Related | American Geriatrics Society Updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults - 2023
S P E C I A L AR T I C L E
American Geriatrics Society 2023 updated AGS Beers
Criteria® for potentially inappropriate medication use
in older adults
By the 2023 American Geriatrics Society Beers Criteria® Update Expert Panel
Correspondence
Mary Jordan Samuel, American Geriatrics
Society, 40 Fulton Street, Suite 809,
New York, NY 10038, USA.
Email: msamuel@americangeriatrics.org
Abstract
The American Geriatrics Society (AGS) Beers Criteria® (AGS Beers Criteria®)
for Potentially Inappropriate Medication (PIM) Use in Older Adults is widely
used by clinicians, educators, researchers, healthcare administrators, and regu-
lators. Since 2011, the AGS has been the steward of the criteria and has pro-
duced updates on a regular cycle. The AGS Beers Criteria® is an 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 conditions. For the 2023
update, an interprofessional expert panel reviewed the evidence published
since the last update (2019) and based on a structured assessment process
approved a number of important changes including the addition of new cri-
teria, modification of existing criteria, and formatting changes to enhance
usability. The criteria are intended to be applied to adults 65 years old and
older in all ambulatory, acute, and institutionalized settings of care, except hos-
pice and end-of-life care settings. Although the AGS Beers Criteria® may be
used internationally, it is specifically designed for use in the United States and
there may be additional considerations for certain drugs in specific countries.
Whenever and wherever used, the AGS Beers Criteria® should be applied
thoughtfully and in a manner that supports, rather than replaces, shared clini-
cal decision-making.
KEYWORD S
Beers criteria, Beers list, inappropriate prescribing, medications and drugs, older adults
INTRODUCTION
The Beers Criteria was developed by the late Mark Beers,
MD, and colleagues at the University of California Los
Angeles in 1991, with the purpose of identifying medica-
tions for which potential harm outweighed the expected
benefit and that should be avoided in nursing home
residents.1 The 1997 update, led by Dr. Beers, expanded
the criteria to apply to all older adults.2 The criteria was
updated by an interprofessional group in 2003 and the
American Geriatrics Society took over stewardship in
2010. The 2023 American Geriatrics Society (AGS) Beers
Criteria® (AGS Beers Criteria®) for Potentially Inappro-
priate Medication (PIM) Use in Older Adults is the sev-
enth overall update and fourth since AGS became the
criteria's steward. As with previous updates, the AGS and
its expert panel have attempted to preserve the spirit and
Listen to the GeriPal Podcast with the authors at https://bit.ly/GeriPalEp266
Panel Members and Affiliations are provided in Appendix.
Received: 7 March 2023 Accepted: 29 March 2023
DOI: 10.1111/jgs.18372
Journal of the
American Geriatrics Society
J Am Geriatr Soc. 2023;1–30. wileyonlinelibrary.com/journal/jgs © 2023 The American Geriatrics Society. 1
intent of the original Beers Criteria by providing an
explicit list of PIMs that are best avoided by older adults
in most circumstances or under specific situations, such
as certain diseases, conditions, or care settings.
The AGS Beers Criteria® comprises drugs and drug
classes that the AGS and its expert panel consider to be
potentially inappropriate medications (PIMs) for use in
older adults. The expert panel organized the criteria into
the same five general categories that were used in the
2019 update:
1. Medications considered as potentially inappropriate
(Table 2);
2. Medications potentially inappropriate in patients with
certain diseases or syndromes (Table 3);
3. Medications to be used with caution (Table 4);
4. Potentially inappropriate drug–drug interactions
(Table 5); and
5. Medications whose dosages should be adjusted based
on renal function (Table 6).
Using the five categories of criteria as a framework, an
interprofessional expert panel reviewed new data pub-
lished since the 2019 update (beginning in 2017, the cutoff
date for the prior update's literature review) to identify evi-
dence that would remove, sustain, or alter existing criteria
recommendations, rationale, level of evidence, or strength
of recommendations. The panel also considered evidence
that would support the addition of new criteria. For the
first time, the panel systematically considered usage in the
United States to determine whether any medications (and
resulting criteria) should be removed because of very low
or absent usage in the United States. Finally, the panel
aimed to enhance usability by consolidating the formatting
of the criteria for clarity and space.
OBJECTIVES
The specific aim was to update the 2019 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:
• Convene an interprofessional panel of 12 experts in
geriatric care and pharmacotherapy and three ex-
officio representatives from key stakeholder groups
who would:
� Review evidence published between 2017 and 2022
and use this to update the 2019 AGS Beers Criteria®,
with consideration to removing or modifying exist-
ing criteria and adding new criteria.
� Incorporate exceptions to the 2023 AGS Beers
Criteria® that the panel deemed clinically appropri-
ate. These exceptions were designed to make the cri-
teria more individualized to clinical practice and
more diverse and relevant across settings of care
and populations of older adults.
� Grade the strength and quality of each PIM criterion
based on the level of evidence and strength of
recommendation.
Key points
• The intention of the AGS Beers Criteria® is to:
(1) reduce older adults' exposure to potentially
inappropriate medications (PIMs) by improv-
ing medication selection; (2) educate clinicians
and patients; and (3) serve as a tool for evaluat-
ing the quality of care, cost, and patterns of
drug use in older adults.
• The target audience for the 2023 AGS Beers
Criteria® is practicing clinicians and others
who utilize the criteria including healthcare
consumers, researchers, pharmacy benefits
managers, regulators, and policymakers.
• The criteria are intended to be applied to adults
65 years old and older in all ambulatory, acute,
and institutionalized settings of care, except
hospice and end-of-life care settings.
Why does this paper matter?
The American Geriatrics Society (AGS) Beers
Criteria® (AGS Beers Criteria®) for Potentially
Inappropriate Medication (PIM) Use in Older
Adults is widely used by clinicians, educators,
researchers, healthcare administrators, and regu-
lators. Since 2011, the AGS has been the steward
of the criteria and has produced updates on a reg-
ular cycle. The AGS Beers Criteria® is an explicit
list of PIMs that are typically best avoided by
older adults in most circumstances or under spe-
cific situations, such as in certain diseases or con-
ditions. Although the AGS Beers Criteria® may
be used internationally, it is specifically designed
for use in the United States and there may be
additional considerations for certain drugs in spe-
cific countries. Whenever and wherever used, the
AGS Beers Criteria® should be applied thought-
fully and in a manner that supports, rather than
replaces, shared clinical decision-making.
2 BY THE 2023 AMERICAN GERIATRICS SOCIETY BEERS CRITERIA® UPDATE EXPERT PANEL
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/term
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� Apply a modified Delphi method, informed by the
systematic review and grading, to reach a consensus
on the 2023 update.
INTENT OF CRITERIA
The primary target audience for the 2023 AGS Beers
Criteria® is practicing clinicians. The criteria are
intended to support shared decision-making about phar-
macologic therapy with adults 65 years old and older in
all ambulatory, acute, and institutionalized settings of
care, except hospice and end-of-life care settings. The
intention of the AGS Beers Criteria® is to reduce older
adults' exposure to PIMs by improving medication selec-
tion; educate clinicians and patients; reduce adverse drug
events; and serve as a tool for evaluating the quality of
care, cost, and patterns of drug use in older adults. Others
who utilize the criteria include healthcare consumers,
researchers, pharmacy benefits managers, regulators, and
policymakers. As with previous updates, the panel had
discussions and debates in an effort to attain a balance
between the multiple uses and users. We note that the
criteria are a blunt instrument and that we are unable to
delineate all specialized use cases and possible exceptions
to the criteria.
The AGS and the panel remind users of the AGS Beers
Criteria® that the criteria are not to be used in a punitive
manner. Prescribing for older adults is often a complex
endeavor involving the consideration of many factors, par-
ticularly the preferences and goals of the older person and
their family. Deprescribing studies have demonstrated how
critical patient and family input and buy-in can be to the
success of discontinuing medications responsible for actual
or potential harm or that provide little to no therapeutic
value.3 Quality measures must be clearly defined, easily
applied, and measured with limited information 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 specific crite-
rion should apply. Such a criterion may not be easily
applied as a quality measure, particularly when such sub-
groups cannot be easily identified through structured and
readily accessible electronic data (e.g., when diagnoses, the
purpose of prescribing, or laboratory measures such as kid-
ney function are not available).
METHODS
Methods used for the 2023 update of the AGS Beers
Criteria® were similar to those used in the 2019 update,
including the rigor of the evidence review and synthesis
process.4 These methods were adapted from the Grading
of Recommendations Assessment, Development and
Evaluation (GRADE) guidelines for clinical practice
guideline development and are consistent with recom-
mendations from the National Academy of Medicine.5,6
Panel composition
The AGS Beers Criteria® expert panel included 12 inter-
professional members drawn from medicine, nursing,
and pharmacy, 10 of whom had participated in the 2019
update. Panelists had experience in different practice set-
tings, including ambulatory care, home care, acute hos-
pital care, skilled nursing facilities, and long-term care.
In addition, the panel included ex-officio representa-
tives from the Centers for Medicare & Medicaid Ser-
vices, the National Committee for Quality Assurance,
and the Pharmacy Quality Alliance. Potential conflicts
of interest were disclosed at the beginning of the pro-
cess and before each full panel call and are listed in the
disclosures section of this paper. Panelists were recused
from discussion in areas in which they had a potential
conflict of interest.
Literature review
Literature searches were conducted in PubMed from
June 1, 2017, to May 31, 2022. Search terms for each cri-
terion included individual drugs, drug classes, specific
conditions, and combinations thereof, each with a focus
on “adverse drug events” and “adverse drug reactions,”
as well as on any specific focus defined by the expert
panel. Searches targeted controlled clinical trials, obser-
vational studies, and systematic reviews and meta-
analyses, with filters for human participants, 65 years old
and older, and the English language. Clinical reviews
and guidelines were also included to provide context.
Case reports, case series, letters to the editor, and edito-
rials were excluded.
Searches identified 33,965 references; 7352 abstracts
were sent to panelists for review, of which 1574 references
were selected for full-text review. Among these, 451 manu-
scripts were abstracted into evidence tables, and an addi-
tional 148 were included as background reports.
Development process
The full panel convened for a series of conference calls
between December 2020 and November 2022. Between
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the full panel calls, work was conducted via email. In
addition, the panel was divided into four workgroups,
each assigned a subset of the criteria, with each work-
group leading the review and synthesis of evidence for its
subset of the criteria.
The panel began its work using an anonymous Delphi
process to review the 2019 AGS Beers Criteria®. Using a
5-point Likert scale with anchors of “strongly disagree”
and “strongly agree,” criteria receiving three or more panel
votes of “unsure” or below were brought back for group
discussion and flagged for the individual workgroups to
review for possible updating. Of note, during the full pro-
cess, all legacy criteria were reviewed for accuracy and
appropriateness. Panelists also provided input about drugs
to be explored further for possible addition.
To guide the evidence selection, review, and synthesis
process, each workgroup reviewed and updated work-
sheets created for the 2019 criteria that identified a priori
which clinical outcomes, indications, and comparison
groups were most relevant when considering the evi-
dence for each criterion, that is, 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 workgroup reviewed abstracts from the litera-
ture searches for the criteria in its purview and collec-
tively selected a subset for full-text review. This selection
process considered the methodologic quality of each
study, its relevance to older adults, and its concordance
with the desired evidence noted above. After reviewing
the full text of each selected article, the workgroup then
decided by consensus which papers represented the best
available evidence, based on a balance of these same
three key considerations (methodologic quality, relevance
to older adults, and concordance with desired evidence).
Special emphasis was placed on selecting systematic
reviews and meta-analyses when available because
resource constraints precluded the panel from conducting
these types of comprehensive analyses. In general, a
study was considered relevant to older adults if the mean
or median age of participants was at least 65 years, and
especially relevant if most or all participants were older
than this age threshold.
Papers comprising the best available evidence were
abstracted into evidence tables. These tables summarized
the design, study 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 the AMSTAR criteria for
systematic reviews and meta-analyses.10–12 Each work-
group then synthesized evidence for each criterion from
the 2017–2022 literature reviews informed by GRADE
guidelines and the American College of Physicians' evi-
dence grading framework (Table 1).7,10
Using evidence from the 2017–2022 literature review,
findings from the previous AGS-led 2012, 2015, and 2019
updates, and clinical judgment, each workgroup pre-
sented to the full panel their findings and suggestions for
changes (or no change) to the criteria, with ensuing dis-
cussion. For most criteria, a consensus emerged: to leave
an existing criterion from the 2019 update unchanged, to
modify it, to remove it entirely, or to add a new criterion.
Possible modifications included which drug(s) to include,
the recommendation, the rationale, the quality of evi-
dence, and the strength of the recommendation. As noted
in the GRADE guidelines, the strength of recommenda-
tion ratings incorporate a variety of considerations,
including expert opinion and clinical judgment and con-
text, and thus do not always align with the quality of evi-
dence ratings.
After proposed changes to the criteria were drafted, a
second anonymous Delphi process was used to ascertain
panel consensus on the changes, using the same 5-point
Likert scale as was previously used. As a general rule, cri-
teria receiving three or more panel votes of “unsure” or
disagreement were brought back for group discussion to
reach a consensus decision. Final edits after a public
comment period were approved through the assent of
panel members.
In addition to changes made based on available evi-
dence, the panel decided on several modifications to
improve the clarity and usability of the AGS Beers
Criteria®. The panel changed the order and wording of
certain criteria, recommendations, and rationale state-
ments to improve clarity, avoid possible misinterpreta-
tions, and maintain consistency of formatting. The order
of drugs and categories listed in Table 2 was also modi-
fied for similar reasons. To enhance usability, where fea-
sible we have listed individual drugs that belong to a
specified drug class, not including agents that are rarely
or never used in the United States (as defined using the
methods described immediately below). Note that when
such drug class labels are used, the general intent is that
the criteria apply to all drugs within that class except
when specified otherwise.
To simplify and thereby increase usability, the panel
also voted to omit from key reference tables a number of
medications included in previous iterations of the criteria
that have low or zero usage in the U.S. Drugs that were
moved off the main tables due to low or absent use in the
United States are shown in Table 8. We defined low use
as <4000 U.S. Medicare beneficiaries aged 65 years or
older receiving the drug in 2020 based on data from
Medicare Part D Public Use Files (with the <4000 thresh-
olds representing approximately <0.01% of Medicare
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onditions (https://onlinelibrary.w
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/term
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beneficiaries). Based on group consensus, the panel
decided to retain an explicit listing of certain drugs in key
reference tables despite having <4000 mentions in these
files, based on over-the-counter availability and concerns
that these drugs are still being used commonly enough to
pose a population risk, including in settings not ascer-
tainable through Medicare Part D data. Table 8 also
includes a number of PIMs that are no longer available
in the United States because there is no current manufac-
turer, they have been removed from the market, or avail-
able dosage forms limit use to specific uses outside the
scope of the criteria. These changes should not be inter-
preted as condoning the use of these medications—they
are still considered potentially inappropriate in alignment
with the 2019 AGS Beers Criteria®5 criteria—but were
moved off the main tables to “declutter” the 2023 AGS
Beers Criteria® and not distract from information on
commonly used medications in the United States.
Because medications included in the criteria reflect the
U.S. context, clinicians in other countries should consider
adaptations that may be warranted due to differing pat-
terns of medication approval and use.
The initial draft of the 2023 AGS Beers Criteria® was
reviewed by the AGS Executive Committee, the Chairs/
Vice Chairs of the AGS Clinical Practice and Models of
Care Committee (CPMC), the AGS Ethnogeriatrics Com-
mittee, and the AGS Quality & Performance Measure-
ment Committee (QPMC) and subsequently released for
public comment via the AGS website. The availability of
the criteria for public comment was communicated via
TABLE 1 Designations of quality of evidence and strength of recommendations.
Quality of evidence
Quality of evidence ratings for each criterion are based on a synthetic assessment of 2 complementary approaches to evaluating the quality of
evidence.
ACP-based approach7 GRADE-based approach5
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 5 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,
the potential for confounding, bias in
measurement, etc)
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 the study of
population, comparison group, type of outcomes
measured, etc)?
4. Imprecision: Precision of estimates of effect
5. Publication bias: Risk of bias because of 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 recommendation
Strength of recommendation ratings for each criterion are based on synthetic integration of the quality of evidence, the frequency and severity
of potential adverse events and their relationship to potential benefits, and clinical judgment.
Strong Harms, adverse events, and risks clearly outweigh the benefits.
Weak Harms, adverse events, and risks may not outweigh the benefits.
Source: Adapted from Qaseem et al.,7 Guyatt et al.,8 Andrews et al.9
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or
fo
r
lo
n
g-
te
rm
su
pp
re
ss
io
n
.
L
ow
St
ro
n
g
C
a
rd
io
va
sc
u
la
r
a
n
d
a
n
ti
th
ro
m
bo
ti
cs
A
sp
ir
in
fo
r
pr
im
ar
y
pr
ev
en
ti
on
of
ca
rd
io
va
sc
ul
ar
di
se
as
e
R
is
k
of
m
aj
or
bl
ee
di
n
g
fr
om
as
pi
ri
n
in
cr
ea
se
s
m
ar
ke
dl
y
in
ol
de
r
ag
e.
St
ud
ie
s
su
gg
es
t
a
la
ck
of
n
et
be
n
ef
it
an
d
po
te
n
ti
al
fo
r
n
et
h
ar
m
w
h
en
in
it
ia
te
d
fo
r
pr
im
ar
y
pr
ev
en
ti
on
in
ol
de
r
ad
ul
ts
.
T
h
er
e
is
le
ss
ev
id
en
ce
ab
ou
t
st
op
pi
n
g
as
pi
ri
n
am
on
g
lo
n
g-
te
rm
us
er
s,
al
th
ou
gh
si
m
il
ar
pr
in
ci
pl
es
fo
r
in
it
ia
ti
on
m
ay
ap
pl
y.
N
ot
e:
A
sp
ir
in
is
ge
n
er
al
ly
in
di
ca
te
d
fo
r
se
co
n
da
ry
pr
ev
en
ti
on
in
ol
de
r
ad
ul
ts
w
it
h
es
ta
bl
is
h
ed
ca
rd
io
va
sc
ul
ar
di
se
as
e.
A
vo
id
in
it
ia
ti
n
g
as
pi
ri
n
fo
r
pr
im
ar
y
pr
ev
en
ti
on
of
ca
rd
io
va
sc
ul
ar
di
se
as
e.
C
on
si
de
r
de
pr
es
cr
ib
in
g
as
pi
ri
n
in
ol
de
r
ad
ul
ts
al
re
ad
y
ta
ki
n
g
it
fo
r
pr
im
ar
y
pr
ev
en
ti
on
.
H
ig
h
St
ro
n
g
W
ar
fa
ri
n
fo
r
th
e
tr
ea
tm
en
t
of
n
on
va
lv
ul
ar
at
ri
al
fi
br
ill
at
io
n
or
ve
n
ou
s
th
ro
m
bo
em
bo
lis
m
(V
T
E
)
C
om
pa
re
d
w
it
h
D
O
A
C
s,
w
ar
fa
ri
n
h
as
h
ig
h
er
ri
sk
s
of
m
aj
or
bl
ee
di
n
g
(p
ar
ti
cu
la
rl
y
in
tr
ac
ra
n
ia
lb
le
ed
in
g)
an
d
si
m
il
ar
or
lo
w
er
ef
fe
ct
iv
en
es
s
fo
r
th
e
tr
ea
tm
en
t
of
n
on
va
lv
ul
ar
at
ri
al
fi
br
ill
at
io
n
an
d
V
T
E
.D
O
A
C
s
ar
e
th
us
th
e
pr
ef
er
re
d
ch
oi
ce
fo
r
an
ti
co
ag
ul
at
io
n
fo
r
m
os
t
pe
op
le
w
it
h
th
es
e
co
n
di
ti
on
s.
A
vo
id
st
ar
ti
n
g
w
ar
fa
ri
n
as
in
it
ia
lt
h
er
ap
y
fo
r
th
e
tr
ea
tm
en
t
of
n
on
va
lv
ul
ar
at
ri
al
fi
br
ill
at
io
n
or
V
T
E
un
le
ss
al
te
rn
at
iv
e
op
ti
on
s
(i
.e
.,
D
O
A
C
s)
ar
e
co
n
tr
ai
n
di
ca
te
d
or
th
er
e
ar
e
su
bs
ta
n
ti
al
ba
rr
ie
rs
to
th
ei
r
us
e.
H
ig
h
St
ro
n
g
F
or
ol
de
r
ad
ul
ts
w
h
o
h
av
e
be
en
us
in
g
w
ar
fa
ri
n
lo
ng
-t
er
m
,i
tm
ay
be
re
as
on
ab
le
to
co
nt
in
ue
th
is
m
ed
ic
at
io
n,
pa
rt
ic
ul
ar
ly
am
on
g
th
os
e
w
it
h
w
el
l-
co
n
tr
ol
le
d
IN
R
s
(i
.e
.,
>
70
%
ti
m
e
in
th
e
th
er
ap
eu
ti
c
ra
n
ge
)
an
d
no
ad
ve
rs
e
ef
fe
ct
s.
6 BY THE 2023 AMERICAN GERIATRICS SOCIETY BEERS CRITERIA® UPDATE EXPERT PANEL
15325415, 0, D
ow
nloaded from
https://agsjournals.onlinelibrary.w
iley.com
/doi/10.1111/jgs.18372 by U
niversity O
f W
isconsin - M
adison, W
iley O
nline L
ibrary on [01/06/2023]. See the T
erm
s and C
onditions (https://onlinelibrary.w
iley.com
/term
s-and-conditions) on W
iley O
nline L
ibrary for rules of use; O
A
articles are governed by the applicable C
reative C
om
m
ons L
icense
T
A
B
L
E
2
(C
on
ti
n
u
ed
)
O
rg
an
sy
st
em
,t
h
er
ap
eu
ti
c
ca
te
go
ry
,d
ru
g(
s)
a
R
at
io
n
al
e
R
ec
om
m
en
d
at
io
n
Q
u
al
it
y
of
ev
id
en
ce
b
St
re
n
gt
h
of
re
co
m
m
en
d
at
io
n
b
Se
e
al
so
cr
it
er
ia
on
ri
va
ro
xa
ba
n
(T
ab
le
2)
an
d
da
bi
ga
tr
an
(T
ab
le
4)
an
d
fo
ot
n
ot
e
re
ga
rd
in
g
ch
oi
ce
am
on
g
D
O
A
C
s.
R
iv
ar
ox
ab
an
fo
r
lo
n
g-
te
rm
tr
ea
tm
en
t
of
n
on
va
lv
ul
ar
at
ri
al
fi
br
ill
at
io
n
or
ve
n
ou
s
th
ro
m
bo
em
bo
lis
m
(V
T
E
)
A
t
do
se
s
us
ed
fo
r
lo
n
g-
te
rm
tr
ea
tm
en
t
of
V
T
E
or
n
on
va
lv
ul
ar
at
ri
al
fi
br
ill
at
io
n
,r
iv
ar
ox
ab
an
ap
pe
ar
s
to
h
av
e
a
h
ig
h
er
ri
sk
of
m
aj
or
bl
ee
di
n
g
an
d
G
I
bl
ee
di
n
g
in
ol
de
r
ad
ul
ts
th
an
ot
h
er
D
O
A
C
s,
pa
rt
ic
ul
ar
ly
ap
ix
ab
an
.c
A
vo
id
fo
r
lo
n
g-
te
rm
tr
ea
tm
en
t
of
at
ri
al
fi
br
ill
at
io
n
or
V
T
E
in
fa
vo
r
of
sa
fe
r
an
ti
co
ag
ul
an
t
al
te
rn
at
iv
es
.
Se
e
al
so
cr
it
er
ia
on
w
ar
fa
ri
n
(T
ab
le
2)
an
d
da
bi
ga
tr
an
(T
ab
le
4)
an
d
fo
ot
n
ot
e
re
ga
rd
in
g
th
e
ch
oi
ce
be
tw
ee
n
w
ar
fa
ri
n
an
d
D
O
A
C
s
an
d
am
on
g
D
O
A
C
s.
M
od
er
at
e
St
ro
n
g
R
iv
ar
ox
ab
an
m
ay
be
re
as
on
ab
le
in
sp
ec
ia
l
si
tu
at
io
n
s,
fo
r
ex
am
pl
e
w
h
en
on
ce
-d
ai
ly
do
si
n
g
is
n
ec
es
sa
ry
to
fa
ci
lit
at
e
m
ed
ic
at
io
n
ad
h
er
en
ce
.
A
ll
D
O
A
C
s
co
n
fe
r
a
lo
w
er
ri
sk
of
in
tr
ac
ra
n
ia
l
h
em
or
rh
ag
e
th
an
w
ar
fa
ri
n
.c
D
ip
yr
id
am
ol
e,
or
al
sh
or
t-
ac
ti
n
g
(d
oe
s
n
ot
ap
pl
y
to
ex
te
n
de
d-
re
le
as
e
co
m
bi
n
at
io
n
w
it
h
as
pi
ri
n
)
M
ay
ca
us
e
or
th
os
ta
tic
hy
po
te
ns
io
n;
m
or
e
ef
fe
ct
iv
e
al
te
rn
at
iv
es
av
ai
la
bl
e;
IV
fo
rm
ac
ce
pt
ab
le
fo
r
us
e
in
ca
rd
ia
c
st
re
ss
te
st
in
g.
A
vo
id
M
od
er
at
e
St
ro
n
g
N
on
-s
el
ec
ti
ve
pe
ri
ph
er
al
al
ph
a-
1
bl
oc
ke
rs
fo
r
th
e
tr
ea
tm
en
t
of
h
yp
er
te
n
si
on
D
ox
az
os
in
Pr
az
os
in
T
er
az
os
in
H
ig
h
ri
sk
of
or
th
os
ta
ti
c
h
yp
ot
en
si
on
an
d
as
so
ci
at
ed
h
ar
m
s,
es
pe
ci
al
ly
in
ol
de
r
ad
ul
ts
;n
ot
re
co
m
m
en
de
d
as
ro
ut
in
e
tr
ea
tm
en
t
fo
r
h
yp
er
te
n
si
on
;a
lt
er
n
at
iv
e
ag
en
ts
h
av
e
su
pe
ri
or
ri
sk
/b
en
ef
it
pr
of
ile
.
A
vo
id
us
e
as
an
an
ti
h
yp
er
te
n
si
ve
.
M
od
er
at
e
St
ro
n
g
C
en
tr
al
al
ph
a-
ag
on
is
ts
fo
r
th
e
tr
ea
tm
en
t
of
h
yp
er
te
n
si
on
C
lo
n
id
in
e
G
ua
n
fa
ci
n
e
H
ig
h
ri
sk
of
ad
ve
rs
e
C
N
S
ef
fe
ct
s;
m
ay
ca
us
e
br
ad
yc
ar
di
a
an
d
or
th
os
ta
ti
c
h
yp
ot
en
si
on
;n
ot
re
co
m
m
en
de
d
as
ro
ut
in
e
tr
ea
tm
en
t
fo
r
h
yp
er
te
n
si
on
.
A
vo
id
cl
on
id
in
e
as
fi
rs
t-
li
n
e
tr
ea
tm
en
t
fo
r
h
yp
er
te
n
si
on
.
L
ow
St
ro
n
g
A
vo
id
ot
h
er
ce
n
tr
al
al
ph
a-
ag
on
is
ts
fo
r
th
e
tr
ea
tm
en
t
of
h
yp
er
te
n
si
on
.
N
if
ed
ip
in
e,
im
m
ed
ia
te
re
le
as
e
Po
te
n
ti
al
fo
r
h
yp
ot
en
si
on
;r
is
k
of
pr
ec
ip
it
at
in
g
m
yo
ca
rd
ia
li
sc
h
em
ia
.
A
vo
id
H
ig
h
St
ro
n
g
A
m
io
da
ro
n
e
E
ff
ec
tiv
e
fo
r
m
ai
nt
ai
ni
ng
si
nu
s
rh
yt
hm
bu
th
as
gr
ea
te
r
to
xi
ci
tie
s
th
an
ot
he
r
an
tia
rr
hy
th
m
ic
s
us
ed
in
at
ri
al
fib
ri
lla
tio
n;
m
ay
be
re
as
on
ab
le
fir
st
-li
ne
th
er
ap
y
in
pa
tie
nt
s
w
ith
co
nc
om
ita
nt
he
ar
t
fa
ilu
re
or
su
bs
ta
nt
ia
ll
ef
tv
en
tr
ic
ul
ar
hy
pe
rt
ro
ph
y
if
rh
yt
hm
co
nt
ro
li
s
pr
ef
er
re
d
ov
er
ra
te
co
nt
ro
l.
A
vo
id
as
fi
rs
t-
lin
e
th
er
ap
y
fo
r
at
ri
al
fi
br
ill
at
io
n
un
le
ss
th
e
pa
ti
en
t
h
as
h
ea
rt
fa
il
ur
e
or
su
bs
ta
n
ti
al
le
ft
ve
n
tr
ic
u
la
r
h
yp
er
tr
op
h
y.
H
ig
h
St
ro
n
g
D
ro
ne
da
ro
n
e
W
or
se
ou
tc
om
es
in
pe
op
le
w
ho
ha
ve
pe
rm
an
en
t
at
ri
al
fib
ri
lla
ti
on
or
se
ve
re
or
re
ce
nt
ly
de
co
m
pe
ns
at
ed
he
ar
tf
ai
lu
re
.I
n
so
m
e
ci
rc
um
st
an
ce
s,
w
or
se
ou
tc
om
es
ha
ve
al
so
be
en
re
po
rt
ed
in
pe
op
le
w
it
h
H
F
rE
F
(e
.g
.,
le
ft
ve
nt
ri
cu
la
r
ej
ec
tio
n
fr
ac
tio
n
≤
35
%
)
w
ho
ha
ve
m
ild
er
sy
m
pt
om
s
(N
Y
H
A
cl
as
s
I
or
II
).
A
vo
id
in
in
di
vi
du
al
s
w
ith
pe
rm
an
en
ta
tr
ia
l
fib
ri
lla
tio
n
or
se
ve
re
or
re
ce
nt
ly
de
co
m
pe
ns
at
ed
he
ar
tf
ai
lu
re
.U
se
ca
ut
io
n
in
pa
tie
nt
s
w
ith
H
Fr
E
F
w
ith
le
ss
se
ve
re
sy
m
pt
om
s
(N
Y
H
A
cl
as
s
I
or
II
).
H
ig
h
St
ro
n
g
(C
on
ti
n
ue
s)
AGS 2023 BEERS CRITERIA® 7
15325415, 0, D
ow
nloaded from
https://agsjournals.onlinelibrary.w
iley.com
/doi/10.1111/jgs.18372 by U
niversity O
f W
isconsin - M
adison, W
iley O
nline L
ibrary on [01/06/2023]. See the T
erm
s and C
onditions (https://onlinelibrary.w
iley.com
/term
s-and-conditions) on W
iley O
nline L
ibrary for rules of use; O
A
articles are governed by the applicable C
reative C
om
m
ons L
icense
T
A
B
L
E
2
(C
on
ti
n
u
ed
)
O
rg
an
sy
st
em
,t
h
er
ap
eu
ti
c
ca
te
go
ry
,d
ru
g(
s)
a
R
at
io
n
al
e
R
ec
om
m
en
d
at
io
n
Q
u
al
it
y
of
ev
id
en
ce
b
St
re
n
gt
h
of
re
co
m
m
en
d
at
io
n
b
D
ig
ox
in
fo
r
fi
rs
t-
lin
e
tr
ea
tm
en
t
of
at
ri
al
fi
br
ill
at
io
n
or
h
ea
rt
fa
ilu
re
U
se
in
at
ri
al
fi
br
ill
at
io
n
:s
h
ou
ld
n
ot
be
us
ed
as
a
fi
rs
t-
lin
e
ag
en
t
be
ca
us
e
th
er
e
ar
e
sa
fe
r
an
d
m
or
e
ef
fe
ct
iv
e
al
te
rn
at
iv
es
fo
r
ra
te
co
n
tr
ol
.
U
se
in
he
ar
tf
ai
lu
re
:e
vi
de
nc
e
fo
r
be
ne
fit
s
an
d
ha
rm
s
of
di
go
xi
n
is
co
nf
lic
tin
g
an
d
of
lo
w
er
qu
al
ity
;m
os
t
(b
ut
no
ta
ll)
ev
id
en
ce
co
nc
er
ns
us
e
in
H
Fr
E
F.
T
he
re
is
st
ro
ng
ev
id
en
ce
fo
r
ot
he
r
ag
en
ts
as
fir
st
-
lin
e
th
er
ap
y
to
re
du
ce
ho
sp
ita
liz
at
io
ns
an
d
m
or
ta
lit
y
in
ad
ul
ts
w
ith
H
Fr
E
F.
In
he
ar
tf
ai
lu
re
,
hi
gh
er
do
sa
ge
s
ar
e
no
ta
ss
oc
ia
te
d
w
ith
ad
di
tio
na
l
be
ne
fit
s
an
d
m
ay
in
cr
ea
se
th
e
ri
sk
of
to
xi
ci
ty
.U
se
ca
ut
io
n
in
di
sc
on
tin
ui
ng
di
go
xi
n
am
on
g
cu
rr
en
t
us
er
s
w
ith
H
Fr
E
F,
gi
ve
n
lim
ite
d
ev
id
en
ce
su
gg
es
tin
g
w
or
se
cl
in
ic
al
ou
tc
om
es
af
te
r
di
sc
on
tin
ua
tio
n.
A
vo
id
th
is
ra
te
co
n
tr
ol
ag
en
t
as
fi
rs
t-
lin
e
th
er
ap
y
fo
r
at
ri
al
fi
br
ill
at
io
n
.
A
vo
id
as
fi
rs
t-
lin
e
th
er
ap
y
fo
r
h
ea
rt
fa
il
ur
e.
Se
e
ra
ti
on
al
e
fo
r
ca
ut
io
n
ab
ou
t
w
it
h
dr
aw
al
in
lo
n
g-
te
rm
us
er
s
w
it
h
H
F
rE
F
.
If
us
ed
fo
r
at
ri
al
fi
br
ill
at
io
n
or
h
ea
rt
fa
il
ur
e,
av
oi
d
do
sa
ge
s
>
0.
12
5
m
g/
da
y.
A
tr
ia
lf
ib
ri
ll
at
io
n
;
h
ea
rt
fa
il
u
re
:l
ow
D
os
ag
e
>
0.
12
5
m
g/
da
y:
m
od
er
at
e
St
ro
n
g
D
ec
re
as
ed
re
n
al
cl
ea
ra
n
ce
of
di
go
xi
n
m
ay
le
ad
to
an
in
cr
ea
se
d
ri
sk
of
to
xi
c
ef
fe
ct
s;
fu
rt
h
er
do
se
re
du
ct
io
n
m
ay
be
n
ec
es
sa
ry
fo
r
th
os
e
w
it
h
St
ag
e
4
or
5
ch
ro
n
ic
ki
dn
ey
di
se
as
e.
C
en
tr
a
l
n
er
vo
u
s
sy
st
em
A
n
ti
de
pr
es
sa
n
ts
w
it
h
st
ro
n
g
an
ti
ch
ol
in
er
gi
c
ac
ti
vi
ty
,a
lo
n
e
or
in
co
m
bi
n
at
io
n
A
m
it
ri
pt
yl
in
e
A
m
ox
ap
in
e
C
lo
m
ip
ra
m
in
e
D
es
ip
ra
m
in
e
D
ox
ep
in
>
6
m
g/
da
y
Im
ip
ra
m
in
e
N
or
tr
ip
ty
lin
e
Pa
ro
xe
ti
n
e
H
ig
h
ly
an
ti
ch
ol
in
er
gi
c,
se
da
ti
n
g,
an
d
ca
us
e
or
th
os
ta
ti
c
h
yp
ot
en
si
on
;t
h
e
sa
fe
ty
pr
of
ile
of
lo
w
-d
os
e
do
xe
pi
n
(≤
6
m
g/
da
y)
is
co
m
pa
ra
bl
e
to
th
at
of
pl
ac
eb
o.
A
vo
id
H
ig
h
St
ro
n
g
A
n
ti
pa
rk
in
so
n
ia
n
ag
en
ts
w
it
h
st
ro
n
g
an
ti
ch
ol
in
er
gi
c
ac
ti
vi
ty
B
en
zt
ro
pi
n
e
(o
ra
l)
T
ri
h
ex
yp
h
en
id
yl
N
ot
re
co
m
m
en
de
d
fo
r
pr
ev
en
ti
on
or
tr
ea
tm
en
t
of
ex
tr
ap
yr
am
id
al
sy
m
pt
om
s
du
e
to
an
ti
ps
yc
h
ot
ic
s;
m
or
e
ef
fe
ct
iv
e
ag
en
ts
av
ai
la
bl
e
fo
r
th
e
tr
ea
tm
en
t
of
Pa
rk
in
so
n
di
se
as
e.
A
vo
id
M
od
er
at
e
St
ro
n
g
A
n
ti
ps
yc
h
ot
ic
s,
fi
rs
t-
(t
yp
ic
al
)
an
d
se
co
n
d-
(a
ty
pi
ca
l)
ge
n
er
at
io
n
A
ri
pi
pr
az
ol
e
H
al
op
er
id
ol
O
la
n
za
pi
n
e
Q
ue
ti
ap
in
e
R
is
pe
ri
do
n
e
O
th
er
sd
In
cr
ea
se
d
ri
sk
of
st
ro
ke
an
d
gr
ea
te
r
ra
te
of
co
gn
it
iv
e
de
cl
in
e
an
d
m
or
ta
lit
y
in
pe
rs
on
s
w
it
h
de
m
en
ti
a.
A
dd
it
io
n
al
ev
id
en
ce
su
gg
es
ts
an
as
so
ci
at
io
n
of
in
cr
ea
se
d
ri
sk
be
tw
ee
n
an
ti
ps
yc
h
ot
ic
m
ed
ic
at
io
n
an
d
m
or
ta
lit
y
in
de
pe
n
de
n
t
of
de
m
en
ti
a.
A
vo
id
,e
xc
ep
t
in
F
D
A
-a
pp
ro
ve
d
in
di
ca
ti
on
s
su
ch
as
sc
h
iz
op
h
re
n
ia
,
bi
po
la
r
di
so
rd
er
,P
ar
ki
n
so
n
di
se
as
e
ps
yc
h
os
is
(s
ee
T
ab
le
3)
,a
dj
un
ct
iv
e
tr
ea
tm
en
t
of
m
aj
or
de
pr
es
si
ve
di
so
rd
er
,
or
fo
r
sh
or
t-
te
rm
us
e
as
an
an
ti
em
et
ic
.
M
od
er
at
e
St
ro
n
g
8 BY THE 2023 AMERICAN GERIATRICS SOCIETY BEERS CRITERIA® UPDATE EXPERT PANEL
15325415, 0, D
ow
nloaded from
https://agsjournals.onlinelibrary.w
iley.com
/doi/10.1111/jgs.18372 by U
niversity O
f W
isconsin - M
adison, W
iley O
nline L
ibrary on [01/06/2023]. See the T
erm
s and C
onditions (https://onlinelibrary.w
iley.com
/term
s-and-conditions) on W
iley O
nline L
ibrary for rules of use; O
A
articles are governed by the applicable C
reative C
om
m
ons L
icense
T
A
B
L
E
2
(C
on
ti
n
u
ed
)
O
rg
an
sy
st
em
,t
h
er
ap
eu
ti
c
ca
te
go
ry
,d
ru
g(
s)
a
R
at
io
n
al
e
R
ec
om
m
en
d
at
io
n
Q
u
al
it
y
of
ev
id
en
ce
b
St
re
n
gt
h
of
re
co
m
m
en
d
at
io
n
b
A
vo
id
an
ti
ps
yc
h
ot
ic
s
fo
r
be
h
av
io
ra
lp
ro
bl
em
s
of
de
m
en
ti
a
or
de
lir
iu
m
un
le
ss
do
cu
m
en
te
d
n
on
ph
ar
m
ac
ol
og
ic
op
ti
on
s
(e
.g
.,
be
h
av
io
ra
l
in
te
rv
en
ti
on
s)
h
av
e
fa
il
ed
an
d/
or
th
e
pa
ti
en
t
is
th
re
at
en
in
g
su
bs
ta
n
ti
al
h
ar
m
to
se
lf
or
ot
h
er
s.
If
us
ed
,p
er
io
di
c
de
pr
es
cr
ib
in
g
at
te
m
pt
s
sh
ou
ld
be
co
n
si
de
re
d
to
as
se
ss
on
go
in
g
n
ee
d
an
d/
or
th
e
lo
w
es
t
ef
fe
ct
iv
e
do
se
.
B
ar
bi
tu
ra
te
s
B
ut
al
bi
ta
l
Ph
en
ob
ar
bi
ta
l
Pr
im
id
on
e
H
ig
h
ra
te
of
ph
ys
ic
al
de
pe
n
de
n
ce
,t
ol
er
an
ce
to
sl
ee
p
be
n
ef
it
s,
gr
ea
te
r
ri
sk
of
ov
er
do
se
at
lo
w
do
sa
ge
s.
A
vo
id
H
ig
h
St
ro
n
g
B
en
zo
di
az
ep
in
es
A
lp
ra
zo
la
m
C
h
lo
rd
ia
ze
po
xi
de
(a
lo
n
e
or
in
co
m
bi
n
at
io
n
w
it
h
am
it
ri
pt
yl
in
e
or
cl
id
in
iu
m
)
C
lo
ba
za
m
C
lo
n
az
ep
am
C
lo
ra
ze
pa
te
D
ia
ze
pa
m
E
st
az
ol
am
L
or
az
ep
am
M
id
az
ol
am
O
xa
ze
pa
m
T
em
az
ep
am
T
ri
az
ol
am
T
h
e
us
e
of
be
n
zo
di
az
ep
in
es
ex
po
se
s
us
er
s
to
ri
sk
s
of
ab
us
e,
m
is
us
e,
an
d
ad
di
ct
io
n
.C
on
co
m
it
an
t
us
e
of
op
io
id
s
m
ay
re
su
lt
in
pr
of
ou
n
d
se
da
ti
on
,
re
sp
ir
at
or
y
de
pr
es
si
on
,c
om
a,
an
d
de
at
h
.
A
vo
id
M
od
er
at
e
St
ro
n
g
O
ld
er
ad
ul
ts
h
av
e
in
cr
ea
se
d
se
n
si
ti
vi
ty
to
be
n
zo
di
az
ep
in
es
an
d
de
cr
ea
se
d
m
et
ab
ol
is
m
of
lo
n
g-
ac
ti
n
g
ag
en
ts
;t
h
e
co
n
ti
n
ue
d
us
e
of
be
n
zo
di
az
ep
in
es
m
ay
le
ad
to
cl
in
ic
al
ly
si
gn
if
ic
an
t
ph
ys
ic
al
de
pe
n
de
n
ce
.I
n
ge
n
er
al
,a
ll
be
n
zo
di
az
ep
in
es
in
cr
ea
se
th
e
ri
sk
of
co
gn
it
iv
e
im
pa
ir
m
en
t,
de
lir
iu
m
,f
al
ls
,f
ra
ct
ur
es
,a
n
d
m
ot
or
ve
h
ic
le
cr
as
h
es
in
ol
de
r
ad
ul
ts
.
M
ay
be
ap
pr
op
ri
at
e
fo
r
se
iz
ur
e
di
so
rd
er
s,
ra
pi
d
ey
e
m
ov
em
en
t
sl
ee
p
be
h
av
io
r
di
so
rd
er
,
be
n
zo
di
az
ep
in
e
w
it
h
dr
aw
al
,e
th
an
ol
w
it
h
dr
aw
al
,s
ev
er
e
ge
n
er
al
iz
ed
an
xi
et
y
di
so
rd
er
,a
n
d
pe
ri
pr
oc
ed
ur
al
an
es
th
es
ia
.
N
on
be
n
zo
di
az
ep
in
e
be
n
zo
di
az
ep
in
e
re
ce
pt
or
ag
on
is
t
h
yp
n
ot
ic
s
(“
Z
-d
ru
gs
”)
E
sz
op
ic
lo
n
e
Z
al
ep
lo
n
Z
ol
pi
de
m
N
on
be
n
zo
di
az
ep
in
e
be
n
zo
di
az
ep
in
e
re
ce
pt
or
ag
on
is
t
h
yp
n
ot
ic
s
(“
Z
-d
ru
gs
”)
h
av
e
ad
ve
rs
e
ev
en
ts
si
m
ila
r
to
th
os
e
of
be
n
zo
di
az
ep
in
es
in
ol
de
r
ad
ul
ts
(e
.g
.,
de
lir
iu
m
,f
al
ls
,f
ra
ct
ur
es
,
in
cr
ea
se
d
em
er
ge
n
cy
ro
om
vi
si
ts
/
h
os
pi
ta
liz
at
io
n
s,
m
ot
or
ve
h
ic
le
cr
as
h
es
);
m
in
im
al
im
pr
ov
em
en
t
in
sl
ee
p
la
te
n
cy
an
d
du
ra
ti
on
.
A
vo
id
M
od
er
at
e
St
ro
n
g
M
ep
ro
ba
m
at
e
H
ig
h
ra
te
of
ph
ys
ic
al
de
pe
n
de
n
ce
;v
er
y
se
da
ti
n
g.
A
vo
id
M
od
er
at
e
St
ro
n
g
E
rg
ol
oi
d
m
es
yl
at
es
(d
eh
yd
ro
ge
n
at
ed
er
go
t
al
ka
lo
id
s)
L
ac
k
of
ef
fi
ca
cy
.
A
vo
id
H
ig
h
St
ro
n
g
(C
on
ti
n
ue
s)
AGS 2023 BEERS CRITERIA® 9
15325415, 0, D
ow
nloaded from
https://agsjournals.onlinelibrary.w
iley.com
/doi/10.1111/jgs.18372 by U
niversity O
f W
isconsin - M
adison, W
iley O
nline L
ibrary on [01/06/2023]. See the T
erm
s and C
onditions (https://onlinelibrary.w
iley.com
/term
s-and-conditions) on W
iley O
nline L
ibrary for rules of use; O
A
articles are governed by the applicable C
reative C
om
m
ons L
icense
T
A
B
L
E
2
(C
on
ti
n
ue
d)
O
rg
an
sy
st
em
,t
h
er
ap
eu
ti
c
ca
te
go
ry
,d
ru
g(
s)
a
R
at
io
n
al
e
R
ec
om
m
en
d
at
io
n
Q
u
al
it
y
of
ev
id
en
ce
b
St
re
n
gt
h
of
re
co
m
m
en
d
at
io
n
b
E
n
d
oc
ri
n
e
A
n
dr
og
en
s
M
et
h
yl
te
st
os
te
ro
n
e
T
es
to
st
er
on
e
Po
te
n
ti
al
fo
r
ca
rd
ia
c
pr
ob
le
m
s;
po
te
n
ti
al
ri
sk
s
in
m
en
w
it
h
pr
os
ta
te
ca
n
ce
r.
A
vo
id
un
le
ss
in
di
ca
te
d
fo
r
co
n
fi
rm
ed
h
yp
og
on
ad
is
m
w
it
h
cl
in
ic
al
sy
m
pt
om
s.
M
od
er
at
e
W
ea
k
E
st
ro
ge
n
s
w
it
h
or
w
it
h
ou
t
pr
og
es
ti
n
s
(i
n
cl
ud
es
n
at
ur
al
an
d
sy
n
th
et
ic
es
tr
og
en
pr
ep
ar
at
io
n
s)
E
vi
de
n
ce
of
ca
rc
in
og
en
ic
po
te
n
ti
al
(b
re
as
t
an
d
en
do
m
et
ri
um
);
la
ck
of
ca
rd
io
pr
ot
ec
ti
ve
ef
fe
ct
an
d
co
gn
it
iv
e
pr
ot
ec
ti
on
in
ol
de
r
w
om
en
.
F
or
w
om
en
w
h
o
st
ar
t
H
R
T
at
ag
e
60
an
d
ol
de
r,
th
e
ri
sk
s
of
H
R
T
ar
e
gr
ea
te
r
th
an
th
e
be
n
ef
it
s,
as
H
R
T
is
lin
ke
d
to
a
h
ig
h
er
ri
sk
of
h
ea
rt
di
se
as
e,
st
ro
ke
,b
lo
od
cl
ot
s,
an
d
de
m
en
ti
a.
E
vi
de
n
ce
in
di
ca
te
s
th
at
va
gi
n
al
es
tr
og
en
s
fo
r
th
e
tr
ea
tm
en
t
of
va
gi
n
al
dr
yn
es
s
ar
e
sa
fe
an
d
ef
fe
ct
iv
e;
w
om
en
w
it
h
a
h
is
to
ry
of
br
ea
st
ca
n
ce
r
w
h
o
do
n
ot
re
sp
on
d
to
n
on
h
or
m
on
al
th
er
ap
ie
s
ar
e
ad
vi
se
d
to
di
sc
us
s
th
e
ri
sk
s
an
d
be
n
ef
it
s
of
lo
w
-d
os
e
va
gi
n
al
es
tr
og
en
(e
.g
.,
do
sa
ge
s
of
es
tr
ad
io
l<
25
m
cg
tw
ic
e
w
ee
kl
y)
w
it
h
th
ei
r
h
ea
lt
h
ca
re
pr
ov
id
er
.
D
o
n
ot
in
it
ia
te
sy
st
em
ic
es
tr
og
en
(e
.g
.,
or
al
ta
bl
et
s
or
tr
an
sd
er
m
al
pa
tc
h
es
).
C
on
si
de
r
de
pr
es
cr
ib
in
g
am
on
g
ol
de
r
w
om
en
al
re
ad
y
us
in
g
th
is
m
ed
ic
at
io
n
.
V
ag
in
al
cr
ea
m
or
va
gi
n
al
ta
bl
et
s:
ac
ce
pt
ab
le
to
us
e
lo
w
-d
os
e
in
tr
av
ag
in
al
es
tr
og
en
fo
r
th
e
m
an
ag
em
en
t
of
dy
sp
ar
eu
n
ia
,r
ec
ur
re
n
t
lo
w
er
ur
in
ar
y
tr
ac
t
in
fe
ct
io
n
s,
an
d
ot
h
er
va
gi
n
al
sy
m
pt
om
s.
O
ra
la
n
d
pa
tc
h
:h
ig
h
V
ag
in
al
cr
ea
m
or
va
gi
n
al
ta
bl
et
s:
m
od
er
at
e
O
ra
la
n
d
pa
tc
h
:
st
ro
n
g
T
op
ic
al
va
gi
n
al
cr
ea
m
or
ta
bl
et
s:
w
ea
k
In
su
lin
,s
lid
in
g
sc
al
e
(i
n
su
lin
re
gi
m
en
s
co
n
ta
in
in
g
on
ly
sh
or
t-
or
ra
pi
d-
ac
ti
n
g
in
su
lin
do
se
d
ac
co
rd
in
g
to
cu
rr
en
t
bl
oo
d
gl
uc
os
e
le
ve
ls
w
it
h
ou
t
co
n
cu
rr
en
t
us
e
of
ba
sa
lo
r
lo
n
g-
ac
ti
n
g
in
su
lin
)
H
ig
h
er
ri
sk
of
h
yp
og
ly
ce
m
ia
w
it
h
ou
t
im
pr
ov
em
en
t
in
h
yp
er
gl
yc
em
ia
m
an
ag
em
en
t
re
ga
rd
le
ss
of
ca
re
se
tt
in
g.
A
vo
id
in
su
li
n
re
gi
m
en
s
th
at
in
cl
ud
e
on
ly
sh
or
t-
or
ra
pi
d-
ac
ti
n
g
in
su
lin
do
se
d
ac
co
rd
in
g
to
cu
rr
en
t
bl
oo
d
gl
uc
os
e
le
ve
ls
w
it
h
ou
t
co
n
cu
rr
en
t
us
e
of
ba
sa
l
or
lo
n
g-
ac
ti
n
g
in
su
lin
.T
h
is
re
co
m
m
en
da
ti
on
do
es
n
ot
ap
pl
y
to
re
gi
m
en
s
th
at
co
n
ta
in
ba
sa
l
in
su
lin
or
lo
n
g-
ac
ti
n
g
in
su
lin
.
A
vo
id
M
od
er
at
e
St
ro
n
g
Su
lf
on
yl
ur
ea
s
(a
ll,
in
cl
ud
in
g
sh
or
t-
an
d
lo
n
ge
r-
ac
ti
n
g)
G
lic
la
zi
de
G
lim
ep
ir
id
e
G
lip
iz
id
e
G
ly
bu
ri
de
(G
lib
en
cl
am
id
e)
Su
lf
on
yl
ur
ea
s
h
av
e
a
h
ig
h
er
ri
sk
of
ca
rd
io
va
sc
ul
ar
ev
en
ts
,a
ll-
ca
us
e
m
or
ta
lit
y,
an
d
h
yp
og
ly
ce
m
ia
th
an
al
te
rn
at
iv
e
ag
en
ts
.S
ul
fo
n
yl
ur
ea
s
m
ay
in
cr
ea
se
th
e
ri
sk
of
ca
rd
io
va
sc
ul
ar
de
at
h
an
d
is
ch
em
ic
st
ro
ke
.
A
m
on
g
su
lf
on
yl
ur
ea
s,
lo
n
g-
ac
ti
n
g
ag
en
ts
(e
.g
.,
gl
yb
ur
id
e,
gl
im
ep
ir
id
e)
co
n
fe
r
a
h
ig
h
er
ri
sk
of
pr
ol
on
ge
d
h
yp
og
ly
ce
m
ia
th
an
sh
or
t-
ac
ti
n
g
ag
en
ts
(e
.g
.,
gl
ip
iz
id
e)
.
A
vo
id
su
lf
on
yl
ur
ea
s
as
fi
rs
t-
or
se
co
n
d-
li
n
e
m
on
ot
h
er
ap
y
or
ad
d-
on
th
er
ap
y
un
le
ss
th
er
e
ar
e
su
bs
ta
n
ti
al
ba
rr
ie
rs
to
th
e
u
se
of
sa
fe
r
an
d
m
or
e
ef
fe
ct
iv
e
ag
en
ts
.
If
a
su
lf
on
yl
ur
ea
is
us
ed
,c
h
oo
se
sh
or
t-
ac
ti
n
g
ag
en
ts
(e
.g
.,
gl
ip
iz
id
e)
ov
er
lo
n
g-
ac
ti
n
g
ag
en
ts
(e
.g
.,
gl
yb
ur
id
e,
gl
im
ep
ir
id
e)
.
H
yp
og
ly
ce
m
ia
:H
ig
h
C
V
ev
en
ts
an
d
al
l-
ca
u
se
m
or
ta
li
ty
:
M
od
er
at
e
C
V
de
at
h
an
d
is
ch
em
ic
st
ro
ke
:
L
ow
St
ro
n
g
D
es
ic
ca
te
d
th
yr
oi
d
C
on
ce
rn
s
ab
ou
t
ca
rd
ia
c
ef
fe
ct
s;
sa
fe
r
al
te
rn
at
iv
es
av
ai
la
bl
e.
A
vo
id
L
ow
St
ro
n
g
10 BY THE 2023 AMERICAN GERIATRICS SOCIETY BEERS CRITERIA® UPDATE EXPERT PANEL
15325415, 0, D
ow
nloaded from
https://agsjournals.onlinelibrary.w
iley.com
/doi/10.1111/jgs.18372 by U
niversity O
f W
isconsin - M
adison, W
iley O
nline L
ibrary on [01/06/2023]. See the T
erm
s and C
onditions (https://onlinelibrary.w
iley.com
/term
s-and-conditions) on W
iley O
nline L
ibrary for rules of use; O
A
articles are governed by the applicable C
reative C
om
m
ons L
icense
T
A
B
L
E
2
(C
on
ti
n
u
ed
)
O
rg
an
sy
st
em
,t
h
er
ap
eu
ti
c
ca
te
go
ry
,d
ru
g(
s)
a
R
at
io
n
al
e
R
ec
om
m
en
d
at
io
n
Q
u
al
it
y
of
ev
id
en
ce
b
St
re
n
gt
h
of
re
co
m
m
en
d
at
io
n
b
M
eg
es
tr
ol
M
in
im
al
ef
fe
ct
on
w
ei
gh
t;
in
cr
ea
se
s
th
e
ri
sk
of
th
ro
m
bo
ti
c
ev
en
ts
an
d
po
ss
ib
ly
de
at
h
in
ol
de
r
ad
ul
ts
.
A
vo
id
M
od
er
at
e
St
ro
n
g
G
ro
w
th
h
or
m
on
e
Im
pa
ct
on
bo
dy
co
m
po
si
ti
on
is
sm
al
la
n
d
as
so
ci
at
ed
w
it
h
ed
em
a,
ar
th
ra
lg
ia
,c
ar
pa
l
tu
n
n
el
sy
n
dr
om
e,
gy
n
ec
om
as
ti
a,
an
d
im
pa
ir
ed
fa
st
in
g
gl
uc
os
e.
A
vo
id
,e
xc
ep
t
fo
r
pa
ti
en
ts
ri
go
ro
us
ly
di
ag
n
os
ed
by
ev
id
en
ce
-b
as
ed
cr
it
er
ia
w
it
h
gr
ow
th
h
or
m
on
e
de
fi
ci
en
cy
du
e
to
an
es
ta
bl
is
h
ed
et
io
lo
gy
.
H
ig
h
St
ro
n
g
G
a
st
ro
in
te
st
in
a
l
Pr
ot
on
-p
um
p
in
h
ib
it
or
s
D
ex
la
n
so
pr
az
ol
e
E
so
m
ep
ra
zo
le
L
an
so
pr
az
ol
e
O
m
ep
ra
zo
le
Pa
n
to
pr
az
ol
e
R
ab
ep
ra
zo
le
R
is
k
of
C
.d
iff
ic
ile
in
fe
ct
io
n
,p
n
eu
m
on
ia
,G
I
m
al
ig
n
an
ci
es
,b
on
e
lo
ss
,a
n
d
fr
ac
tu
re
s.
A
vo
id
sc
h
ed
ul
ed
us
e
fo
r
>
8
w
ee
ks
u
n
le
ss
fo
r
h
ig
h
-r
is
k
pa
ti
en
ts
(e
.g
.,
or
al
co
rt
ic
os
te
ro
id
s
or
ch
ro
n
ic
N
SA
ID
u
se
),
er
os
iv
e
es
op
h
ag
it
is
,B
ar
re
tt
's
es
op
h
ag
it
is
,
pa
th
ol
og
ic
h
yp
er
se
cr
et
or
y
co
n
di
ti
on
,o
r
de
m
on
st
ra
te
d
n
ee
d
fo
r
m
ai
n
te
n
an
ce
tr
ea
tm
en
t
(e
.g
.,
be
ca
us
e
of
fa
il
ur
e
of
dr
ug
di
sc
on
ti
n
ua
ti
on
tr
ia
lo
r
H
2-
re
ce
pt
or
an
ta
go
n
is
ts
).
C
.d
iff
ic
ile
,b
on
e
lo
ss
,
an
d
fr
ac
tu
re
s:
H
ig
h
P
n
eu
m
on
ia
an
d
G
I
m
al
ig
n
an
ci
es
:
M
od
er
at
e
St
ro
n
g
M
et
oc
lo
pr
am
id
e
C
an
ca
us
e
ex
tr
ap
yr
am
id
al
ef
fe
ct
s,
in
cl
ud
in
g
ta
rd
iv
e
dy
sk
in
es
ia
;t
h
e
ri
sk
m
ay
be
gr
ea
te
r
in
fr
ai
lo
ld
er
ad
ul
ts
an
d
w
it
h
pr
ol
on
ge
d
ex
po
su
re
.
A
vo
id
,u
n
le
ss
fo
r
ga
st
ro
pa
re
si
s
w
it
h
a
du
ra
ti
on
of
us
e
n
ot
to
ex
ce
ed
12
w
ee
ks
ex
ce
pt
in
ra
re
ca
se
s.
M
od
er
at
e
St
ro
n
g
G
I
an
ti
sp
as
m
od
ic
s
w
it
h
st
ro
n
g
an
ti
ch
ol
in
er
gi
c
ac
ti
vi
ty
A
tr
op
in
e
(e
xc
lu
de
s
op
h
th
al
m
ic
)
C
lid
in
iu
m
-c
h
lo
rd
ia
ze
po
xi
de
D
ic
yc
lo
m
in
e
H
yo
sc
ya
m
in
e
Sc
op
ol
am
in
e
H
ig
h
ly
an
ti
ch
ol
in
er
gi
c,
un
ce
rt
ai
n
ef
fe
ct
iv
en
es
s.
A
vo
id
M
od
er
at
e
St
ro
n
g
M
in
er
al
oi
l,
gi
ve
n
or
al
ly
Po
te
n
ti
al
fo
r
as
pi
ra
ti
on
an
d
ad
ve
rs
e
ef
fe
ct
s;
sa
fe
r
al
te
rn
at
iv
es
av
ai
la
bl
e.
A
vo
id
M
od
er
at
e
St
ro
n
g
G
en
it
ou
ri
n
a
ry
D
es
m
op
re
ss
in
H
ig
h
ri
sk
of
h
yp
on
at
re
m
ia
;s
af
er
al
te
rn
at
iv
e
tr
ea
tm
en
ts
fo
r
n
oc
tu
ri
a
(i
n
cl
ud
in
g
n
on
-
ph
ar
m
ac
ol
og
ic
).
A
vo
id
fo
r
tr
ea
tm
en
t
of
n
oc
tu
ri
a
or
n
oc
tu
rn
al
po
ly
ur
ia
.
M
od
er
at
e
St
ro
n
g
P
a
in
m
ed
ic
a
ti
on
s
N
on
-C
O
X
-2
-s
el
ec
ti
ve
N
SA
ID
s,
or
al
:
A
sp
ir
in
>
32
5
m
g/
da
y
D
ic
lo
fe
n
ac
D
if
lu
n
is
al
E
to
do
la
c
F
lu
rb
ip
ro
fe
n
In
cr
ea
se
d
ri
sk
of
G
I
bl
ee
di
n
g
or
pe
pt
ic
ul
ce
r
di
se
as
e
in
h
ig
h
-r
is
k
gr
ou
ps
,i
n
cl
ud
in
g
th
os
e
>
75
ye
ar
s
ol
d
or
ta
ki
n
g
or
al
or
pa
re
n
te
ra
l
co
rt
ic
os
te
ro
id
s,
an
ti
co
ag
ul
an
ts
,o
r
an
ti
pl
at
el
et
ag
en
ts
;u
se
of
pr
ot
on
-p
um
p
in
h
ib
it
or
or
m
is
op
ro
st
ol
re
du
ce
s
bu
t
do
es
n
ot
el
im
in
at
e
A
vo
id
ch
ro
n
ic
us
e
un
le
ss
ot
h
er
al
te
rn
at
iv
es
ar
e
n
ot
ef
fe
ct
iv
e
an
d
th
e
pa
ti
en
t
ca
n
ta
ke
a
ga
st
ro
pr
ot
ec
ti
ve
ag
en
t
(p
ro
to
n
-p
um
p
in
h
ib
it
or
or
m
is
op
ro
st
ol
).
M
od
er
at
e
St
ro
n
g
A
vo
id
sh
or
t-
te
rm
sc
h
ed
ul
ed
us
e
in
co
m
bi
n
at
io
n
w
it
h
or
al
or
pa
re
n
te
ra
l
(C
on
ti
n
ue
s)
AGS 2023 BEERS CRITERIA® 11
15325415, 0, D
ow
nloaded from
https://agsjournals.onlinelibrary.w
iley.com
/doi/10.1111/jgs.18372 by U
niversity O
f W
isconsin - M
adison, W
iley O
nline L
ibrary on [01/06/2023]. See the T
erm
s and C
onditions (https://onlinelibrary.w
iley.com
/term
s-and-conditions) on W
iley O
nline L
ibrary for rules of use; O
A
articles are governed by the applicable C
reative C
om
m
ons L
icense
T
A
B
L
E
2
(C
on
ti
n
ue
d)
O
rg
an
sy
st
em
,t
h
er
ap
eu
ti
c
ca
te
go
ry
,d
ru
g(
s)
a
R
at
io
n
al
e
R
ec
om
m
en
d
at
io
n
Q
u
al
it
y
of
ev
id
en
ce
b
St
re
n
gt
h
of
re
co
m
m
en
d
at
io
n
b
Ib
up
ro
fe
n
In
do
m
et
h
ac
in
K
et
or
ol
ac
M
el
ox
ic
am
N
ab
um
et
on
e
N
ap
ro
xe
n
O
xa
pr
oz
in
Pi
ro
xi
ca
m
Su
lin
da
c
ri
sk
.U
pp
er
G
I
ul
ce
rs
,g
ro
ss
bl
ee
di
n
g,
or
pe
rf
or
at
io
n
ca
us
ed
by
N
SA
ID
s
oc
cu
r
in
�1
%
of
pa
ti
en
ts
tr
ea
te
d
fo
r
3–
6
m
on
th
s
an
d
in
�2
%
–4
%
of
pa
ti
en
ts
tr
ea
te
d
fo
r
1
ye
ar
;t
h
es
e
tr
en
ds
co
n
ti
n
ue
w
it
h
lo
n
ge
r
du
ra
ti
on
of
us
e.
A
ls
o
ca
n
in
cr
ea
se
bl
oo
d
pr
es
su
re
an
d
in
du
ce
ki
dn
ey
in
ju
ry
.R
is
ks
ar
e
do
se
-r
el
at
ed
.
co
rt
ic
os
te
ro
id
s,
an
ti
co
ag
ul
an
ts
,o
r
an
ti
pl
at
el
et
ag
en
ts
un
le
ss
ot
h
er
al
te
rn
at
iv
es
ar
e
n
ot
ef
fe
ct
iv
e
an
d
th
e
pa
ti
en
t
ca
n
ta
ke
a
ga
st
ro
pr
ot
ec
ti
ve
ag
en
t
(p
ro
to
n
-p
um
p
in
h
ib
it
or
or
m
is
op
ro
st
ol
).
In
do
m
et
h
ac
in
K
et
or
ol
ac
(o
ra
la
n
d
pa
re
n
te
ra
l)
In
cr
ea
se
d
ri
sk
of
G
I
bl
ee
di
n
g/
pe
pt
ic
ul
ce
r
di
se
as
e
an
d
ac
ut
e
ki
dn
ey
in
ju
ry
in
ol
de
r
ad
ul
ts
.O
fa
ll
th
e
N
SA
ID
s,
in
do
m
et
h
ac
in
h
as
th
e
m
os
t
ad
ve
rs
e
ef
fe
ct
s,
in
cl
ud
in
g
a
h
ig
h
er
ri
sk
of
ad
ve
rs
e
C
N
S
ef
fe
ct
s.
A
vo
id
M
od
er
at
e
St
ro
n
g
M
ep
er
id
in
e
O
ra
la
n
al
ge
si
c
n
ot
ef
fe
ct
iv
e
in
do
sa
ge
s
co
m
m
on
ly
us
ed
;m
ay
h
av
e
a
h
ig
h
er
ri
sk
of
n
eu
ro
to
xi
ci
ty
,
in
cl
ud
in
g
de
lir
iu
m
,t
h
an
ot
h
er
op
io
id
s;
sa
fe
r
al
te
rn
at
iv
es
av
ai
la
bl
e.
A
vo
id
M
od
er
at
e
St
ro
n
g
Sk
el
et
al
m
us
cl
e
re
la
xa
n
ts
C
ar
is
op
ro
do
l
C
h
lo
rz
ox
az
on
e
C
yc
lo
be
n
za
pr
in
e
M
et
ax
al
on
e
M
et
h
oc
ar
ba
m
ol
O
rp
he
n
ad
ri
n
e
M
us
cl
e
re
la
xa
n
ts
ty
pi
ca
lly
us
ed
to
tr
ea
t
m
us
cu
lo
sk
el
et
al
co
m
pl
ai
nt
s
ar
e
po
or
ly
to
le
ra
te
d
by
ol
de
r
ad
ul
ts
du
e
to
an
ti
ch
ol
in
er
gi
c
ad
ve
rs
e
ef
fe
ct
s,
se
da
ti
on
,a
nd
in
cr
ea
se
d
ri
sk
of
fr
ac
tu
re
s;
ef
fe
ct
iv
en
es
s
at
do
sa
ge
s
to
le
ra
te
d
by
ol
de
r
ad
ul
ts
is
qu
es
ti
on
ab
le
.
T
h
is
cr
it
er
io
n
do
es
n
ot
ap
pl
y
to
sk
el
et
al
m
us
cl
e
re
la
xa
n
ts
ty
pi
ca
ll
y
us
ed
fo
r
th
e
m
an
ag
em
en
t
of
sp
as
ti
ci
ty
(i
.e
.,
ba
cl
of
en
an
d
ti
za
n
id
in
e)
al
th
ou
gh
th
es
e
dr
ug
s
ca
n
al
so
ca
us
e
su
bs
ta
n
ti
al
ad
ve
rs
e
ef
fe
ct
s.
A
vo
id
M
od
er
at
e
St
ro
n
g
A
bb
re
vi
at
io
n
s:
C
N
S,
ce
n
tr
al
n
er
vo
us
sy
st
em
;C
O
X
,c
yc
lo
ox
yg
en
as
e;
C
rC
l,
cr
ea
ti
n
in
e
cl
ea
ra
n
ce
;C
V
,c
ar
di
ov
as
cu
la
r;
D
O
A
C
s,
di
re
ct
or
al
an
ti
co
ag
ul
an
ts
;G
I,
ga
st
ro
in
te
st
in
al
;H
F
rE
F
,h
ea
rt
fa
ilu
re
w
it
h
re
du
ce
d
ej
ec
ti
on
fr
ac
ti
on
;H
R
T
,h
or
m
on
e
re
pl
ac
em
en
t
th
er
ap
y;
IN
R
,i
n
te
rn
at
io
n
al
n
or
m
al
iz
ed
ra
ti
o;
N
SA
ID
s,
n
on
st
er
oi
da
la
n
ti
-i
n
fl
am
m
at
or
y
dr
ug
s;
N
Y
H
A
,N
ew
Y
or
k
H
ea
rt
A
ss
oc
ia
ti
on
;S
IA
D
H
,
sy
n
dr
om
e
of
in
ap
pr
op
ri
at
e
an
ti
di
ur
et
ic
h
or
m
on
e
se
cr
et
io
n
;V
T
E
,v
en
ou
s
th
ro
m
bo
em
bo
li
sm
.
a U
n
de
r
ea
ch
dr
ug
cl
as
s,
dr
ug
s
co
m
m
on
ly
us
ed
in
th
e
U
n
it
ed
St
at
es
ar
e
li
st
ed
,e
xc
ep
t
in
ca
se
s
w
h
er
e
do
in
g
so
is
in
fe
as
ib
le
du
e
to
sp
ac
e
co
n
si
de
ra
ti
on
s.
U
n
le
ss
st
at
ed
ot
h
er
w
is
e,
al
ld
ru
gs
w
it
h
in
a
st
at
ed
dr
u
g
cl
as
s
ar
e
co
n
si
de
re
d
po
te
n
ti
al
ly
in
ap
pr
op
ri
at
e
in
th
e
co
n
te
xt
of
th
e
cr
it
er
io
n
in
w
h
ic
h
th
ey
ap
pe
ar
,e
ve
n
if
n
ot
li
st
ed
in
th
is
ta
bl
e.
b
Q
ua
lit
y
of
ev
id
en
ce
an
d
st
re
n
gt
h
of
re
co
m
m
en
da
ti
on
ra
ti
n
gs
ap
pl
y
to
al
ld
ru
gs
an
d
re
co
m
m
en
da
ti
on
s
w
it
h
in
ea
ch
cr
it
er
io
n
un
le
ss
st
at
ed
ot
h
er
w
is
e.
c W
h
en
se
le
ct
in
g
am
on
g
D
O
A
C
s
an
d
ch
oo
si
n
g
a
do
se
,p
ay
sp
ec
ia
lc
on
si
de
ra
ti
on
to
ki
dn
ey
fu
n
ct
io
n
(s
ee
T
ab
le
6)
,i
n
di
ca
ti
on
,a
n
d
bo
dy
w
ei
gh
t.
d
A
n
ti
ps
yc
h
ot
ic
s
us
ed
in
th
e
U
n
it
ed
St
at
es
in
cl
ud
e:
F
ir
st
-g
en
er
at
io
n
(“
ty
pi
ca
l”
)—
ch
lo
rp
ro
m
az
in
e,
fl
up
h
en
az
in
e,
h
al
op
er
id
ol
,p
er
ph
en
az
in
e;
Se
co
n
d-
ge
n
er
at
io
n
(“
at
yp
ic
al
”)
—
ar
ip
ip
ra
zo
le
,b
re
xp
ip
ra
zo
le
,
ca
ri
pr
az
in
e,
cl
oz
ap
in
e,
lu
ra
si
do
n
e,
ol
an
za
pi
n
e,
pa
lip
er
id
on
e,
pi
m
av
an
se
ri
n
,q
ue
ti
ap
in
e,
ri
sp
er
id
on
e,
zi
pr
as
id
on
e.
T
h
is
li
st
do
es
n
ot
in
cl
ud
e
an
ti
ps
yc
h
ot
ic
s
ra
re
ly
or
n
ev
er
u
se
d
in
th
e
U
.S
.a
m
on
g
ol
de
r
ad
ul
ts
.
12 BY THE 2023 AMERICAN GERIATRICS SOCIETY BEERS CRITERIA® UPDATE EXPERT PANEL
15325415, 0, D
ow
nloaded from
https://agsjournals.onlinelibrary.w
iley.com
/doi/10.1111/jgs.18372 by U
niversity O
f W
isconsin - M
adison, W
iley O
nline L
ibrary on [01/06/2023]. See the T
erm
s and C
onditions (https://onlinelibrary.w
iley.com
/term
s-and-conditions) on W
iley O
nline L
ibrary for rules of use; O
A
articles are governed by the applicable C
reative C
om
m
ons L
icense
AGS' regular communication channels for reaching the
public. AGS members were also encouraged to submit
comments with multiple posts included on the weekly
member listserv and notices in MyAGSOnline, the
society's online member community. AGS also made out-
reach to 47 organizations to alert them to the public com-
ment period and with a request that they provide expert,
external review. Fifty-eight total comment forms were
submitted comprising more than 200 comments and sug-
gestions; the expert panel reviewed these and modified
the criteria and accompanying text based on the strength
of the evidence supporting each recommended change
and clinical judgment. The AGS Executive Committee
and CPMC Chair and Vice Chair reviewed the resulting
draft of the 2023 AGS Beers Criteria®. The Criteria went
through peer review by the Journal of the American Geri-
atrics Society (JAGS).
RESULTS
Noteworthy changes to PIMS for older
adults
The drugs and drug class criteria included in the 2023
AGS Beers Criteria® are listed in Tables 2–6. To enhance
clarity, a special box that summarizes the criteria for anti-
coagulants (warfarin, rivaroxaban, and dabigatran) has
been added (Box 1). Table 7 is a list of drugs with strong
anticholinergic properties referred to in Tables 2, 3, and 5.
Table 8 is a list of drugs from the 2019 AGS Beers Criteria
that the panel still considers to be PIMs (unless specified
otherwise) but which are now moved off of Tables 2–7 on
account of having low usage in the United States, not
being currently available in the United States, or for other
reasons. A summary of modifications and additions to the
criteria is shown in Tables 9 and 10. Online supplemental
Appendix S1 contains a list of drugs removed from the
AGS Beers Criteria® since the 2012 update.
In Table 2, the rationale for anticholinergic drugs to
avoid has been expanded to recognize the risks associated
with concurrent use (cumulative anticholinergic burden)
and is also recognized in Tables 3 and 5. The criterion for
the use of aspirin for the primary prevention of cardiovas-
cular disease has been revised and moved from the “use
with caution” table (Table 4) to Table 2, with the new
recommendation being to avoid initiating aspirin for the
primary prevention of cardiovascular disease in older
adults (in agreement with the U.S. Preventive Services
Task Force's recommendation).13 For older adults who
are already taking aspirin for primary prevention, the
panel recommends deprescribing be considered, pending
any new data on this issue.
Changes to the criteria involving anticoagulation
were discussed at length, including the proposed
changes, the supporting literature, and ramifications. The
recommendation for rivaroxaban has changed from “use
with caution” to “avoid” for long-term treatment of non-
valvular atrial fibrillation and venous thromboembolism
(VTE), with the rationale being that observational studies
and network meta-analyses find that this drug confers a
higher risk of major and gastrointestinal bleeding in
older adults than other direct-acting oral anticoagulants
(DOACs), particularly apixaban, but also dabigatran. The
panel recognizes there may be circumstances when rivar-
oxaban may be a reasonable choice, including for other
BOX 1 Synthesis of anticoagulation recommendations.
Explanation Recommendation
This criterion summarizes recommendations for warfarin
(Table 2), rivaroxaban (Table 2), and dabigatran
(Table 4)—anticoagulants to avoid or to use with caution.
A “use with caution” recommendation reflects less concern
and/or less clear evidence than an “avoid”
recommendation. See individual criteria on these
medications for more information about anticoagulant-
related recommendations.
When selecting among DOACs and choosing a dosage, pay
special consideration to kidney function (see Table 6),
indication, and body weight.
Warfarin: Avoid starting warfarin as initial therapy for the
treatment of venous thromboembolism (VTE) or nonvalvular
atrial fibrillation unless alternative options (e.g., DOACs) are
contraindicated or there are substantial barriers to their use.
For older adults who have been using warfarin long-term, it
may be reasonable to continue this medication, particularly
among those with well-controlled INRs (i.e., >70% time in the
therapeutic range) and no adverse effects.
Rivaroxaban: Avoid rivaroxaban for long-term treatment of
nonvalvular atrial fibrillation or VTE in favor of safer
anticoagulant alternatives.
Dabigatran: Use caution in selecting dabigatran over other
DOACs (e.g., apixaban) for long-term treatment of nonvalvular
atrial fibrillation or VTE.
AGS 2023 BEERS CRITERIA® 13
15325415, 0, D
ow
nloaded from
https://agsjournals.onlinelibrary.w
iley.com
/doi/10.1111/jgs.18372 by U
niversity O
f W
isconsin - M
adison, W
iley O
nline L
ibrary on [01/06/2023]. See the T
erm
s and C
onditions (https://onlinelibrary.w
iley.com
/term
s-and-conditions) on W
iley O
nline L
ibrary for rules of use; O
A
articles are governed by the applicable C
reative C
om
m
ons L
icense
T
A
B
L
E
3
20
23
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
po
te
n
ti
al
ly
in
ap
pr
op
ri
at
e
m
ed
ic
at
io
n
us
e
in
ol
de
r
ad
ul
ts
du
e
to
dr
ug
–d
is
ea
se
or
dr
ug
–s
yn
dr
om
e
in
te
ra
ct
io
n
s
th
at
m
ay
ex
ac
er
ba
te
th
e
di
se
as
e
or
sy
n
dr
om
e.
D
is
ea
se
or
sy
n
d
ro
m
e
D
ru
g(
s)
a
R
at
io
n
al
e
R
ec
om
m
en
d
at
io
n
Q
u
al
it
y
of
ev
id
en
ce
b
St
re
n
gt
h
of
re
co
m
m
en
d
at
io
n
b
C
a
rd
io
va
sc
u
la
r
H
ea
rt
fa
ilu
re
C
ilo
st
az
ol
D
ex
tr
om
et
h
or
ph
an
-q
u
in
id
in
e
N
on
di
h
yd
ro
py
ri
di
n
e
ca
lc
iu
m
ch
an
n
el
bl
oc
ke
rs
(C
C
B
s)
D
ilt
ia
ze
m
V
er
ap
am
il
D
ro
n
ed
ar
on
e
N
SA
ID
s
an
d
C
O
X
-2
in
h
ib
it
or
s
T
h
ia
zo
lid
in
ed
io
n
es
Pi
og
lit
az
on
e
Po
te
n
ti
al
to
pr
om
ot
e
fl
ui
d
re
te
n
ti
on
an
d/
or
ex
ac
er
ba
te
h
ea
rt
fa
il
ur
e
(N
SA
ID
s
an
d
C
O
X
-2
in
h
ib
it
or
s,
n
on
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ih
yd
ro
py
ri
di
n
e
C
C
B
s,
th
ia
zo
li
di
n
ed
io
n
es
);
po
te
n
ti
al
to
in
cr
ea
se
m
or
ta
li
ty
in
ol
de
r
ad
ul
ts
w
it
h
h
ea
rt
fa
il
ur
e
(c
il
os
ta
zo
la
n
d
dr
on
ed
ar
on
e)
;c
on
ce
rn
s
ab
ou
t
Q
T
pr
ol
on
ga
ti
on
(d
ex
tr
om
et
h
or
ph
an
-q
ui
n
id
in
e)
.
N
ot
e:
T
h
is
is
n
ot
a
co
m
pr
eh
en
si
ve
li
st
of
m
ed
ic
at
io
n
s
to
av
oi
d
in
pa
ti
en
ts
w
it
h
h
ea
rt
fa
il
ur
e.
A
vo
id
:
C
il
os
ta
zo
l
D
ex
tr
om
et
h
or
ph
an
-q
u
in
id
in
e
--
--
--
--
--
--
--
--
--
--
--
--
--
--
--
-
A
vo
id
in
h
ea
rt
fa
il
ur
e
w
it
h
re
du
ce
d
ej
ec
ti
on
fr
ac
ti
on
:
N
on
di
h
yd
ro
py
ri
di
n
e
ca
lc
iu
m
ch
an
n
el
bl
oc
ke
rs
(C
C
B
s)
D
il
ti
az
em
V
er
ap
am
il
--
--
--
--
--
--
--
--
--
--
--
--
--
--
--
-
U
se
w
it
h
ca
ut
io
n
in
pa
ti
en
ts
w
it
h
h
ea
rt
fa
il
ur
e
w
h
o
ar
e
as
ym
pt
om
at
ic
;a
vo
id
in
pa
ti
en
ts
w
it
h
sy
m
pt
om
at
ic
h
ea
rt
fa
il
ur
e:
D
ro
n
ed
ar
on
e
N
SA
ID
s
an
d
C
O
X
-2
in
h
ib
it
or
s
T
h
ia
zo
li
di
n
ed
io
n
es
Pi
og
li
ta
zo
n
e
C
il
os
ta
zo
l,
de
xt
ro
m
et
h
or
ph
an
-
qu
in
id
in
e,
C
O
X
-2
in
h
ib
it
or
s:
L
ow
N
on
-d
ih
yd
ro
py
ri
di
n
e
C
C
B
s,
N
SA
ID
s:
M
od
er
at
e
D
ro
n
ed
ar
on
e,
th
ia
zo
li
de
n
ed
io
n
es
:
H
ig
h
St
ro
n
g
Sy
n
co
pe
A
n
ti
ps
yc
h
ot
ic
s
(s
el
ec
te
d)
C
h
lo
rp
ro
m
az
in
e
O
la
n
za
pi
n
e
C
h
ol
in
es
te
ra
se
in
h
ib
it
or
s
(A
C
h
E
Is
)
D
on
ep
ez
il
G
al
an
ta
m
in
e
R
iv
as
ti
gm
in
e
N
on
-s
el
ec
ti
ve
pe
ri
ph
er
al
al
ph
a-
1
bl
oc
ke
rs
D
ox
az
os
in
Pr
az
os
in
T
er
az
os
in
T
er
ti
ar
y
tr
ic
yc
lic
an
ti
de
pr
es
sa
n
ts
(T
C
A
s)
A
m
it
ri
pt
yl
in
e
C
lo
m
ip
ra
m
in
e
D
ox
ep
in
Im
ip
ra
m
in
e
A
n
ti
ps
yc
h
ot
ic
s
li
st
ed
an
d
te
rt
ia
ry
T
C
A
s
in
cr
ea
se
th
e
ri
sk
of
or
th
os
ta
ti
c
h
yp
ot
en
si
on
.
A
C
h
E
Is
ca
us
e
br
ad
yc
ar
di
a
an
d
sh
ou
ld
be
av
oi
de
d
in
ol
de
r
ad
ul
ts
w
h
os
e
sy
n
co
pe
m
ay
be
du
e
to
br
ad
yc
ar
di
a.
N
on
-s
el
ec
ti
ve
pe
ri
ph
er
al
al
ph
a-
1
bl
oc
ke
rs
ca
us
e
or
th
os
ta
ti
c
bl
oo
d
pr
es
su
re
ch
an
ge
s
an
d
sh
ou
ld
be
av
oi
de
d
in
ol
de
r
ad
ul
ts
w
h
os
e
sy
n
co
pe
m
ay
be
du
e
to
or
th
os
ta
ti
c
h
yp
ot
en
si
on
.
A
vo
id
H
ig
h
A
n
ti
ps
yc
h
ot
ic
s,
n
on
-
se
le
ct
iv
e
pe
ri
ph
er
al
al
ph
a-
1
bl
oc
ke
rs
:
W
ea
k
A
C
h
E
Is
,t
er
ti
ar
y
T
C
A
s:
St
ro
n
g
14 BY THE 2023 AMERICAN GERIATRICS SOCIETY BEERS CRITERIA® UPDATE EXPERT PANEL
15325415, 0, D
ow
nloaded from
https://agsjournals.onlinelibrary.w
iley.com
/doi/10.1111/jgs.18372 by U
niversity O
f W
isconsin - M
adison, W
iley O
nline L
ibrary on [01/06/2023]. See the T
erm
s and C
onditions (https://onlinelibrary.w
iley.com
/term
s-and-conditions) on W
iley O
nline L
ibrary for rules of use; O
A
articles are governed by the applicable C
reative C
om
m
ons L
icense
T
A
B
L
E
3
(C
on
ti
n
u
ed
)
D
is
ea
se
or
sy
n
d
ro
m
e
D
ru
g(
s)
a
R
at
io
n
al
e
R
ec
om
m
en
d
at
io
n
Q
u
al
it
y
of
ev
id
en
ce
b
St
re
n
gt
h
of
re
co
m
m
en
d
at
io
n
b
C
en
tr
a
l
n
er
vo
u
s
sy
st
em
D
el
ir
iu
m
A
n
ti
ch
ol
in
er
gi
cs
(s
ee
T
ab
le
7)
A
n
ti
ps
yc
h
ot
ic
sc
B
en
zo
di
az
ep
in
es
C
or
ti
co
st
er
oi
ds
(o
ra
la
n
d
pa
re
n
te
ra
l)
d
H
2-
re
ce
pt
or
an
ta
go
n
is
ts
C
im
et
id
in
e
F
am
ot
id
in
e
N
iz
at
id
in
e
N
on
be
n
zo
di
az
ep
in
e
be
n
zo
di
az
ep
in
e
re
ce
pt
or
ag
on
is
t
h
yp
n
ot
ic
s
(“
Z
-
dr
ug
s”
)
E
sz
op
ic
lo
n
e
Z
al
ep
lo
n
Z
ol
pi
de
m
O
pi
oi
ds
A
vo
id
in
ol
de
r
ad
ul
ts
w
it
h
or
at
h
ig
h
ri
sk
of
de
li
ri
um
be
ca
us
e
of
th
e
po
te
n
ti
al
of
in
du
ci
n
g
or
w
or
se
n
in
g
de
li
ri
um
.
A
n
ti
ps
yc
h
ot
ic
s:
av
oi
d
fo
r
be
h
av
io
ra
lp
ro
bl
em
s
of
de
m
en
ti
a
or
de
li
ri
um
un
le
ss
n
on
ph
ar
m
ac
ol
og
ic
op
ti
on
s
(e
g,
be
h
av
io
ra
li
n
te
rv
en
ti
on
s)
h
av
e
fa
il
ed
or
ar
e
n
ot
po
ss
ib
le
an
d
th
e
ol
de
r
ad
ul
t
is
th
re
at
en
in
g
su
bs
ta
n
ti
al
h
ar
m
to
se
lf
or
ot
h
er
s.
If
us
ed
,p
er
io
di
c
de
pr
es
cr
ib
in
g
at
te
m
pt
s
sh
ou
ld
be
co
n
si
de
re
d
to
as
se
ss
on
go
in
g
n
ee
d
an
d/
or
th
e
lo
w
es
t
ef
fe
ct
iv
e
do
se
.
C
or
ti
co
st
er
oi
ds
:i
fn
ee
de
d,
us
e
th
e
lo
w
es
t
po
ss
ib
le
do
se
fo
r
th
e
sh
or
te
st
du
ra
ti
on
an
d
m
on
it
or
fo
r
de
li
ri
um
.
O
pi
oi
ds
:e
m
er
gi
n
g
da
ta
h
ig
h
li
gh
ts
an
as
so
ci
at
io
n
be
tw
ee
n
op
io
id
ad
m
in
is
tr
at
io
n
an
d
de
li
ri
um
.F
or
ol
de
r
ad
ul
ts
w
it
h
pa
in
,u
se
a
ba
la
n
ce
d
ap
pr
oa
ch
,
in
cl
ud
in
g
th
e
us
e
of
va
li
da
te
d
pa
in
as
se
ss
m
en
t
to
ol
s
an
d
m
ul
ti
m
od
al
st
ra
te
gi
es
th
at
in
cl
ud
e
n
on
dr
ug
ap
pr
oa
ch
es
to
m
in
im
iz
e
op
io
id
us
e.
A
vo
id
,e
xc
ep
t
in
si
tu
at
io
n
s
li
st
ed
un
de
r
th
e
ra
ti
on
al
e
st
at
em
en
t.
H
2-
re
ce
pt
or
an
ta
go
n
is
ts
:
L
ow
A
ll
ot
h
er
s:
M
od
er
at
e
St
ro
n
g
D
em
en
ti
a
or
co
gn
it
iv
e
im
pa
ir
m
en
t
A
n
ti
ch
ol
in
er
gi
cs
(s
ee
T
ab
le
7)
A
n
ti
ps
yc
h
ot
ic
s,
ch
ro
n
ic
us
e
or
pe
rs
is
te
n
t
as
-n
ee
de
d
us
ec
B
en
zo
di
az
ep
in
es
N
on
be
n
zo
di
az
ep
in
e
be
n
zo
di
az
ep
in
e
re
ce
pt
or
ag
on
is
t
h
yp
n
ot
ic
s
(“
Z
-
dr
ug
s”
)
E
sz
op
ic
lo
n
e
Z
al
ep
lo
n
Z
ol
pi
de
m
A
vo
id
be
ca
us
e
of
ad
ve
rs
e
C
N
S
ef
fe
ct
s.
Se
e
cr
it
er
ia
on
in
di
vi
du
al
dr
ug
s
fo
r
ad
di
ti
on
al
in
fo
rm
at
io
n
.
A
n
ti
ps
yc
h
ot
ic
s:
in
cr
ea
se
d
ri
sk
of
st
ro
ke
an
d
gr
ea
te
r
ra
te
of
co
gn
it
iv
e
de
cl
in
e
an
d
m
or
ta
li
ty
in
pe
op
le
w
it
h
de
m
en
ti
a.
A
vo
id
an
ti
ps
yc
h
ot
ic
s
fo
r
be
h
av
io
ra
lp
ro
bl
em
s
of
de
m
en
ti
a
or
de
li
ri
um
un
le
ss
do
cu
m
en
te
d
n
on
ph
ar
m
ac
ol
og
ic
op
ti
on
s
(e
.g
.,
be
h
av
io
ra
li
n
te
rv
en
ti
on
s)
h
av
e
fa
il
ed
an
d/
or
th
e
pa
ti
en
t
is
th
re
at
en
in
g
su
bs
ta
n
ti
al
h
ar
m
to
se
lf
or
ot
h
er
s.
If
us
ed
,p
er
io
di
c
de
pr
es
cr
ib
in
g
at
te
m
pt
s
sh
ou
ld
be
co
n
si
de
re
d
to
as
se
ss
on
go
in
g
n
ee
d
an
d/
or
th
e
lo
w
es
t
ef
fe
ct
iv
e
do
se
.
A
vo
id
M
od
er
at
e
St
ro
n
g
H
is
to
ry
of
fa
lls
or
fr
ac
tu
re
s
A
n
ti
ch
ol
in
er
gi
cs
(s
ee
T
ab
le
7)
A
n
ti
de
pr
es
sa
n
ts
(s
el
ec
te
d
cl
as
se
s)
SN
R
Is
SS
R
Is
T
ri
cy
cl
ic
an
ti
de
pr
es
sa
n
ts
(T
C
A
s)
A
n
ti
ep
ile
pt
ic
s
A
n
ti
ps
yc
h
ot
ic
sc
B
en
zo
di
az
ep
in
es
M
ay
ca
us
e
at
ax
ia
,i
m
pa
ir
ed
ps
yc
h
om
ot
or
fu
n
ct
io
n
,
sy
n
co
pe
,o
r
ad
di
ti
on
al
fa
ll
s.
A
n
ti
de
pr
es
sa
n
ts
(s
el
ec
te
d
cl
as
se
s)
:e
vi
de
n
ce
fo
r
ri
sk
of
fa
ll
s
an
d
fr
ac
tu
re
s
is
m
ix
ed
;n
ew
er
ev
id
en
ce
su
gg
es
ts
th
at
SN
R
Is
m
ay
in
cr
ea
se
fa
ll
s
ri
sk
.
B
en
zo
di
az
ep
in
es
:s
h
or
te
r-
ac
ti
n
g
on
es
ar
e
n
ot
sa
fe
r
th
an
lo
n
g-
ac
ti
n
g
on
es
.
If
on
e
of
th
e
dr
ug
s
m
us
t
be
us
ed
,c
on
si
de
r
re
du
ci
n
g
th
e
us
e
of
ot
h
er
C
N
S-
ac
ti
ve
m
ed
ic
at
io
n
s
th
at
in
cr
ea
se
th
e
ri
sk
of
fa
ll
s
an
d
fr
ac
tu
re
s
A
vo
id
un
le
ss
sa
fe
r
al
te
rn
at
iv
es
ar
e
n
ot
av
ai
la
bl
e.
A
n
ti
ep
il
ep
ti
cs
:a
vo
id
ex
ce
pt
fo
r
se
iz
ur
es
an
d
m
oo
d
di
so
rd
er
s.
O
pi
oi
ds
:a
vo
id
ex
ce
pt
fo
r
pa
in
m
an
ag
em
en
t
in
th
e
se
tt
in
g
of
se
ve
re
ac
ut
e
pa
in
.
A
n
ti
de
pr
es
sa
n
ts
,o
pi
oi
ds
:
M
od
er
at
e
A
ll
ot
h
er
s:
H
ig
h
St
ro
n
g
(C
on
ti
n
ue
s)
AGS 2023 BEERS CRITERIA® 15
15325415, 0, D
ow
nloaded from
https://agsjournals.onlinelibrary.w
iley.com
/doi/10.1111/jgs.18372 by U
niversity O
f W
isconsin - M
adison, W
iley O
nline L
ibrary on [01/06/2023]. See the T
erm
s and C
onditions (https://onlinelibrary.w
iley.com
/term
s-and-conditions) on W
iley O
nline L
ibrary for rules of use; O
A
articles are governed by the applicable C
reative C
om
m
ons L
icense
T
A
B
L
E
3
(C
on
ti
n
u
ed
)
D
is
ea
se
or
sy
n
d
ro
m
e
D
ru
g(
s)
a
R
at
io
n
al
e
R
ec
om
m
en
d
at
io
n
Q
u
al
it
y
of
ev
id
en
ce
b
St
re
n
gt
h
of
re
co
m
m
en
d
at
io
n
b
H
is
to
ry
of
fa
lls
an
d
fr
ac
tu
re
s,
co
n
t'd
N
on
be
n
zo
di
az
ep
in
e
be
n
zo
di
az
ep
in
e
re
ce
pt
or
ag
on
is
t
h
yp
n
ot
ic
s
(“
Z
-
dr
ug
s”
)
E
sz
op
ic
lo
n
e
Z
al
ep
lo
n
Z
ol
pi
de
m
O
pi
oi
ds
(i
.e
.,
an
ti
ch
ol
in
er
gi
cs
,s
el
ec
te
d
an
ti
de
pr
es
sa
n
ts
,
an
ti
ep
il
ep
ti
cs
,a
n
ti
ps
yc
h
ot
ic
s,
se
da
ti
ve
/h
yp
n
ot
ic
s
in
cl
ud
in
g
be
n
zo
di
az
ep
in
es
an
d,
n
on
be
n
zo
di
az
ep
in
e
be
n
zo
di
az
ep
in
e
re
ce
pt
or
ag
on
is
t
h
yp
n
ot
ic
s,
op
io
id
s)
an
d
im
pl
em
en
t
ot
h
er
st
ra
te
gi
es
to
re
du
ce
fa
ll
ri
sk
.
Pa
rk
in
so
n
di
se
as
e
A
n
ti
em
et
ic
s
M
et
oc
lo
pr
am
id
e
Pr
oc
h
lo
rp
er
az
in
e
Pr
om
et
h
az
in
e
A
n
ti
ps
yc
h
ot
ic
s
(e
xc
ep
t
cl
oz
ap
in
e,
pi
m
av
an
se
ri
n
,a
n
d
qu
et
ia
pi
n
e)
D
op
am
in
e-
re
ce
pt
or
an
ta
go
n
is
ts
w
it
h
th
e
po
te
n
ti
al
to
w
or
se
n
pa
rk
in
so
n
ia
n
sy
m
pt
om
s
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ID
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n
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th
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sh
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at
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,a
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s)
bu
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ay
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pl
y
as
w
el
l.
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ibrary on [01/06/2023]. See the T
erm
s and C
onditions (https://onlinelibrary.w
iley.com
/term
s-and-conditions) on W
iley O
nline L
ibrary for rules of use; O
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reative C
om
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icense
TABLE 4 2023 American Geriatrics Society Beers Criteria® for potentially inappropriate medications: drugs to be used with caution in
older adultsa.
Drug(s)b Rationale Recommendation
Quality of
evidencec
Strength of
recommendationc
Dabigatran for long-term
treatment of nonvalvular
atrial fibrillation or venous
thromboembolism (VTE)
Increased risk of GI bleeding compared
with warfarin (based on head-to-head
clinical trials) and of GI bleeding and
major bleeding compared with apixaban
(based on observational studies and
meta-analyses) in older adults when
used for long-term treatment of
nonvalvular atrial fibrillation or VTE.
Use caution in selecting
dabigatran over other DOACs
(e.g., apixaban) for long-term
treatment of nonvalvular
atrial fibrillation or VTE.
Moderate Strong
See also criteria on warfarin
and rivaroxaban (Table 2)
and footnoted regarding
choice among DOACs.
Prasugrel
Ticagrelor
Both increase the risk of major bleeding in
older adults compared with clopidogrel,
especially among those 75 years old and
older. However, this risk may be offset
by cardiovascular benefits in select
patients.
Use with caution, particularly
in adults 75 years old and
older.
Moderate Strong
If prasugrel is used, consider a
lower dose (5 mg) for those
75 years old and older.
Antidepressants (selected)
Mirtazipine
SNRIs
SSRIs
TCAs
Antiepileptics (selected)
Carbamazepine
Oxcarbazepine
Antipsychotics
Diuretics
Tramadol
May exacerbate or cause SIADH or
hyponatremia; monitor sodium levels
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 the treatment of
pseudobulbar affect). May increase the
risk of falls and concerns with clinically
significant drug interactions and with
use in those with heart failure (see
Table 3).
Use with caution Moderate Strong
Trimethoprim-
sulfamethoxazole
Increased risk of hyperkalemia when used
concurrently with an ACEI, ARB, or
ARNI in presence of decreased CrCl.
Use with caution in patients on
ACEI, ARB, or ARNI and
decreased CrCl.
Low Strong
Sodium-glucose co-
transporter-2 (SGLT2)
inhibitors
Canigliflozin
Dapagliflozin
Emplaglifozin
Ertuglifozin
Older adults may be at increased risk of
urogenital infections, particularly
women in the first month of treatment.
An increased risk of euglycemic diabetic
ketoacidosis has also been seen in older
adults.
Use with caution.
Monitor patients for urogenital
infections and ketoacidosis.
Moderate Weak
Abbreviations: ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; ARNI, angiotensin receptor-neprilysin inhibitor;
CrCl, creatinine clearance; DOAC, direct oral anticoagulant; GI, gastrointestinal; SIADH, syndrome of inappropriate antidiuretic hormone secretion;
SGLT2, sodium glucose co-transporter-2; SNRIs, serotonin-norepinephrine reuptake inhibitors; SSRIs, selective serotonin reuptake inhibitors; TCAs,
tricyclic antidepressants; VTE, venous thromboembolism.
a“Use with caution” recommendations reflect concern about the balance of benefits and harms of medication compared with alternatives in the
situation when those concerns do not rise to the level of “avoid” recommendations in other Tables because of limited evidence, a lesser degree of
potential harm compared with alternative therapies, and/or extenuating clinical circumstances.
bUnder each drug class, drugs commonly used in the United States are listed, except in cases where doing so is infeasible due to space considerations.
Unless stated otherwise, all drugs within a stated drug class are considered potentially inappropriate in the context of the criterion in which they
appear, even if not listed in this table.
cQuality of evidence and strength of recommendation ratings apply to all drugs and recommendations within each criterion unless stated otherwise.
dWhen selecting among DOACs and choosing a dosage, pay special consideration to kidney function (see Table 6), indication, and body weight.
AGS 2023 BEERS CRITERIA® 17
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iley O
nline L
ibrary on [01/06/2023]. See the T
erm
s and C
onditions (https://onlinelibrary.w
iley.com
/term
s-and-conditions) on W
iley O
nline L
ibrary for rules of use; O
A
articles are governed by the applicable C
reative C
om
m
ons L
icense
clinical conditions and in special circumstances such as
when a once-daily DOAC is necessary to facilitate medi-
cation adherence, and that all DOACs have a lower risk
of intracranial hemorrhage than warfarin.
Warfarin has been added to Table 2 as a medication
to be avoided when starting initial therapy for VTE or
nonvalvular atrial fibrillation unless alternatives
(e.g., DOACs) are contraindicated or there are substantial
barriers to the use of an alternative. The distinction
between starting warfarin as initial therapy versus main-
taining warfarin among current long-term users (espe-
cially those with well-controlled international
normalized ratio [INR] levels) reflects different evidence
for these scenarios as well as considerations of shared
decision-making. The AGS is concerned that there are
significant barriers to the use of newer alternatives
including high out-of-pocket drug costs and formulary
restrictions. These barriers could lead to inequitable
access to DOACs that may be safer for older adults. We
urge policymakers, insurers, and organizations in the
pharmaceutical supply chain to ensure that out-of-pocket
costs and access restrictions are not a barrier to safe and
effective anticoagulation for all of us as we age. AGS and
the expert panel recognize that cost and access will con-
tinue to be a factor in individualized decision-making
between warfarin and DOACs and among different
DOACs until payment policies are enacted that support
equitable access for all individuals regardless of their eco-
nomic and insurance status. The recommendation for
dabigatran remains as “use with caution” for the long-
term treatment of nonvalvular atrial fibrillation and VTE
(Table 4) because of evidence suggesting an increased
risk of gastrointestinal and major bleeding compared
with alternatives such as apixaban.
Another change from the 2019 criteria pertains to the
initiation and continuation of estrogen in postmeno-
pausal women. The initiation of oral and transdermal
estrogen is to be avoided in older women; topical vaginal
estrogen remains appropriate for its major indications of
symptomatic vaginal atrophy or urinary tract infection
prophylaxis. Deprescribing should be considered for older
women already using nonvaginal estrogen replacement.
The recommendation for sulfonylureas has been expanded
to avoid all sulfonylureas as first- or second-line monother-
apy or add on-therapy in recognition of their association
with a higher risk of cardiovascular events, all-cause mor-
tality, and hypoglycemia than alternative choices. Here the
panel recognizes there may be substantial barriers to or
pressures opposing the recommendation, including finan-
cial ones, with similar considerations as those discussed
above for anticoagulants. If a sulfonylurea must be used,
then a short-acting agent is preferred because of the higher
risk of prolonged hypoglycemia with longer-acting
sulfonylureas (e.g., glimepiride, chlorpropramide, or glybur-
ide, which is also known as glibenclamide).
Changes to the criteria involving PIMs exacerbating
specific drug diseases and drug syndromes (Table 3) are
relatively minimal. The combination of dextromethor-
phan/quinidine was added to the list of drugs to avoid
in patients with heart failure. In the criterion of PIMs
to avoid in older adults with a history of falls or frac-
tures, the level of evidence for antidepressants has been
lowered to “moderate.” Modifications and clarifications
were made to the criteria for delirium, dementia, and
Parkinson disease, including adding opioids to the list
of drugs that can exacerbate delirium. The update con-
tinues to stress the need to avoid antipsychotics and
other medications for behavioral problems of dementia
and delirium as their use is frequently associated with
harm and increased during and after pandemic
lockdowns.14–16 The use of behavioral interventions
and search for modifiable triggers for behavior14,17
remains the preferred management strategy and should
be clearly documented in the health record. The use of
antipsychotics and other medications listed in these cri-
teria should be a last resort in collaboration and with
the use of shared decision-making with older adults
and their care partners. Many evidence-based
approaches for behavior in persons with dementia are
now available including the Describe, Investigate, Cre-
ate, Evaluate (DICE) approach and others.18,19 We
remind readers that the AGS Beers Criteria® do not
apply to care in hospice and at the end of life, in which
setting decision-making about these and other drugs
may require other considerations.
As mentioned above, the criteria for aspirin and rivar-
oxaban have been moved from Table 4 to Table 2. Tica-
grelor has been added to the criterion about prasugrel,
advising that it be used with caution, particularly among
adults 75 years old and older because of concerns of
major bleeding. A new criterion was added advising that
sodium-glucose co-transporter-2 (SGLT2) inhibitors be
used with caution because of the increased risk of uro-
genital infection and euglycemic diabetic ketoacidosis,
and recommends monitoring early during treatment. Of
note, the panel recognizes the value of SGLT2-inhibitors
but also wishes to emphasize that patients taking these
drugs should be monitored actively for possible adverse
effects.
The panel worked to clarify and consolidate the clini-
cally important drug–drug interactions (Table 5), most
notably the use of multiple agents with anticholinergic
activity, the concurrent use of ≥3 CNS-active drugs from
specific therapeutic categories (which now include skele-
tal muscle relaxants), and the addition of SSRIs to the list
of warfarin drug–drug interactions.
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isconsin - M
adison, W
iley O
nline L
ibrary on [01/06/2023]. See the T
erm
s and C
onditions (https://onlinelibrary.w
iley.com
/term
s-and-conditions) on W
iley O
nline L
ibrary for rules of use; O
A
articles are governed by the applicable C
reative C
om
m
ons L
icense
T
A
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L
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or
h
ig
h
er
.
M
od
er
at
e
St
ro
n
g
O
pi
oi
ds
B
en
zo
di
az
ep
in
es
In
cr
ea
se
d
ri
sk
of
ov
er
do
se
an
d
ad
ve
rs
e
ev
en
ts
.
A
vo
id
M
od
er
at
e
St
ro
n
g
O
pi
oi
ds
G
ab
ap
en
ti
n
P
re
ga
ba
lin
In
cr
ea
se
d
ri
sk
of
se
ve
re
se
da
ti
on
-r
el
at
ed
ad
ve
rs
e
ev
en
ts
,i
n
cl
ud
in
g
re
sp
ir
at
or
y
de
pr
es
si
on
an
d
de
at
h
.
A
vo
id
;e
xc
ep
ti
on
s
ar
e
w
h
en
tr
an
si
ti
on
in
g
fr
om
op
io
id
th
er
ap
y
to
ga
ba
pe
n
ti
n
or
pr
eg
ab
al
in
,o
r
w
h
en
us
in
g
ga
ba
pe
n
ti
n
oi
ds
to
re
du
ce
op
io
id
do
se
,a
lt
h
ou
gh
ca
ut
io
n
sh
ou
ld
be
us
ed
in
al
lc
ir
cu
m
st
an
ce
s.
M
od
er
at
e
St
ro
n
g
A
n
ti
ch
ol
in
er
gi
c
A
n
ti
ch
ol
in
er
gi
c
U
se
of
m
or
e
th
an
on
e
m
ed
ic
at
io
n
w
it
h
an
ti
ch
ol
in
er
gi
c
pr
op
er
ti
es
in
cr
ea
se
s
th
e
ri
sk
of
co
gn
it
iv
e
de
cl
in
e,
de
lir
iu
m
,a
n
d
fa
lls
or
fr
ac
tu
re
s.
A
vo
id
;m
in
im
iz
e
th
e
n
um
be
r
of
an
ti
ch
ol
in
er
gi
c
dr
ug
s
(T
ab
le
7)
.
M
od
er
at
e
St
ro
n
g
A
n
ti
ep
ile
pt
ic
s
(i
n
cl
u
di
n
g
ga
ba
pe
n
ti
n
oi
ds
)
A
n
ti
de
pr
es
sa
n
ts
(T
C
A
s,
SS
R
Is
,a
n
d
SN
R
Is
)
A
n
ti
ps
yc
h
ot
ic
s
B
en
zo
di
az
ep
in
es
N
on
be
n
zo
di
az
ep
in
e
be
n
zo
di
az
ep
in
e
re
ce
pt
or
ag
on
is
t
h
yp
n
ot
ic
s
(i
.e
.,
“Z
-d
ru
gs
”)
O
pi
oi
ds
Sk
el
et
al
m
u
sc
le
re
la
xa
n
ts
A
n
y
co
m
bi
n
at
io
n
of
≥
3
of
th
es
e
C
N
S-
ac
ti
ve
dr
u
gs
In
cr
ea
se
d
ri
sk
of
fa
lls
an
d
of
fr
ac
tu
re
w
it
h
th
e
co
n
cu
rr
en
t
us
e
of
≥
3
C
N
S-
ac
ti
ve
ag
en
ts
(a
n
ti
ep
ile
pt
ic
s
in
cl
ud
in
g
ga
ba
pe
n
ti
n
oi
ds
,a
n
ti
de
pr
es
sa
n
ts
,
an
ti
ps
yc
h
ot
ic
s,
be
n
zo
di
az
ep
in
es
,
n
on
be
n
zo
di
az
ep
in
e
be
n
zo
di
az
ep
in
e
re
ce
pt
or
ag
on
is
t
h
yp
n
ot
ic
s,
op
io
id
s,
an
d
sk
el
et
al
m
us
cl
e
re
la
xa
n
ts
).
A
vo
id
co
n
cu
rr
en
t
us
e
of
≥
3
C
N
S-
ac
ti
ve
dr
ug
s
(a
m
on
g
ty
pe
s
as
lis
te
d
at
le
ft
);
m
in
im
iz
e
th
e
n
um
be
r
of
C
N
S-
ac
ti
ve
dr
ug
s.
H
ig
h
St
ro
n
g
L
it
h
iu
m
A
C
E
Is
In
cr
ea
se
d
ri
sk
of
lit
h
iu
m
to
xi
ci
ty
.
A
vo
id
;m
on
it
or
lit
h
iu
m
co
n
ce
n
tr
at
io
n
s.
M
od
er
at
e
St
ro
n
g
A
R
B
s
A
R
N
Is
L
it
h
iu
m
L
oo
p
di
ur
et
ic
s
In
cr
ea
se
d
ri
sk
of
lit
h
iu
m
to
xi
ci
ty
.
A
vo
id
;m
on
it
or
lit
h
iu
m
co
n
ce
n
tr
at
io
n
s.
M
od
er
at
e
St
ro
n
g
N
on
-s
el
ec
ti
ve
pe
ri
ph
er
al
al
ph
a-
1
bl
oc
ke
rs
b
L
oo
p
di
ur
et
ic
s
In
cr
ea
se
d
ri
sk
of
ur
in
ar
y
in
co
n
ti
n
en
ce
in
ol
de
r
w
om
en
.
A
vo
id
in
ol
de
r
w
om
en
,u
n
le
ss
co
n
di
ti
on
s
w
ar
ra
n
t
bo
th
dr
ug
s.
M
od
er
at
e
St
ro
n
g
Ph
en
yt
oi
n
T
ri
m
et
h
op
ri
m
-
su
lf
am
et
h
ox
az
ol
e
In
cr
ea
se
d
ri
sk
of
ph
en
yt
oi
n
to
xi
ci
ty
A
vo
id
M
od
er
at
e
St
ro
n
g
(C
on
ti
n
ue
s)
AGS 2023 BEERS CRITERIA® 19
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erm
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onditions (https://onlinelibrary.w
iley.com
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The anticoagulants also dominated the panel's atten-
tion when updating drugs to avoid or reduce doses with
varying levels of kidney function (Table 6). The criterion
for apixaban has been removed given the evidence for its
safe use in patients with end-stage renal disease. Rivarox-
aban's dosing in reduced kidney function is variable and
is based on indication; thus, the criteria refer to the prod-
uct label. Baclofen has been added with a recommenda-
tion to avoid its use when eGFR is <60 mL/min because
of the increased risk for encephalopathy in older adults.
Finally, the use of NSAIDs by patients with a CrCl
<30 mL/min was moved from Table 3 to Table 6 for con-
sistency of presentation.
DISCUSSION
The AGS Beers Criteria® continues to evolve to address
the changing landscape of available medications and
emerging data about their harms and benefits. Some of
the most notable updates from the 2019 criteria include a
series of new and revised criteria regarding anticoagu-
lants and expanding the “avoid” recommendation for sul-
fonylureas, which previously focused on long-acting
sulfonylureas but now includes all medications in this
class (in particular, avoiding them as first- or second-line
therapy, while still advising that if a sulfonylurea is used,
shorter-acting ones pose less risk of hypoglycemia than
longer-acting ones).
The introductory section of this article describes the
intent of the criteria. In addition, we strongly encourage
readers to understand and apply the guidance on how to
interpret the recommendations, apply them to policy and
practice, use best practices for deprescribing, and under-
stand the criteria's strengths and limitations. These are
explained below.
Interpreting recommendations
The original Beers Criteria used “avoid” as a recommen-
dation, meaning “the medication should be avoided
except under unusual circumstances.”1 Such circum-
stances include (but are not limited to) when a safer
alternative did not achieve the desired therapeutic out-
come. Thus, PIMs “would be chosen infrequently
through such careful considerations of benefit and risk.”1
“Avoid” in the 2023 AGS Beers Criteria® has the same
meaning. “Avoid” is not defined as an absolute contrain-
dication unless specified in the medication's label. It is
the expert panel's intent that when a PIM is chosen, it is
done so through shared decision-making that includes
recognition of its potential harms and consideration ofT
A
B
L
E
5
(C
on
ti
n
ue
d)
O
bj
ec
t
d
ru
g
or
cl
as
s
In
te
ra
ct
in
g
d
ru
g
or
cl
as
s
R
is
k
ra
ti
on
al
e
R
ec
om
m
en
d
at
io
n
Q
u
al
it
y
of
ev
id
en
ce
a
St
re
n
gt
h
of
re
co
m
m
en
d
at
io
n
a
T
h
eo
ph
yl
lin
e
C
im
et
id
in
e
In
cr
ea
se
d
ri
sk
of
th
eo
ph
yl
lin
e
to
xi
ci
ty
A
vo
id
M
od
er
at
e
St
ro
n
g
T
h
eo
ph
yl
lin
e
C
ip
ro
fl
ox
ac
in
In
cr
ea
se
d
ri
sk
of
th
eo
ph
yl
lin
e
to
xi
ci
ty
A
vo
id
M
od
er
at
e
St
ro
n
g
W
ar
fa
ri
n
A
m
io
da
ro
n
e
C
ip
ro
fl
ox
ac
in
M
ac
ro
li
de
s
(e
xc
lu
di
n
g
az
it
h
ro
m
yc
in
)
T
ri
m
et
h
op
ri
m
-
su
lf
am
et
h
ox
az
ol
e
SS
R
Is
In
cr
ea
se
d
ri
sk
of
bl
ee
di
n
g.
A
vo
id
w
h
en
po
ss
ib
le
;i
f
us
ed
to
ge
th
er
,
m
on
it
or
IN
R
cl
os
el
y.
M
od
er
at
e
St
ro
n
g
N
ot
e:
T
h
is
ta
bl
e
is
n
ot
a
co
m
pr
eh
en
si
ve
lis
t
of
al
ld
ru
g–
dr
ug
in
te
ra
ct
io
n
s
re
le
va
n
t
fo
r
ol
de
r
ad
ul
ts
.
A
bb
re
vi
at
io
n
s:
A
C
E
Is
,a
n
gi
ot
en
si
n
-c
on
ve
rt
in
g
en
zy
m
e
in
h
ib
it
or
s;
A
R
B
s,
an
gi
ot
en
si
n
re
ce
pt
or
bl
oc
ke
rs
;A
R
N
Is
,a
n
gi
ot
en
si
n
re
ce
pt
or
-n
ep
ri
ly
si
n
in
h
ib
it
or
s;
C
N
S,
ce
n
tr
al
n
er
vo
u
s
sy
st
em
;I
N
R
,i
n
te
rn
at
io
n
al
n
or
m
al
iz
ed
ra
ti
o;
N
SA
ID
s,
n
on
st
er
oi
da
la
n
ti
-i
n
fl
am
m
at
or
y
dr
ug
s;
R
A
S,
re
n
in
-a
n
gi
ot
en
si
n
sy
st
em
;S
N
R
Is
=
se
ro
to
n
in
-n
or
ep
in
ep
h
ri
n
e
re
up
ta
ke
in
h
ib
it
or
s;
SS
R
Is
,s
el
ec
ti
ve
se
ro
to
n
in
re
u
pt
ak
e
in
h
ib
it
or
s;
T
C
A
s,
tr
ic
yc
li
c
an
ti
de
pr
es
sa
n
ts
.
a Q
ua
lit
y
of
ev
id
en
ce
an
d
st
re
n
gt
h
of
re
co
m
m
en
da
ti
on
ra
ti
n
gs
ap
pl
y
to
al
ld
ru
gs
an
d
re
co
m
m
en
da
ti
on
s
w
it
h
in
ea
ch
cr
it
er
io
n
un
le
ss
st
at
ed
ot
h
er
w
is
e.
b
D
at
a
ar
e
lim
it
ed
fo
r
se
le
ct
iv
e
pe
ri
ph
er
al
al
ph
a-
1
bl
oc
ke
rs
(e
.g
.,
ta
m
su
lo
si
n
,s
il
od
os
in
,a
n
d
ot
h
er
s)
bu
t
m
ay
ap
pl
y
as
w
el
l.
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iley O
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ibrary on [01/06/2023]. See the T
erm
s and C
onditions (https://onlinelibrary.w
iley.com
/term
s-and-conditions) on W
iley O
nline L
ibrary for rules of use; O
A
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reative C
om
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ons L
icense
TABLE 6 2023 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.
Drug
CrCl (mL/min)
at which action
is required Rationale Recommendation
Quality of
evidence
Strength of
recommendation
Anti-infective
Ciprofloxacin <30 Increased risk of CNS
effects (e.g., seizures,
confusion) and tendon
rupture.
Dosages used to treat
common infections
typically require
reduction when CrCl
<30 mL/min.
Moderate Strong
Nitrofurantoin <30 Potential for pulmonary
toxicity, hepatoxicity,
and peripheral
neuropathy, especially
with long-term use. (See
also Table 2).
Avoid if CrCl <30 mL/
min
Low Strong
Trimethoprim-
sulfamethoxazole
<30 Increased risk of
worsening of kidney
function and
hyperkalemia; risk of
hyperkalemia especially
prominent with
concurrent use of an
ACE, ARB, or ARNI.
Reduce dosage if CrCl is
15–29 mL/min.
Avoid if CrCl <15 mL/
min.
Moderate Strong
Cardiovascular and antithrombotics
Amiloride <30 Hyperkalemia and
hyponatremia
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
CrCl 15–30 mL/min
based on
pharmacokinetic data.
Avoid when CrCl
<30 mL/min; dose
adjustment is advised
when CrCl >30 mL/min
in the presence of drug–
drug interactions.
Moderate Strong
Dofetilide <60 QTc prolongation and
torsades de pointes.
Reduce dose if CrCl is 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 CrCl
<30 mL/min.
Reduce dose if CrCl is 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 people with
CrCl <15 mL/min;
limited evidence for
CrCl 15–30 mL/min.
Avoid if CrCl <15 mL/
min.
Reduce the dose if CrCl is
15–50 mL/min
following manufacturer
dosing
recommendations based
on indication-specific
dosing.
Moderate Strong
(Continues)
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iley.com
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the older person's preferences and goals of care. As in
previous updates to the AGS Beers Criteria®, the panel
has included caveats about when choosing a PIM may be
reasonable, for example, a benzodiazepine for alcohol
withdrawal.
The panel also deliberated about and recognizes that
clinicians and older adults may face substantial financial
pressures to use PIMs—such as when a safer treatment
option incurs substantially higher out-of-pocket costs—
and that drug affordability is an important consideration
TABLE 6 (Continued)
Drug
CrCl (mL/min)
at which action
is required Rationale Recommendation
Quality of
evidence
Strength of
recommendation
Spironolactone <30 Hyperkalemia Avoid Moderate Strong
Triamterene <30 Hyperkalemia and
hyponatremia
Avoid Moderate Strong
Central nervous system and analgesics
Baclofen eGFR <60 Increased risk of
encephalopathy
requiring hospitalization
in older adults with
eGFR <60 mL/min or
who require chronic
dialysis.
Avoid baclofen in older
adults with impaired
kidney function (eGFR
<60 mL/min). When
baclofen cannot be
avoided, use the lowest
effective dose and
monitor for signs of
CNS toxicity, including
altered mental status.
Moderate Strong
Duloxetine <30 Increased GI 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
NSAIDs (non-
selective, COX-2
selective, and
nonacetylated
salicylates, oral and
parenteral)a
< 30 May increase the risk of
acute kidney injury and
a further decline in
kidney function
Avoid 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
Hyperuricemia
Colchicine <30 GI, neuromuscular, and
bone marrow toxicity
Reduce dose; monitor for
adverse effects.
Moderate Strong
Probenecid <30 Loss of effectiveness Avoid Moderate Strong
Note: This table is not a comprehensive list of all drugs that should be avoided or dose-adjusted in older adults with renal impairment.
Abbreviations: ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; ARNI, angiotensin receptor-neprilysin inhibitor; CNS,
central nervous system; CrCl, creatinine clearance; eGFR, estimated glomerular filtration rate; GI, gastrointestinal.
aNSAIDs include: Non-selective: diclofenac, diflunisal, etodolac, flurbiprofen, ibuprofen, indomethacin, ketorolac, meloxicam, nabumetone, naproxen,
oxaprozin, piroxicam, sulindac; COX-2 selective: celecoxib; Nonacetylated salicylates: diflunisal, magnesium salicylate. This list does not include NSAIDs rarely
or never used in the U.S. among older adults.
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iley.com
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icense
for many older adults and their caregivers. In general,
the panel did not account for drug costs to different
stakeholders when making decisions about which PIMs
to include in the criteria. However, costs of care may play
an important role in shared decision-making, and the
panel strongly encourages policymakers and health plans
to ensure that safer alternatives to PIMs are affordable so
that access to safe, appropriate treatment is not limited
and inequities are not exacerbated. In addition to drug
costs, costs of avoidable drug-related harms should be
considered as well.
While most of the criteria (i.e., those listed in Tables 2,
3, 5, and 6) generally use the “avoid” recommendation
noted above, Table 4 comprises drugs to “use with cau-
tion.” The intent of this “use with caution” table is to high-
light drugs that raise some cause for concern but not to the
level of an “avoid” recommendation. This can occur
because the evidence for the concern is limited or lacks
consistency, the degree of harm relative to alternative ther-
apies is not high enough to warrant an “avoid” recommen-
dation, or extenuating clinical circumstances are often
present. The panel encourages clinicians to recognize the
potential harms of these medications and, as the moniker
states, to use them with caution. We also remind readers
that drugs removed from the AGS Beers Criteria® due to
low usage or unavailability in the United States (Table 8)
are still considered potentially inappropriate per recom-
mendations of the 2019 AGS Beers Criteria® update.
Unless specified otherwise, the criteria are designed
to apply to adults 65 years old and older. The panel recog-
nizes that drug-related harms are typically more pro-
nounced in the “old-old” than in the “young-old” and in
persons with complex multimorbidity and frailty. Thus,
two older adults of the same age can have markedly dif-
ferent risks of drug-related harm. Certain criteria include
a specific age cutoff; these are provided when the evi-
dence is specific to that age group. However, for most cri-
teria, the evidence base is insufficient to set a specific age
threshold for applying the criteria or to set a threshold
for other factors that can increase the risk of medication-
related harms (e.g., functional and cognitive status, the
burden of multimorbidity, and polypharmacy). We
encourage clinicians to use common sense in applying
the criteria in clinical practice.
For some criteria, the panel distinguished between initi-
ating a medication versus continuing one already in long-
standing use. Such distinctions were considered by the
panel in cases when the evidence suggested differential risk
of harm in these two scenarios, when the evidence primar-
ily addressed initiation rather than a continuation, and/or
when other professional society recommendations made
this distinction. In a number of these criteria, the criteria
recommend avoiding initiating the drug in nonusers and
considering deprescribing among current users.
TABLE 7 Drugs with strong anticholinergic properties.
Antidepressants
Amitriptyline
Amoxapine
Clomipramine
Desipramine
Doxepin (>6 mg/day)
Imipramine
Nortriptyline
Paroxetine
Antiemetics
Prochlorperazine
Promethazine
Antihistamines (first-generation)
Brompheniramine
Chlorpheniramine
Cyproheptadine
Dimenhydrinate
Diphenhydramine
Doxylamine
Hydroxyzine
Meclizine
Promethazine
Triprolidine
Antimuscarinics (urinary incontinence)a
Darifenacin
Fesoterodine
Flavoxate
Oxybutynin
Solifenacin
Tolterodine
Trospium
Antiparkinsonian agents
Benztropine
Trihexyphenidyl
Antipsychotics
Chlorpromazine
Clozapine
Olanzapine
Perphenazine
Antispasmodics
Atropine
Clidinium-chlordiazepoxide
Dicyclomine
Homatropine
Hyoscyamine
Scopolamine
Skeletal muscle relaxants
Cyclobenzaprine
Orphenadrine
Note: This table is not a comprehensive list of all medications with
anticholinergic properties.
aData on whether certain bladder antimuscarinics confer greater
adverse cognitive effects than others lack consistent quality.
Oxybutynin has the best evidence for adverse cognitive effects.
However, caution is warranted for all bladder antimuscarinics
given their potential anticholinergic effects.20
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TABLE 8 Medications/criteria removed since 2019 American Geriatrics Society Beers Criteria®a.
Medication/Criterion Reason for removalb
Independent of diagnosis or condition (Table 2)
Carbinoxaminec Low use
Clemastinec Low use
Dextrobromphiniraminec Not on the U.S. market
Dexchlorpheniraminec Low use
Pyrilaminec Not on the U.S. market
Belladonna alkaloidsc Not on the U.S. market
Methscopolaminec Low use
Propanthelinec Not on the U.S. market
Guanabenz Not on the U.S. market
Methyldopa Not on the U.S. market
Reserpine (>0.1 mg/day) Not on the U.S. market
Disopyramidec Low use
Protriptylinec Low use
Trimipraminec Low use
Amobarbital Low use, available only as an injection
Butobarbital Low use
Mephobarbital Not on the U.S. market
Pentobarbital Not on the U.S. market
Secobarbital Not on the U.S. market
Flurazepam Low use
Quazepam Low use
Isoxsuprine Not on the U.S. market
Chlorpropamide Not on the U.S. market
Fenoprofen Low use
Ketoprofen Low use
Meclofenamate Low use
Mefenamic acid Low use
Tolmetin Not on the U.S. market
Considering disease and syndrome interactions (Table 3)
Heart failure
Rosiglitazone Not on the U.S. market
Syncope
Thioridazinec Low use
Delirium
Meperidine Specific mention of meperidine was removed from this criterion because it is subsumed
under the general category of opioids, which was added to this criterion.
Ranitidine Removed from the U.S. market
Clinically important drug–drug interactions (Table 5)
Corticosteroids, oral or
parenteral + NSAIDs
Incorporated into oral NSAIDs criterion in Table 2
Warfarin + NSAIDs Incorporated into oral NSAID criterion in Table 2 (i.e, recommendation to avoid short-term
regular, scheduled use of NSAIDs in older adults taking an anticoagulant)
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Applying the criteria to policy and practice
The panel continues to be aware of and discuss the con-
troversies and misinformation about the proper interpre-
tation of the AGS Beers Criteria®. As such, the panel
advises users of the criteria to read and use guidance
from companion articles written to accompany the 2015
and 2019 AGS Beers Criteria® that advise patients,
providers, and health systems on how to use (and not
use) the AGS Beers Criteria®, as these recommendations
are applicable to the 2023 update.21,22 Key recommenda-
tions from those articles are summarized in Table 11.
Certain clarifications to items in the table and additional
considerations that arose during the 2023 update panel
discussion merit special note. First, as noted above, differ-
ent older adults may have markedly different risks of
TABLE 8 (Continued)
Medication/Criterion Reason for removalb
Medications that should be avoided or have their dosage reduced with reduced kidney function (Table 6)
Apixaban in patients with
CrCl <25 mL/min
Emerging evidence and clinical experience supporting safe use at lower
levels of renal function.
Ranitidine Removed from the U.S. market
Drugs with strong anticholinergic properties (Table 7)
Loxapine Low use
Trifluoperazone Low use
Abbreviations: CrCl, creatinine clearance; NSAIDs, nonsteroidal anti-inflammatory drugs.
aDrugs removed from Tables 2–6 on account of low usage or unavailability in the U.S. are still considered potentially inappropriate per recommendations in the
2019 AGS Beers Criteria®4 update. Enhanced attention to these drugs may be necessary for countries outside the U.S., where they may be more widely used.
bNot on the U.S. market = no product is currently marketed in the U.S. (although a product could be marketed in the future); this is not the same as being
removed from the U.S. market.
cRemoved from Table 7 as well.
TABLE 9 Medications/criteria added since 2019 American Geriatrics Society Beers Criteria®.
Medication/Criterion Reason for addition
Independent of diagnosis or condition (Table 2)
Warfarin Emerging data and changes in national recommendations/expert guidance
Considering disease and syndrome interactions (Table 3)
Heart failure
Dextromethorphan-quinidine Supported by package insert
Delirium
Opioids Emerging data
History of falls or fractures
Anticholinergics
Emerging data and consistency across recommendations
Use with caution (Table 4)
Ticagrelor Emerging data
Sodium-glucose co-transporter-2 (SGLT2) inhibitors Emerging data and clinical concern
Clinically important drug–drug interactions (Table 5)
Skeletal muscle relaxants added to any combination
of ≥3 of these CNS-active drugs
Concern for adverse effects when used in combination with
other CNS-active drugs
Lithium + ARBs and ARNIs Supported by data and reference sources
Warfarin + SSRIs Supported by data
Medications that should be avoided or have their dosage reduced with reduced kidney function (Table 6)
Baclofen Data supporting concern
Note: The updated version of the criteria includes specific lists of drugs that were not included in prior versions. These lists are meant to enhance clarity and
searchability, and unless stated otherwise do not change the intent of the prior version of the criteria.
Abbreviations: ARBs, angiotensin receptor blockers; ARNIs, angiotensin receptor-neprilysin inhibitors; CNS, central nervous system; SSRIs, selective serotonin
reuptake inhibitors.
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TABLE 10 Medications/criteria modified since 2019 American Geriatrics Society Beers Criteria®.
Medication/Criterion Modification
Independent of diagnosis or condition (Table 2)
Aspirin Moved from Table 4 to Table 2 on basis of new evidence.
Rivaroxaban Moved from Table 4 to Table 2 on basis of accumulating evidence
Dronedarone Clarified to reflect data about potential risks in people with non-severe forms of
heart failure
Digoxin Added statement clarifying that caution should be used discontinuing digoxin among
current users with HFrEF.
Antidepressants with strong
anticholinergic activity
Clarified that this criterion refers to antidepressants with strong anticholinergic
activity
Antipsychotics Updated language to reflect new evidence and enhance clarity
Benzodiazepines Clarified language
Androgens Clarified that androgens pose potential risks but are not firmly contraindicated in
men with a history of prostate cancer.
Estrogens, systemic Provided additional information, supported by data
Sulfonylureas Expanded criterion from long-acting sulfonylureas to all sulfonylureas given data
supporting adverse outcomes for all sulfonylureas.
Proton pump inhibitors Noted additional adverse outcomes in the rationale statement given supporting data.
NSAIDs, oral Clarified application in high-risk scenarios for short-term use (i.e., including drug–
drug interactions such as with warfarin)
Skeletal muscle relaxants Clarified language to differentiate skeletal muscle relaxants typically used for
musculoskeletal complaints from those used to treat spasticity.
Considering disease and syndrome interactions (Table 3)
Syncope—TCAs
Amitriptyline
Clomipramine
Doxepin
Imipramine
Clarified that the tertiary TCAs referenced by this criterion include those listed here.
Dementia
Antipsychotics
Modified language to reflect data and enhance clarity
Delirium Updated rationale to comment on opioids and enhance clarity
History of falls or fracture Antidepressants Level of evidence lowered from “high” to “moderate” based on evidence; updated
rationale to reflect new evidence and enhance clarity.
Parkinson disease Rationale shortened for clarity.
Urinary incontinence in women Modified language to enhance clarity
Use with caution (Table 4)
Prasugrel Adding dosing consideration, supported by American College of Cardiology/
American Heart Association guidelines.
Dextromethorphan-quinidine Added heart failure concerns, supported by package insert.
Trimethoprim-sulfamethoxazole Added ARNIs for completeness (given that they contain ARBs).
Clinically important drug–drug interactions (Table 5)
Opioid + benzodiazepine Modified to include risk for adverse effects; supported by data.
Anticholinergic + anticholinergic Modified to recognize specific adverse events.
Use of ≥3 CNS active agents Clarified classes of medications of concern; level of evidence raised to “high.”
Warfarin Consolidated interacting drugs into a list versus reporting as separate lines for each
interaction.
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experiencing severe medication-related harms, with
advanced age, cognitive and physical impairment, multi-
morbid burden, frailty, renal impairment, and a high
degree of polypharmacy each conferring risk. A person's
underlying risk of experiencing drug-related harms
should inform decisions about using drugs in the criteria.
Second, close attention to the recommendations is essen-
tial to avoid misinterpretation; many criteria note excep-
tions and other considerations and should not be overly
simplified as “avoid in everyone over age 65.” Third, the
risk of harm arises not just from drugs considered in isola-
tion but from how multiple drugs affect an older adult
when given together. Thus, evaluations of medication
appropriateness should be made in the context of the total-
ity of a person's medication regimen and their goals of care.
Fourth, the intent of the AGS Beers Criteria® is not simply
to swap out a better drug in place of a worse one. In many
cases, nonpharmacologic treatments (or no treatment at
all) may be preferable. Finally, the panel affirms the impor-
tance of shared decision-making in selecting and changing
treatment regimens. There may be situations in which ini-
tiating or continuing a drug on the criteria is reasonable
because it is consistent with an older person's stated prefer-
ences, values, and treatment goals.
Deprescribing
Successful deprescribing of medications on the AGS
Beers Criteria® involves much more than a clinician sim-
ply telling an older person to stop taking a medication.
Communication gaps and misunderstandings, patient
reluctance and fear of stopping, coordination among mul-
tiple clinicians, dosage tapering, withdrawal symptoms,
and conveying stop orders to pharmacies are just some of
the challenges that can arise. The panel encourages clini-
cians to be aware of and develop skills to address these
challenges. Useful resources include:
• https://deprescribing.org/resources/—deprescribing
resources, especially evidence-based guidelines and
easy-to-use algorithms about when and how to stop
common types of medications
• https://www.deprescribingnetwork.ca/professionals—
resources for healthcare professionals, including
deprescribing-oriented patient handouts about medica-
tions that are commonly inappropriate for older adults
Systemic solutions are essential as well, for example
increasing the adoption of the CancelRx Script Standard
to communicate to pharmacies when a drug is stopped
and should no longer be refilled.
TABLE 10 (Continued)
Medication/Criterion Modification
Medications that should be avoided or have their dosage reduced with reduced kidney function (Table 6)
Nitrofurantoin Existing recommendations from Table 2 are duplicated in Table 6 to enhance clarity
and usability.
Trimethoprim-sulfamethoxazole Added clarifying language to support clinical usability.
Rivaroxaban Clarified CrCl cutoffs per available evidence and package insert.
NSAIDs Moved this criterion from Table 3 for greater consistency; clarified language.
Abbreviations: ARB, angiotensin receptor blocker; ARNI, angiotensin receptor-neprilysin inhibitor; CNS, central nervous system; CrCl, creatinine clearance.
aIn addition to the changes listed above, a number of formatting and other changes were made to enhance clarity and usability without changing the meaning
of the criteria. This includes specific lists of drugs that were not included in prior versions; these lists are meant to enhance clarity and searchability, and unless
stated otherwise do not change the intent of the prior version of the criteria.
TABLE 11 Principles for how patients, clinicians, health
systems, and payors should use the AGS Beers Criteria®.
Medications in the AGS Beers Criteria® are potentially
inappropriate, not definitely inappropriate.
Read the rationale and recommendations statements for each
criterion. The caveats and guidance listed there are
important.
Understand why medications are included in the AGS Beers
Criteria® and adjust your approach to those medications
accordingly.
Optimal application of the AGS Beers Criteria® involves
identifying PIMs and, when appropriate, offering safer
nonpharmacologic and pharmacologic therapies.
The AGS Beers Criteria® should be a starting point for a
comprehensive process of identifying and improving
medication appropriateness and safety.
Access to medications included in the AGS Beers Criteria®
should not be excessively restricted by prior authorization
and/or health plan coverage policies.
The AGS Beers Criteria® are not equally applicable to all
countries (because of cross-national differences in drug
availability).
Source: Adapted from Steinman et al.21,22
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Strengths and limitations
As with previous versions of the AGS Beers Criteria®, this
update is subject to the same limitations. First, the evi-
dence available is often plagued by the small number of
clinical trials in older adults or by the lack of inclusion of
a sufficient number of older adults to conduct an age-
specific analysis. The panel often relied on observational
studies and meta-analyses for evidence of harm and
whether the harm was more common or resulted in more
serious outcomes in older adults.
Second, the lack of diversity in study populations was
another challenge to the panel. Inadequate enrollment of
underrepresented, disproportionately affected, and
understudied populations in clinical trials is a distress-
ingly well-described phenomenon. In the evidence the
panel reviewed, a seemingly larger number of studies
identified were generated within a specific country, pos-
sibly contributing to greater racial and ethnic homogene-
ity among study participants. Even when more diverse
populations were included in a study, there was often
inadequate power to determine outcomes by specific
groups. Third, the criteria include only medications
available in the United States. Clinicians outside the
United States, with access to different medications from
the same drug class as those the criteria recommends
avoiding, will need to adapt the criteria to their local con-
text. Fourth, it is possible that our literature search did
not identify all published evidence that would have been
pertinent. Our search strategy did not include unpub-
lished studies, papers not published in English, white
papers, abstracts, technical reports, or other evidence
published in the “gray literature.”
Despite its limitations, the 2023 AGS Beers Criteria®
has its strengths. The panel and staff are highly experi-
enced; most have participated in updating the criteria
since 2012, and some since 2003. Their familiarity with
the process and modified Delphi technique is an advan-
tage. The panel also included ad hoc members from
important stakeholders, namely the Centers for Medicare
and Medicaid, the National Committee for Quality Assur-
ance, and the Pharmacy Quality Alliance, who provided
valuable insight and feedback throughout the process.
Robust internal review and external public comment pro-
cesses are additional strengths.
CONCLUSION
The 2023 update of the AGS Beers Criteria® includes
many modifications including a number of new and sig-
nificantly modified criteria and many minor changes in for-
matting and wording to enhance clarity and usability. To
support clinicians in practice, the AGS has released the
2023 AGS Beers Criteria® App as well as a pocket card,
both of which can be accessed via GeriatricsCareOnline.org.
As with past updates, the AGS has also created a suite of
public education materials that are available for free at
HealthinAging.org, a resource created by the AGS Founda-
tion for Health in Aging to bring the expertise of geriatrics
to the public. It is the hope of the AGS and the 2023 AGS
Beers Criteria® expert panel that the updated criteria will
be used as intended—to improve drug therapy and out-
comes for all of us as we age by identifying and reducing
prescribing of PIMs in older adults through a process of
shared decision-making that focuses on goals of care.
AUTHOR CONTRIBUTIONS
All panel members contributed to the concept and
design, acquisition of subjects and/or data, analysis, and
interpretation of data, and preparation of the manuscript.
ACKNOWLEDGMENTS
The decisions and content of the 2023 AGS Beers
Criteria® are those of the AGS and the panel members
and are not necessarily those of the U.S. government or
the U.S. Department of Veterans Affairs.
Sue Radcliff, Independent Researcher from Denver,
Colorado, provided research services. Jirong Yue provided
additional research services. Susan E. Aiello, DVM, ELS,
provided editorial services. Laura Banks, Aimee Cegelka,
Elvy Ickowicz, MPH, and Mary Jordan Samuel provided
additional research, technical, and administrative support.
Thanks to the AGS Executive Committee and the Chairs/
Vice Chairs of the AGS CPMC, Ethnogeriatrics, and QPMC
Committees. The panel must also acknowledge the work of
the late Mark H. Beers, MD, whose vision for a better qual-
ity 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: AMDA—The Society for Post-Acute and Long-
Term Care Medicine, American Academy of Neurology,
American Academy of Nursing, American Association of
Clinical Endocrinologists, American College of Clinical
Pharmacy, American College of Emergency Physicians,
American Pharmacists Association, American Public
Health Association, American Psychiatric Nurses Associ-
ation, American Society of Anesthesiologists, American
Society of Consultant Pharmacists, American Society of
Health-System Pharmacists, American Society of
Nephrology, American Urological Association, Centers
for Medicare and Medicaid Systems, Gerontological
Advanced Practice Nurses Association, National Council
on Aging, National Committee on Quality Assurance,
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Nurses Improving Care for Healthsystem Elders, Phar-
macy Quality Alliance, and Society of Urodynamics,
Female Pelvic Medicine & Urogenital Reconstruction.
FUNDING INFORMATION
There was no sponsor for this paper.
CONFLICT OF INTEREST STATEMENT
Drs. Brandt, Digmann, DuBeau, Dombrowski, Flanagan,
George, Harrington, Hines, Hollmann, Laird, and Steinman
had no conflicts to disclose. Dr. Beizer is a consultant to Lex-
iComp, Inc., a Wolters-Kluwer company. Dr. Fick is a con-
sultant for Precision Health Economics. Dr. Holmes receives
grant funding from Blue Cross/Blue Shield for a study on
deprescribing. Dr. Linnebur is a Committee Member for
both the Colorado Access Pharmacy and Therapeutics Com-
mittee and the CVS Pharmacy and Therapeutics Committee
and has received honoraria from Springer Nature and Merck
Manuals. Dr. Semla is a consultant to UnitedHealthcare and
to LexiComp, Inc., a Wolters-Kluwer company; his spouse
holds shares of Abbvie and Abbott stock.
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SUPPORTING INFORMATION
Additional supporting information can be found online
in the Supporting Information section at the end of this
article.
Appendix S1. Supporting information.
AGS 2023 BEERS CRITERIA® 29
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How to cite this article: By the 2023 American
Geriatrics Society Beers Criteria® Update Expert
Panel. American Geriatrics Society 2023 updated
AGS Beers Criteria® for potentially inappropriate
medication use in older adults. J Am Geriatr Soc.
2023;1‐30. doi:10.1111/jgs.18372
APPENDIX A: PANEL MEMBERS AND
AFFILIATIONS
The following individuals were members of the AGS Panel
convened to update the 2023 AGS Beers Criteria®: (co-
chair) Todd P. Semla, PharmD, MS, BCPG, FCCP, AGSF,
Northwestern University Feinberg School of Medicine,
Chicago, IL; (co-chair) Michael Steinman, MD, University
of California San Francisco and San Francisco Veterans
Affairs Medical Center, San Francisco, CA; (co-chair)
Judith Beizer, PharmD, BCGP, FASCP, AGSF, St. John's
University, Queens, NY; Nicole Brandt, PharmD, MBA,
BCPP, BCGP, FASCP, University of Maryland, Baltimore,
MD; Rachel Digmann, PharmD, Pharmacy Quality
Alliance, Alexandria, VA (nonvoting member); Robert
Dombrowski, PharmD, Centers for Medicare and Medic-
aid Services, Baltimore, MD (nonvoting member); Cather-
ine E. DuBeau, MD, Dartmouth-Hitchcock Medical
Center, Lebanon, NH; Donna M. Fick, PhD, RN, FGSA,
AGSF, FAAN, College of Nursing and Medicine, The
Pennsylvania State University, University Park, PA; Nina
Flanagan, PhD, GNP-BC, APHM-BC, Binghamton Univer-
sity, Vestal, NY; Claudene George, MD, MS, RPh, Monte-
fiore Medical Center, The Bronx, NY; Rachel Harrington,
PhD, National Committee for Quality Assurance,
Washington, DC (nonvoting member); Peter Hollmann,
MD, AGSF, Brown Medicine, Providence, RI; Holly
Holmes, MD, MS,AGSF, McGovern Medical School at UT
Health, Houston, TX; Rosemary Laird, MD, MHSA, AGSF,
Winter Park Memorial Hospital, Winter Park, FL; and
Sunny Linnebur, PharmD, FCCP, BCPS, BCGP, FASCP,
University of Colorado, Aurora, CO.
30 BY THE 2023 AMERICAN GERIATRICS SOCIETY BEERS CRITERIA® UPDATE EXPERT PANEL
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American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults
INTRODUCTION
OBJECTIVES
Key points
Why does this paper matter?
INTENT OF CRITERIA
METHODS
Panel composition
Literature review
Development process
RESULTS
Noteworthy changes to PIMS for older adults
DISCUSSION
Interpreting recommendations
Applying the criteria to policy and practice
Deprescribing
Strengths and limitations
CONCLUSION
AUTHOR CONTRIBUTIONS
ACKNOWLEDGMENTS
FUNDING INFORMATION
CONFLICT OF INTEREST STATEMENT
REFERENCES
APPENDIX A PANEL MEMBERS AND AFFILIATIONS