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 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 � 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 AGS 2023 BEERS CRITERIA® 3 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 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 4 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 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 AGS 2023 BEERS CRITERIA® 5 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 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 . 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 n ti h is ta m in es F ir st -g en er at io n an ti h is ta m in es B ro m ph en ir am in e C h lo rp h en ir am in e C yp ro h ep ta di n e D im en h yd ri n at e D ip h en h yd ra m in e (o ra l) D ox yl am in e H yd ro xy zi n e M ec liz in e Pr om et h az in e T ri pr ol id in e H ig hl y an ti ch ol in er gi c; cl ea ra nc e re du ce d w ith ad va nc ed ag e, an d to le ra nc e de ve lo ps w he n us ed as hy pn ot ic ;r is k of co nf us io n, dr y m ou th , co ns tip at io n, an d ot he r an tic ho lin er gi c ef fe ct s or to xi ci ty .C um ul at iv e ex po su re to an tic ho lin er gi c dr ug s is as so ci at ed w it h an in cr ea se d ri sk of fa lls , de lir iu m ,a nd de m en tia ,e ve n in yo un ge r ad ul ts . C on si de r to ta la nt ic ho lin er gi c bu rd en du ri ng re gu la r m ed ic at io n re vi ew s an d be ca ut io us in “y ou ng -o ld ” as w el la s “o ld -o ld ” ad ul ts . U se of di ph en h yd ra m in e in si tu at io n s su ch as ac ut e tr ea tm en t of se ve re al le rg ic re ac ti on s m ay be ap pr op ri at e. A vo id M od er at e St ro n g A n ti -i n fe ct iv e N it ro fu ra n to in Po te n ti al fo r pu lm on ar y to xi ci ty ,h ep at ox ic it y, an d pe ri ph er al n eu ro pa th y, es pe ci al ly w it h lo n g- te rm us e; sa fe r al te rn at iv es av ai la bl e. A vo id in in di vi du al s w it h C rC l< 30 m L / m in 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 -d 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 E xc ep ti on s: cl oz ap in e, pi m av an se ri n ,a n d qu et ia pi n e ap pe ar to be le ss li ke ly to pr ec ip it at e th e w or se n in g of Pa rk in so n di se as e th an ot h er an ti ps yc h ot ic s. A vo id M od er at e St ro n g G a st ro in te st in a l H is to ry of ga st ri c or du od en al ul ce rs A sp ir in N on -C O X -2 se le ct iv e N SA ID s M ay ex ac er ba te ex is ti n g ul ce rs or ca us e n ew /a dd it io n al ul ce rs A vo id 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 (i .e ., pr ot on -p um p in h ib it or or m is op ro st ol ). M od er at e St ro n g K id n ey /u ri n a ry tr a ct U ri n ar y in co n ti n en ce (a ll ty pe s) in w om en N on -s el ec ti ve pe ri ph er al al ph a- 1 bl oc ke rs e D ox az os in Pr az os in T er az os in E st ro ge n ,o ra la n d tr an sd er m al (e xc lu de s in tr av ag in al es tr og en ) A gg ra va ti on of in co n ti n en ce (a lp h a- 1 bl oc ke rs ), la ck of ef fi ca cy (o ra le st ro ge n ) A vo id in w om en Se e al so re co m m en da ti on on es tr og en (T ab le 2) N on -s el ec ti ve pe ri ph er al al ph a- 1 bl oc ke rs : M od er at e E st ro ge n :H ig h N on -s el ec ti ve pe ri ph er al al ph a- 1 bl oc ke rs :S tr on g E st ro ge n :S tr on g L ow er ur in ar y tr ac t sy m pt om s, be n ig n pr os ta ti c h yp er pl as ia St ro n gl y an ti ch ol in er gi c dr ug s, ex ce pt an ti m us ca ri n ic s fo r ur in ar y in co n ti n en ce (s ee T ab le 7) M ay de cr ea se ur in ar y fl ow an d ca us e ur in ar y re te n ti on A vo id in m en M od er at e St ro n g A bb re vi at io n s: A C h E I, ac et yl ch ol in es te ra se in h ib it or ;C C B s, ca lc iu m ch an n el bl oc ke rs ;C N S, ce n tr al n er vo us sy st em ;C O PD ,c h ro n ic ob st ru ct iv e pu lm on ar y di se as e; 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 ; N SA ID s, n on st er oi da la n ti -i n fl am m at or y dr ug s; SN R Is ,s er ot on 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 up ta ke in h ib it or s; T C A s, tr ic yc li c an ti de pr es sa n ts . 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 M ay be re qu ir ed to tr ea t co n cu rr en t sc h iz op h re n ia ,b ip ol ar di so rd er ,a n d ot h er se le ct ed m en ta lh ea lt h an d n eu ro ps yc h ia tr ic co n di ti on s bu t sh ou ld be pr es cr ib ed in th e lo w es t ef fe ct iv e do se an d fo r th e sh or te st po ss ib le du ra ti on . d E xc lu de s in h al ed an d to pi ca lf or m s. O ra la n d pa re n te ra lc or ti co st er oi ds m ay be re qu ir ed fo r co n di ti on s su ch as ex ac er ba ti on of C O PD bu t sh ou ld be pr es cr ib ed in th e lo w es t ef fe ct iv e do se an d fo r th e sh or te st po ss ib le du ra ti on . e 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. 16 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 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 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 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. 18 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 5 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 cl in ic al ly im po rt an t dr ug –d ru g in te ra ct io n s th at sh ou ld be av oi de d in ol de r ad ul ts . 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 R A S in h ib it or s (A C E Is , A R B s, A R N Is ,a lis ki re n ) or po ta ss iu m -s pa ri n g di ur et ic s (a m ilo ri de , tr ia m te re n e) A n ot h er R A S in h ib it or or a po ta ss iu m - sp ar in g di ur et ic In cr ea se d ri sk of h yp er ka le m ia . A vo id ro ut in el y us in g 2 or m or e R A S in h ib it or s, or a R A S in h ib it or an d po ta ss iu m -s pa ri n g di ur et ic , co n cu rr en tl y in th os e w it h ch ro n ic ki dn ey di se as e St ag e 3a 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 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 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. 20 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 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) AGS 2023 BEERS CRITERIA® 21 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 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. 22 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 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 AGS 2023 BEERS CRITERIA® 23 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 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) 24 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 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. AGS 2023 BEERS CRITERIA® 25 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 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. 26 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 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 AGS 2023 BEERS CRITERIA® 27 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 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, 28 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 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. 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PMID: 36548636. 21. Steinman MA, Fick DM. Using wisely: a reminder on the proper use of the American Geriatrics Society Beers criteria®. J Am Ger- iatr Soc. 2019;67(4):644-646. doi:10.1001/jama.2022.4983 22. Steinman MA, Beizer JL, DuBeau CE, et al. How to use the American Geriatrics Society 2015 Beers Criteria—a guide for patients, clinicians, health systems, and payors. J Am Geriatr Soc. 2015;63:e1-e7. doi:10.1111/jgs.13701 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 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 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 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 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