GC079 (supp-4)ags Beers Criteria For Potentially Inappropriate Med Use: Pocket Guide: 2023
The 2023 AGS Beers Criteria is an evidence-based guideline listing medications that are potentially inappropriate for older adults (≥65 years) due to unfavorable risk–benefit profiles, intended to improve prescribing safety in geriatric care.
The 2023 AGS Beers Criteria® Pocket Guide is the clinical cheat-sheet version of the full AGS Beers Criteria publication. It catalogues Potentially Inappropriate Medications (PIMs) for adults ≥65 years old — drugs whose risks often outweigh benefits because of age-related pharmacokinetic and pharmacodynamic changes. It is one of two major inappropriate prescribing screening tools tested in HKUMed (the other being STOPP/START). For your exam, you need to know which drug classes are flagged, why they are dangerous in older adults, the specific exceptions, and the renal dose thresholds [1][2][3].
Learning Objectives
- Understand the origin, purpose, and limitations of the AGS Beers Criteria.
- Identify PIMs across major organ systems (Table 1).
- Recognise drug–disease/syndrome interactions that worsen specific geriatric conditions (Table 2).
- Know the "use with caution" category (Table 3) and why it differs from "avoid."
- Identify key drug–drug interactions to avoid in older adults (Table 4).
- Apply renal function-based dose adjustment or avoidance (Table 5).
- Apply principles of deprescribing and the anticholinergic burden concept.
Core Concepts and First Principles
Physiologic changes of aging alter pharmacokinetics (absorption, distribution, metabolism, excretion) and pharmacodynamics (receptor sensitivity). Reduced renal clearance, increased body fat, decreased hepatic blood flow, and BBB permeability changes all conspire to increase drug exposure and adverse effects [1].
| Pharmacokinetic Change | Clinical Consequence |
|---|---|
| ↓ Renal clearance (GFR falls ~1 mL/min/year after 40) | Accumulation of renally-cleared drugs (digoxin, DOACs, gabapentin) |
| ↓ Hepatic metabolism (Phase I > Phase II) | Prolonged half-life of benzodiazepines, TCAs |
| ↑ Body fat / ↓ lean mass | ↑ Volume of distribution for lipophilic drugs (diazepam) |
| ↓ Serum albumin | ↑ Free fraction of highly protein-bound drugs (warfarin, phenytoin) |
| ↑ CNS sensitivity | Greater sedation, delirium risk from anticholinergics, opioids, BZDs |
Key Principle — Not Definitely Inappropriate
The criteria are a blunt instrument. A PIM is not a "never use" — it means the risks often outweigh benefits in most older adults. Clinical judgment, patient values, and goals of care still apply. The Beers list should not be applied punitively or as an absolute formulary restriction. It is a starting point for medication review and deprescribing conversations [1][2].
- Adults ≥ 65 years old, all settings (ambulatory, acute, institutionalized) [1]
- Excludes hospice and end-of-life care — in palliative settings, comfort may override PIM concerns [1]
- Primarily designed for the US market, but principles are widely applicable (HK examiners may test general concepts rather than US-specific drug names)
- Reduce PIM exposure by improving medication selection
- Educate clinicians and patients
- Serve as a quality-of-care evaluation tool for drug use patterns and cost
Table-by-Table High-Yield Content
TABLE 1: PIMs Independent of Diagnosis or Condition
This is the most tested table. Drugs here are potentially inappropriate in any older adult regardless of comorbidities.
Avoid all first-generation antihistamines (brompheniramine, chlorpheniramine, cyproheptadine, dimenhydrinate, diphenhydramine oral, doxylamine, hydroxyzine, meclizine, promethazine, triprolidine) [1]
Why: Highly anticholinergic. Clearance ↓ with age, tolerance develops for hypnotic effect but anticholinergic toxicity persists. Cumulative anticholinergic exposure increases risk of falls, delirium, and dementia — even in "young-old" adults [1].
Exception: Diphenhydramine in acute severe allergic reaction may be appropriate.
Exam Trap — Anticholinergic Burden
Don't just look at one drug. Examiners may give a drug list and ask you to count the total anticholinergic burden. First-gen antihistamines, TCAs, GI antispasmodics, and some antipsychotics all contribute. The cumulative load matters more than any single agent.
| Drug | Recommendation | Rationale |
|---|---|---|
| Nitrofurantoin | Avoid if CrCl < 30 mL/min or for long-term suppression | Pulmonary toxicity, hepatotoxicity, peripheral neuropathy; safer alternatives exist [1] |
| Drug/Class | Recommendation | Why | QE/SR |
|---|---|---|---|
| Aspirin for primary prevention | Avoid initiation. Consider deprescribing in current users. | ↑ Major bleeding risk in older age; no net benefit for primary prevention. Still indicated for secondary prevention. | High/Strong |
| Warfarin for non-valvular AF or VTE | Avoid starting as initial therapy (use DOACs instead). Long-term users with well-controlled INR ( > 70% TTR) may continue. | Higher intracranial bleeding risk vs DOACs; similar or lower effectiveness | High/Strong |
| Rivaroxaban for long-term AF/VTE | Avoid in favour of safer DOACs (especially apixaban) | Higher GI and major bleeding risk vs other DOACs in older adults. Once-daily dosing may be reasonable if adherence is critical. | Moderate/Strong |
| Dipyridamole, oral short-acting | Avoid | Orthostatic hypotension; more effective alternatives. IV form OK for cardiac stress testing. | Moderate/Strong |
| Alpha-1 blockers (doxazosin, prazosin, terazosin) for HTN | Avoid as antihypertensive | High orthostatic hypotension risk; not recommended for routine HTN | Moderate/Strong |
| Central alpha-agonists (clonidine, guanfacine) for HTN | Avoid clonidine as first-line; avoid others entirely | CNS effects, bradycardia, orthostatic hypotension | Low/Strong |
| Nifedipine IR | Avoid | Hypotension → may precipitate myocardial ischaemia | High/Strong |
| Amiodarone | Avoid as first-line for AF unless HF or significant LVH | Greater toxicities than other antiarrhythmics | High/Strong |
| Dronedarone | Avoid in permanent AF or severe/decompensated HF | ↑ Mortality in these groups. Caution in HFrEF NYHA I-II. | High/Strong |
| Digoxin as first-line | Avoid as first-line for AF or HF. If used, dose ≤ 0.125 mg/day | Not first-line — safer rate control agents exist. ↓ Renal clearance → toxicity. Caution in discontinuing in HFrEF long-term users. | Low-Moderate/Strong |
High-Yield Anticoagulant Hierarchy for Older Adults
For non-valvular AF / VTE: Apixaban is the preferred DOAC (lowest bleeding risk). Dabigatran and rivaroxaban carry higher GI bleeding risk. Warfarin is last resort (highest intracranial haemorrhage risk). All DOACs have lower intracranial haemorrhage risk than warfarin [1].
| Drug/Class | Recommendation | Rationale |
|---|---|---|
| Anticholinergic antidepressants (amitriptyline, amoxapine, clomipramine, desipramine, doxepin > 6 mg/d, imipramine, nortriptyline, paroxetine) | Avoid | Highly anticholinergic, sedating, orthostatic hypotension. Doxepin ≤ 6 mg/d is comparable to placebo in safety. |
| Anticholinergic antiparkinsonian agents (benztropine oral, trihexyphenidyl) | Avoid | Not recommended for antipsychotic-induced EPS; better agents for PD exist. |
| Antipsychotics — all first and second generation | Avoid except for FDA-approved indications (schizophrenia, bipolar, PD psychosis, adjunctive MDD, short-term antiemetic) | ↑ Stroke, cognitive decline, mortality in dementia. Also ↑ mortality independent of dementia. For BPSD: only after non-pharmacologic approaches fail AND patient threatens harm. Periodic deprescribing attempts needed. |
| Barbiturates (butalbital, phenobarbital, primidone) | Avoid | High dependence, tolerance, overdose risk at low doses |
| Benzodiazepines — ALL (short- and long-acting) | Avoid | ↑ Sensitivity, ↓ metabolism; → cognitive impairment, delirium, falls, fractures, MVA. Abuse/addiction risk. With opioids → respiratory depression, death. May be appropriate for seizures, REM sleep behaviour disorder, BZD/ethanol withdrawal, severe GAD, periprocedural anaesthesia. |
| Z-drugs (eszopiclone, zaleplon, zolpidem) | Avoid | Same adverse events as BZDs; minimal improvement in sleep |
| Meprobamate | Avoid | High dependence, very sedating |
| Ergoloid mesylates | Avoid | No efficacy |
Exam Pearl — Shorter-Acting BZDs Are NOT Safer
Common misconception: shorter-acting benzodiazepines are safer than long-acting ones in the elderly. The Beers Criteria say ALL benzodiazepines should be avoided — shorter half-life does not eliminate fall, delirium, or fracture risk [1].
| Drug/Class | Recommendation | Why |
|---|---|---|
| Androgens (testosterone, methyltestosterone) | Avoid unless confirmed hypogonadism with symptoms | Cardiac risk, prostate cancer risk |
| Systemic estrogens | Do not initiate; consider deprescribing. Low-dose intravaginal estrogen is OK for dyspareunia/recurrent UTI/vaginal atrophy. | Carcinogenic (breast, endometrium), no cardio/cognitive protection. In women starting HRT ≥ 60: ↑ heart disease, stroke, clots, dementia. |
| Sliding-scale insulin (short/rapid-acting only, no basal) | Avoid | ↑ Hypoglycemia without improved glycemic control. Must have basal component. |
| Sulfonylureas — ALL | Avoid as first/second-line. If used, choose short-acting (glipizide) over long-acting (glyburide, glimepiride). | ↑ CV events, all-cause mortality, hypoglycemia. Long-acting agents → prolonged hypoglycemia. |
| Desiccated thyroid | Avoid | Cardiac effects; safer alternatives (levothyroxine) |
| Megestrol | Avoid | Minimal weight gain, ↑ thrombotic events, possibly death |
| Growth hormone | Avoid (unless confirmed GH deficiency from established cause) | Small body composition effect; edema, arthralgia, carpal tunnel, gynecomastia, impaired fasting glucose |
SFU Update 2023 — Now ALL Sulfonylureas
The 2019 Beers Criteria only flagged long-acting sulfonylureas. The 2023 update expanded to ALL sulfonylureas as first/second-line agents, reflecting evidence of increased CV events and mortality across the class. If you must use one, glipizide (short-acting) is safer than glyburide/glimepiride [1][2].
| Drug/Class | Recommendation | Why |
|---|---|---|
| PPIs | Avoid scheduled use > 8 weeks unless: erosive esophagitis, Barrett's, pathological hypersecretion, chronic NSAID/corticosteroid use, or failed discontinuation trial | C. difficile, pneumonia, GI malignancies, bone loss, fractures |
| Metoclopramide | Avoid (unless gastroparesis, ≤ 12 weeks) | Extrapyramidal effects, tardive dyskinesia; ↑ risk with frailty and prolonged use |
| GI antispasmodics (atropine, clidinium-chlordiazepoxide, dicyclomine, hyoscyamine, scopolamine) | Avoid | Highly anticholinergic, uncertain effectiveness |
| Mineral oil (oral) | Avoid | Aspiration risk |
| Drug | Recommendation | Why |
|---|---|---|
| Desmopressin | Avoid for nocturia/nocturnal polyuria | High risk of hyponatraemia; safer alternatives (including non-pharmacologic) |
| Drug/Class | Recommendation | Why |
|---|---|---|
| Non-COX-2 selective NSAIDs (chronic use) | Avoid unless alternatives fail AND gastroprotection (PPI or misoprostol) given | GI bleeding/PUD in ~1% at 3-6 months, ~2-4% at 1 year; ↑ BP, kidney injury. Dose-related. |
| Indomethacin, ketorolac | Avoid (even short-term) | Worst NSAID adverse effect profile; ↑ CNS effects (indomethacin), AKI |
| Meperidine | Avoid | Oral form not effective; neurotoxicity (delirium) > other opioids |
| Skeletal muscle relaxants (carisoprodol, chlorzoxazone, cyclobenzaprine, metaxalone, methocarbamol, orphenadrine) | Avoid | Anticholinergic effects, sedation, ↑ fractures. Does NOT apply to spasticity agents (baclofen, tizanidine). |
TABLE 2: Drug–Disease/Syndrome Interactions
This table answers the question: "Given this patient's comorbidity, which drugs will make it worse?"
| Disease/Syndrome | Drugs to Avoid | Why |
|---|---|---|
| Heart failure | Cilostazol, dextromethorphan-quinidine (avoid); Diltiazem, verapamil (avoid in HFrEF); Dronedarone, NSAIDs/COX-2 inhibitors, pioglitazone (avoid if symptomatic HF) | Fluid retention, ↑ mortality, QT prolongation |
| Syncope | Chlorpromazine, olanzapine (orthostatic hypotension); AChEIs (donepezil, galantamine, rivastigmine — bradycardia); Alpha-1 blockers (orthostatic); Tertiary TCAs (amitriptyline, clomipramine, doxepin, imipramine — orthostatic) | Exacerbate the mechanism causing syncope |
| Disease/Syndrome | Drugs to Avoid | Why |
|---|---|---|
| Delirium | Anticholinergics, antipsychotics, BZDs, oral/parenteral corticosteroids, H2RAs (cimetidine, famotidine, nizatidine), Z-drugs, opioids | Induce or worsen delirium. Antipsychotics only if non-pharm fails AND patient threatening harm. Steroids: lowest dose, shortest duration. Opioids: use validated pain tools + multimodal strategies. |
| Dementia / cognitive impairment | Anticholinergics, antipsychotics (chronic/persistent PRN), BZDs, Z-drugs | ↑ Stroke, cognitive decline, mortality. Antipsychotics: only when non-pharm fails AND threat of harm; periodic deprescribing. |
In patients with a history of falls or fractures, avoid (unless safer alternatives unavailable): anticholinergics, SSRIs, SNRIs, TCAs, antiepileptics, antipsychotics, BZDs, Z-drugs, opioids [1].
| Drugs to Avoid | Why |
|---|---|
| Metoclopramide, prochlorperazine, promethazine | Dopamine-receptor antagonists worsen PD |
| Most antipsychotics (except clozapine, pimavanserin, quetiapine) | D2 blockade worsens parkinsonism |
| Disease | Drugs to Avoid | Why |
|---|---|---|
| History of gastric/duodenal ulcer | Aspirin, non-COX-2 NSAIDs (unless gastroprotection given and no alternatives) | Exacerbate/cause new ulcers |
| Condition | Drugs to Avoid | Why |
|---|---|---|
| Urinary incontinence (women) | Alpha-1 blockers (doxazosin, prazosin, terazosin); oral/transdermal estrogen | Aggravate incontinence; oral estrogen lacks efficacy for UI |
| BPH / LUTS (men) | Strongly anticholinergic drugs (except antimuscarinics for UI) | ↓ Urinary flow, urinary retention |
"Use with caution" ≠ "Avoid." These drugs have some concern but either the evidence is weaker, the harm is less severe, or there are extenuating clinical circumstances [1][2].
| Drug/Class | Concern | Action |
|---|---|---|
| Dabigatran (long-term AF/VTE) | ↑ GI bleeding vs warfarin and vs apixaban | Prefer apixaban if possible |
| Prasugrel, ticagrelor | ↑ Major bleeding vs clopidogrel, especially ≥ 75 y | Lower prasugrel dose (5 mg) in ≥ 75 y. Benefits may offset risk in select patients. |
| Antidepressants (mirtazapine, SNRIs, SSRIs, TCAs), carbamazepine, oxcarbazepine, antipsychotics, diuretics, tramadol | SIADH / hyponatraemia | Monitor sodium closely when starting or changing dose |
| Dextromethorphan-quinidine | Limited efficacy in BPSD (OK for pseudobulbar affect); ↑ fall risk, drug interactions, HF concerns | Use with caution |
| TMP-SMX | ↑ Hyperkalaemia with ACEI/ARB/ARNI + ↓ CrCl | Monitor potassium |
| SGLT2 inhibitors | ↑ Urogenital infections (especially women, first month); euglycemic DKA | Monitor for infections and ketoacidosis |
This is extremely high-yield for exam MCQ scenarios where you're asked to identify a dangerous combination.
| Object Drug | Interacting Drug | Risk | Recommendation |
|---|---|---|---|
| RAS inhibitor or K+-sparing diuretic | Another RAS inhibitor or K+-sparing diuretic | Hyperkalaemia | Avoid routinely in CKD ≥ Stage 3a |
| Opioids | Benzodiazepines | Overdose, respiratory depression, death | Avoid |
| Opioids | Gabapentin / pregabalin | Severe sedation, respiratory depression, death | Avoid (except when transitioning off opioids or using gabapentinoids to reduce opioid dose — use caution) |
| Anticholinergic | Another anticholinergic | ↑ Cognitive decline, delirium, falls/fractures | Avoid; minimize number |
| ≥ 3 CNS-active drugs (from: antiepileptics/gabapentinoids, antidepressants, antipsychotics, BZDs, Z-drugs, opioids, skeletal muscle relaxants) | Any combination | ↑ Falls and fractures | Avoid concurrent ≥ 3; minimize CNS-active drugs |
| Lithium | ACEI / ARB / ARNI | Lithium toxicity | Avoid; monitor Li levels |
| Lithium | Loop diuretics | Lithium toxicity | Avoid; monitor Li levels |
| Alpha-1 blockers | Loop diuretics | ↑ Urinary incontinence in older women | Avoid in women unless both needed |
| Phenytoin | TMP-SMX | ↑ Phenytoin toxicity | Avoid |
| Theophylline | Cimetidine | ↑ Theophylline toxicity | Avoid |
| Theophylline | Ciprofloxacin | ↑ Theophylline toxicity | Avoid |
| Warfarin | Amiodarone, ciprofloxacin, macrolides (not azithromycin), TMP-SMX, SSRIs | ↑ Bleeding risk | Avoid when possible; monitor INR closely if used |
The 'Rule of 3' for CNS-Active Drugs
Concurrent use of ≥ 3 CNS-active drug types significantly increases fall and fracture risk. Count across these categories: antiepileptics/gabapentinoids, antidepressants, antipsychotics, BZDs, Z-drugs, opioids, skeletal muscle relaxants. Examiners love to present a polypharmacy list and ask you to identify this violation [1].
TABLE 5: Renal Function-Based Dose Adjustment or Avoidance
This table is critical because older adults frequently have reduced CrCl. Know the thresholds.
| Drug | CrCl Threshold | Action |
|---|---|---|
| Ciprofloxacin | < 30 | Reduce dose — ↑ CNS effects (seizures, confusion), tendon rupture |
| Nitrofurantoin | < 30 | Avoid — pulmonary/hepato/neuropathy |
| TMP-SMX | < 30 | Reduce if CrCl 15-29; avoid if < 15 — ↑ renal injury, hyperkalaemia |
| Drug | CrCl Threshold | Action |
|---|---|---|
| Amiloride | < 30 | Avoid — hyperkalaemia, hyponatraemia |
| Dabigatran | < 30 | Avoid — no efficacy/safety data. Dose adjust if > 30 with DDIs |
| Dofetilide | < 60 / < 20 | Reduce dose 20-59; avoid < 20 — QTc prolongation, TdP |
| Edoxaban | 15-50 / < 15 or > 95 | Reduce dose 15-50; avoid < 15 or > 95 |
| Enoxaparin | < 30 | Reduce dose — ↑ bleeding |
| Fondaparinux | < 30 | Avoid — ↑ bleeding |
| Rivaroxaban | < 50 / < 15 | Reduce 15-50 (per indication); avoid < 15 |
| Spironolactone | < 30 | Avoid — hyperkalaemia |
| Triamterene | < 30 | Avoid — hyperkalaemia, hyponatraemia |
| Drug | Threshold | Action |
|---|---|---|
| Baclofen | eGFR < 60 | Avoid — encephalopathy risk requiring hospitalisation. If unavoidable: lowest dose + monitor mental status. New in 2023. |
| Duloxetine | CrCl < 30 | Avoid — ↑ GI adverse effects |
| Gabapentin | CrCl < 60 | Reduce dose — CNS effects |
| Levetiracetam | CrCl ≤ 80 | Reduce dose — CNS effects |
| NSAIDs (all types) | CrCl < 30 | Avoid — ↑ AKI, further renal decline |
| Pregabalin | CrCl < 60 | Reduce dose — CNS effects |
| Tramadol | CrCl < 30 | IR: reduce dose; ER: avoid — CNS effects |
| Drug | Threshold | Action |
|---|---|---|
| Cimetidine, famotidine, nizatidine | CrCl < 50 | Reduce dose — mental status changes |
| Drug | Threshold | Action |
|---|---|---|
| Colchicine | CrCl < 30 | Reduce dose; monitor — GI, neuromuscular, bone marrow toxicity |
| Probenecid | CrCl < 30 | Avoid — loss of effectiveness |
Clinical Approach to Medication Review in Older Adults
- List all medications (prescription, OTC, supplements, herbal)
- Screen against Beers Criteria Tables 1-5 and STOPP/START
- Calculate total anticholinergic burden using standardised scales
- Count CNS-active drugs — flag if ≥ 3
- Check renal function (CrCl by Cockcroft-Gault) and cross-reference Table 5
- Assess drug-disease interactions (Table 2) against the patient's problem list
- Prioritise deprescribing — start with the drug most likely causing harm
- Engage patient/family in shared decision-making about goals of care
- Implement one change at a time (if non-urgent) — monitor for withdrawal effects or symptom recurrence
- Document rationale and schedule follow-up review
- Taper gradually (especially BZDs, opioids, antiepileptics, corticosteroids)
- Monitor for withdrawal syndromes and disease recurrence
- Communicate to pharmacy (cancel repeat prescriptions)
- Use evidence-based deprescribing algorithms (deprescribing.org)
Integration with Related GC Material
| Feature | Beers Criteria | STOPP/START |
|---|---|---|
| Origin | USA (AGS) | Europe/Ireland |
| Format | Drug-centred explicit list | Drug-disease pairs (STOPP) + omission screening (START) |
| Scope | What to avoid/caution | STOPP: what to stop; START: what to start (under-prescribing) |
| Unique value | Renal dosing table; DDI table | Identifies prescribing omissions (e.g., statin not prescribed in high CV risk) |
| Exam use | Often tested as "is this drug appropriate?" | Tested as "what is missing from this patient's regimen?" |
For exams, know both — they are complementary. Beers is better for "what to avoid," STOPP/START is better for "what's missing" [4][5].
- Falls risk medications: BZDs, Z-drugs, anticholinergics, opioids, antipsychotics, SSRIs/SNRIs, antiepileptics
- Table 2 (falls/fractures) and Table 4 (≥ 3 CNS-active drugs) directly feed into falls risk assessment
- Anticholinergics accelerate cognitive decline
- Antipsychotics increase stroke and mortality in dementia — use only after non-pharm measures fail
- AChEIs can cause bradycardia → syncope (Table 2)
- Start low, go slow
- One drug change at a time
- Consider non-pharmacological alternatives
- Regular medication review
Exam Intelligence
-
MCQ Stem: "An 82-year-old woman with CKD Stage 4 (CrCl 22 mL/min) is prescribed nitrofurantoin for recurrent UTI. Which is the most appropriate action?" → Avoid; use alternative antibiotic.
-
SAQ: "List 4 classes of medications from the Beers Criteria that increase fall risk in older adults." → BZDs, Z-drugs, anticholinergics, opioids, antipsychotics, SSRIs/SNRIs, antiepileptics.
-
Mini-case: "A 75-year-old man with non-valvular AF is currently on warfarin with a TTR of 45%. What anticoagulant change would you recommend?" → Switch to apixaban (preferred DOAC); avoid rivaroxaban (higher bleeding risk).
-
MCQ: "Which of the following is an appropriate exception to avoiding benzodiazepines in older adults?" → Seizure disorder, REM sleep behaviour disorder, BZD withdrawal, ethanol withdrawal, severe GAD, periprocedural anaesthesia.
-
SAQ: "Explain why sliding-scale insulin without basal insulin is inappropriate in older adults." → Higher hypoglycemia risk (especially dangerous in elderly — falls, cardiac events, confusion) without improving hyperglycemia management.
| Trap | Truth |
|---|---|
| "Lorazepam is safe because it's short-acting" | ALL BZDs are on the Beers list; shorter half-life ≠ safer |
| "Paroxetine is an SSRI so it's fine in the elderly" | Paroxetine is the most anticholinergic SSRI → listed under anticholinergic antidepressants to avoid |
| "Aspirin is always good for cardiovascular protection" | Avoid for primary prevention in ≥ 65; only for secondary prevention |
| "PPIs are harmless" | Avoid > 8 weeks unless specific indications (erosive esophagitis, Barrett's, chronic NSAID use, etc.) |
| "Digoxin is a first-line drug for AF" | Avoid as first-line; if used, ≤ 0.125 mg/day |
| "Low-dose vaginal estrogen is dangerous" | It is acceptable and safe for vaginal symptoms; systemic estrogen is the one to avoid |
- Apixaban vs Rivaroxaban vs Dabigatran: Apixaban preferred (lowest bleeding). Rivaroxaban: higher bleeding. Dabigatran: higher GI bleeding but less intracranial bleeding than warfarin.
- Glipizide vs Glyburide: If SFU must be used, glipizide (short-acting) is safer. Glyburide (long-acting) → prolonged hypoglycemia.
- Clozapine/Quetiapine/Pimavanserin vs Other Antipsychotics in PD: These three are exceptions — less likely to worsen parkinsonism. All other antipsychotics should be avoided in PD.
High Yield Summary
- Summary
- The 2023 AGS Beers Criteria Pocket Guide is organised into 5 tables: (1) PIMs independent of diagnosis — key drug classes to AVOID include first-gen antihistamines, BZDs, Z-drugs, anticholinergic TCAs, antipsychotics (except specific indications), barbiturates, sliding-scale insulin, all sulfonylureas as first/second-line, PPIs > 8 weeks, chronic NSAIDs, meperidine, skeletal muscle relaxants, aspirin for primary prevention, warfarin/rivaroxaban when DOACs are available; (2) Drug–disease interactions — avoid anticholinergics/BZDs/antipsychotics in delirium and dementia, avoid non-DHP CCBs/NSAIDs/pioglitazone in HF, avoid dopamine antagonists in PD; (3) Use with caution — dabigatran (prefer apixaban), prasugrel/ticagrelor (bleeding), SIADH-causing drugs, SGLT2i (infections/DKA); (4) Drug–drug interactions — opioids + BZDs → death, ≥ 3 CNS-active drugs → falls, anticholinergic stacking; (5) Renal dosing — know the CrCl thresholds for DOACs, gabapentin, baclofen, NSAIDs, nitrofurantoin, colchicine. The criteria apply to ≥ 65 years, all settings except hospice, and are a guide (not absolute prohibition) — always apply clinical judgment and shared decision-making.
Active Recall - AGS Beers Criteria 2023 Pocket Guide
[1] GC 079 (supp-4)AGS Beers Criteria for potentially inappropriate med use_Pocket Guide_2023.pdf (Tables 1-5, all pages) [2] GC 079 (supp-3)AGS Beers Criteria for potentially inappropriate med use_2023.pdf (full article, Tables 1-11) [3] American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults.pdf (full article) [4] GC 079 (supp-1)STOPP-START criteria for potentially inappropriate prescribing in older 2023.pdf [5] GC 079 (supp-2)STOPP-START-V3.pdf [6] AOS - Geriatrics.pdf (Beers Criteria section, p18) [7] Geriatrics AOS.pdf (Beers Criteria section, p18)
GC079 (supp-3)ags Beers Criteria For Potentially Inappropriate Med Use: 2023
The 2023 AGS Beers Criteria is an evidence-based guideline identifying medications that are potentially inappropriate for older adults (≥65 years) due to unfavorable risk-benefit profiles, aimed at optimizing prescribing safety in geriatric care.
GC080 Renal Replacement Therapies
Renal replacement therapies are life-sustaining treatments—including hemodialysis, peritoneal dialysis, and kidney transplantation—that substitute for lost kidney function in patients with end-stage renal disease.