety and effectiveness. Moreover,
other explicit criteria for evaluating PIMs in older adults,
including the screening tool of older people’s prescriptions
and screening tool to alert to right treatment criteria
(STOPP/START criteria) can also be valuable resources for
improving medication therapy.34

Finally, the 2019 AGS Beers Criteria® have several limi-
tations. Evidence for the benefits and harms of medications
in older adults is often limited, particularly from randomized

Table 10. Medications/Criterion Modified Since 2015 American Geriatrics Society Beers Criteria®

Medication/Criterion Modification

Independent of Diagnosis or Condition (Table 2)
Peripheral α-1 blockers For treatment of hypertension
Digoxin for atrial fibrillation and heart failure Added wording to Drug column; modified rationale; QE

for atrial fibrillation changed to Low
Estrogen with or without progestin Added “recurrent” urinary tract infections
Sliding-scale insulin Clarified definition of sliding-scale insulin
Metoclopramide Added duration of use to recommendation
Meperidine Removed caveat from recommendation
Considering Disease and Syndrome Interactions (Table 3)
Heart failure Reorganized recommendations; separated COX-2

inhibitors from other NSAIDs; added QE and SR for
COX-2 inhibitors; changed recommendation for NSAIDs,
COX-2 inhibitors, and thiazolidinediones to use with
caution in asymptomatic heart failure and to avoid in
symptomatic heart failure; modified rationale

Syncope Specified “nonselective peripheral α-1 blockers”;
separated rationales, QE, and SR for AChEIs and
nonselective peripheral alpha-1 blockers; modified QE for
ACHEIs and antipsychotics

Delirium Changed “Sedative/hypnotics” to Nonbenzodiazepine,
benzodiazepine receptor agonist hypnotics; changed QE
of H2-receptor antagonists to low

History of fractures and falls Changed SR of opioids to strong
Parkinson disease Added rationale for quetiapine, clozapine, and

pimavanserin
Chronic kidney disease and NSAIDs Changed wording (minor) of criterion title
Use With Caution (Table 4)
Aspirin as primary prevention Modified age, indication, rationale, and QE
Dabigatran Modified rationale and recommendation
Prasugrel Modified rationale
Clinically Important Drug-Drug Interactions (Table 5)
The table title Dropped “Non–anti-infective”
ACEIs/ARBs and hyperkalemia Changed to renin-angiotensin system inhibitors
Combination of three or more CNS agents
(antidepressants, antiepileptics, antipsychotics,
benzodiazepines, and opioids)

Replaced individual criteria with a single criterion

Medications That Should Be Avoided or Have Their Dosage Reduced With Decreased Kidney Function (Table 6)
Apixaban, dabigatran, edoxaban, and rivaroxaban Revised CrCl at which action is required, rationale and

recommendations to reflect current labeling, and CrCl
exclusion parameters in clinical trials

Abbreviations: ACEI, angiotensin-converting enzyme inhibitor; AChEI, acetylcholinesterase inhibitor; ARB, angiotensin receptor blocker; CNS, central nervous sys-
tem; COX, cyclooxygenase; CrCl, creatinine clearance; NSAID, nonsteroidal anti-inflammatory drug; QE, quality of evidence; SR, strength of recommendation.

JAGS MONTH 2019–VOL. 00, NO. 00 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL 19

https://deprescribing.org

http://www.nursinghometoolkit.com

http://www.nursinghometoolkit.com

http://www.hospitalelderlifeprogram.org

clinical trials, and so decisions on the composition of the cri-
teria were often made in context of best-available, rather
than definitive, evidence. Moreover, evidence assessment
frameworks are not perfectly tuned to drug safety evaluation,
particularly for observational studies from which much of
the relevant evidence derives.35,36 The criteria are unable to
account for the complexity of all individuals and patient sub-
populations, and thus should be taken as guidance to support
clinical decision making and not as “the final word” as to
whether a specific drug is appropriate or inappropriate for
an individual patient. In addition, the criteria are not meant
to apply to patients at the end of life or receiving palliative
care, when risk-benefit considerations of drug therapy can be
different. Medications considered for inclusion in the criteria
were generally those available in the United States, and the
panel did not seek to include agents available in other coun-
tries that may be equally problematic. Finally, the updated
literature search was comprehensive but may have missed
certain sources of evidence, such as articles written in lan-
guages other than English, white papers, technical reports,
and other evidence published in the “gray literature.”

Notwithstanding these limitations, the guideline update
process had a number of important strengths. The expert
panel included members from multiple clinical disciplines,
backgrounds, and types of clinical experience. The inclusion
of ex-officio members from the Centers for Medicare and
Medicaid Services, the Pharmacy Quality Alliance, and the
National Committee for Quality Assurance provided a wel-
come level of expertise when the panel was considering the
opportunities and pitfalls of translating recommendations
into quality measures. In addition, the panel used a rigorous
process for identifying, reviewing, and synthesizing the
available evidence to inform the guideline update process,
and benefited from the close support of the AGS.

In conclusion, the 2019 update has several important
revisions. Important additions among the nearly 70 modifi-
cations to the 2015 AGS Beer Criteria® were new medica-
tions, clarifications of criteria language and rationale, and
the addition of selected drug-drug interactions.

We hope that the criteria will be used thoughtfully and
widely. To facilitate this process, we encourage healthcare
professionals, patients, payors, and health systems to access
resources with information on the criteria, including
patient-oriented information on the Health in Aging Foun-
dation website (www.healthinaging.org/medications-older-
adults/) and guidance for all on the proper use of the cri-
teria.3 Ongoing support from AGS will facilitate future
evidence-based updates, keeping the AGS Beers Criteria®

useful, relevant, and a valuable tool for improving the
health and well-being of older adults.

ACKNOWLEDGMENTS

The decisions and content of the 2019 American Geriatrics
Society (AGS) Beers Criteria® are those of the AGS and the
panel members and are not necessarily those of the US gov-
ernment or US Department of Veterans Affairs.

Sue Radcliff, Independent Researcher, Denver, CO,
provided research services. Jirong Yue and Gina Rocco pro-
vided additional research services. Susan E. Aiello, DVM,
ELS, provided editorial services. Elvy Ickowicz, MPH,

Elisha Medina-Gallagher, and Mary Jordan Samuel pro-
vided additional research and administrative support. We
must also acknowledge the work of the late Mark H. Beers,
MD, whose vision for better quality of care for older adults
remains active through tools like the AGS Beers Criteria®.

The following organizations with special interest and
expertise in the appropriate use of medications in older
adults provided peer review of a preliminary draft of this
guideline: American Medical Directors Association—The
Society for Post-Acute and Long-Term Care Medicine,
American Academy of Home Care Medicine, American
Academy of Neurology, American Academy of Nurse Prac-
titioners, American Academy of Nursing, American Associ-
ation of Geriatric Psychiatry, American College of
Cardiology, American College of Clinical Pharmacy, Ameri-
can College of Obstetrics and Gynecology, American Col-
lege of Osteopathic Internists, American College of
Physicians, American College of Surgeons, American Osteo-
pathic Association, American Psychiatric Nurses Associa-
tion, American Public Health Association, American Society
of Anesthesiologists, American Society of Consultant Phar-
macists, American Society of Health-System Pharmacists,
the Endocrine Society, Gerontological Advanced Practice
Nurses Association, Gerontological Society of America, and
Society of General Internal Medicine.

Conflicts of Interest: Dr. Beizer is a consultant for
Wolters-Klewer. Dr. Brandt is a consultant for Institute for
HealthCare Improvement (Faculty), is section editor for
SLACK, Inc, and received a grant from IMPAQ on MTM;
Enhanced MTM. Dr. Fick is a paid consultant for SLACK
Inc and Precision Health Economics. She receives funding
from the National Institute of Health for delirium studies.
Dr. Hollmann is a paid reviewer for regulatory-required
Rhode Island physician review of Utilization Review (UR)
criteria for CVS/Caremark. Dr. Linnebur is a consultant for
the Colorado Access Pharmacy and Therapeutics Commit-
tee. Dr. Semla is an editor for Lexi-Comp, and Dr. Semla’s
wife holds commercial interest in AbbVie (at which she is
also an employee) and Abbott Labs. Dr. Semla receives
honoraria from the American Geriatrics Society (AGS) for
his contribution as an author of Geriatrics at Your Finger-
tips and for serving as a section editor for the Journal of the
American Geriatrics Society and is a past president and
chair of the AGS Board of Directors.

Author Contributions: All panel members contributed
to the concept, design, and preparation of the manuscript.

Sponsor’s Role: American Geriatrics Society staff par-
ticipated in the final technical preparation and submission
of the manuscript.

Panel Members and Affiliations

The following individuals were members of the American
Geriatrics Society (AGS) Panel to update the 2019 AGS
Beers Criteria®: Donna M. Fick, PhD, RN, FGSA, FAAN,
College of Nursing and Medicine, The Pennsylvania State
University, University Park, PA (cochair); Todd P. Semla,
PharmD, MS, BCPG, FCCP, AGSF, US Department of Vet-
erans Affairs National Pharmacy Benefits Management Ser-
vices (retired) and Northwestern University Feinberg School
of Medicine, Chicago, IL (cochair); Michael Steinman, MD,
University of California San Francisco and San Francisco

20 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL MONTH 2019–VOL. 00, NO. 00 JAGS

http://www.healthinaging.org/medications-older-adults/

http://www.healthinaging.org/medications-older-adults/

Veterans Affairs Medical Center, San Francisco, CA
(cochair); Judith Beizer, PharmD, BCGP, FASCP, AGSF, St
Johns University, Queens, NY; Nicole Brandt, PharmD,
MBA, BCPP, BCGP, FASCP, University of Maryland, Balti-
more, MD; Robert Dombrowski, PharmD, Centers for
Medicare and Medicaid Services, Baltimore, MD (nonvot-
ing member); Catherine E. DuBeau, MD, Dartmouth-
Hitchcock Medical Center, Lebanon, NH; Lynn Pezzullo,
RPh, CPEHR, Pharmacy Quality Alliance, Alexandria, VA
(nonvoting member); Jerome J. Epplin, MD, AGSF, Litch-
field Family Practice Center, Litchfield, IL; Nina Flanagan,
PhD, GNP-BC, APHM-BC, Decker School of Nursing,
Binghamton University, Dunmore, PA; Emily Morden,
MSW, National Committee for Quality Assurance,
Washington, DC (nonvoting member); Joseph Hanlon,
PharmD, MS, BCPS, FASHP, FASCP, FGSA, AGSF,
Department of Medicine (Geriatric Medicine) School of
Medicine, University of Pittsburgh and Geriatric Research,
Education and Clinical Center, Veterans Affairs Healthcare
System, Pittsburgh, PA; Peter Hollmann, MD, AGSF,
Brown Medicine, Providence, RI; Rosemary Laird, MD,
MHSA, AGSF, Geriatric Medical Leader for Florida Hospi-
tal, Winter Park, FL; Sunny Linnebur, PharmD, FCCP,
BCPS, BCGP, FASCP, Skaggs School of Pharmacy and
Pharmaceutical Sciences, University of Colorado, Aurora,
CO; Satinderpal Sandhu, MD, SUNY Upstate Medical Uni-
versity and Syracuse Veterans Affairs Medical Center,
Syracuse, NY.

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https://doi.org/10.1093/gerona/gly078

https://onlinelibrary.wiley.com/doi/10.1111/jgs.13866

https://onlinelibrary.wiley.com/doi/10.1111/jgs.13866

• American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults

OBJECTIVES
INTENT OF CRITERIA
METHODS
Panel Composition
Literature Review
Development Process
RESULTS
Noteworthy Changes to PIMs for Older Adults
Drugs To Be Used With Caution
Drug-Drug Interactions
PIMs Based on Kidney Function
DISCUSSION
ACKNOWLEDGMENTS
Conflicts of Interest
Author Contributions
Sponsor´s Role
Panel Members and Affiliations
REFERENCES