Appendix C: Beers Criteria
TABLE C.1
2019 AMERICAN GERIATRICS SOCIETY BEERS CRITERIA FOR POTENTIALLY INAPPROPRIATE MEDICATION USE IN OLDER ADULTS
| Organ System, Therapeutic Category, Drugs | Rationale | Recommendation | Quality of Evidence | Strength of Recommendation |
|---|---|---|---|---|
| Anticholinergics | ||||
| First-generation antihistamines Brompheniramine Carbinoxamine Chlorpheniramine Clemastine Cyproheptadine Dexbrompheniramine Dexchlorpheniramine Dimenhydrinate Diphenhydramine (oral) Doxylamine Hydroxyzine Meclizine Promethazine Pyrilamine Triprolidine | Highly anticholinergic; clearance reduced with advanced age, and tolerance develops when used as hypnotic; risk of confusion, dry mouth, constipation, and other anticholinergic effects or toxicity. Use of diphenhydramine in situations such as acute treatment of severe allergic reaction may be appropriate. | Avoid | Moderate | Strong |
| Antiparkinsonian Agents | ||||
| Benztropine (oral) Trihexyphenidyl | Not recommended for prevention of extrapyramidal symptoms with antipsychotics; more effective agents available for treatment of Parkinson disease. | Avoid | Moderate | Strong |
| Antispasmodics Atropine (excludes ophthalmic) Belladonna alkaloids Clidinium-chlordiazepoxide Dicyclomine Homatropine (excludes ophthalmic) Hyoscyamine Methscopolamine Propantheline Scopolamine | Highly anticholinergic, uncertain effectiveness. | Avoid | Moderate | Strong |
| Antithrombotics | ||||
| Dipyridamole, oral short-acting (does not apply to the extended-release combination with aspirin) | May cause orthostatic hypotension; more effective alternatives available; intravenous form acceptable for use in cardiac stress testing. | Avoid | Moderate | Strong |
| Anti-Infective | ||||
| Nitrofurantoin | Potential for pulmonary toxicity, hepatotoxicity, and peripheral neuropathy, especially with long-term use; safer alternatives available. | Avoid in individuals with creatinine clearance <30 mL/min or for long-term suppression. | Low | Strong |
| Cardiovascular | ||||
| Peripheral alpha-1 blockers for treatment of hypertension Doxazosin Prazosin Terazosin | High risk of orthostatic hypotension and associated harms, especially in older adults; not recommended as routine treatment for hypertension; alternative agents have superior risk–benefit profile. | Avoid use as an antihypertensive. | Moderate | Strong |
| Central alpha agonists Clonidine for first-line treatment of hypertension Other Guanabenz Guanfacine Methyldopa Reserpine (>0.1 mg/d) | High risk of adverse | Avoid clonidine as first-line antihypertensive. Avoid others as listed. | Low | Strong |
| Disopyramide | May induce heart failure in older adults due to potent negative inotropic action; strongly anticholinergic; other antiarrhythmic drugs preferred. | Avoid. | Low | Strong |
| Dronedarone | Worse outcomes have been reported in clients taking dronedarone who have permanent atrial fibrillation or severe or recently decompensated heart failure. | Avoid in individuals with permanent atrial fibrillation or severe or recently decompensated heart failure. | High | Strong |
| Digoxin | Use in atrial fibrillation: should not be used as a first-line agent in atrial fibrillation because there are safer and more effective alternatives for rate control supported by high-quality evidence. | Avoid as first-line therapy for atrial fibrillation. | Atrial fibrillation: low | Atrial fibrillation: strong |
| Use in heart failure: evidence for benefits and harms of digoxin is conflicting and of lower quality; most but not all of the evidence concerns use in | Avoid as first-line therapy for heart failure. | Heart failure: low | Heart failure: strong | |
| Decreased renal clearance of digoxin may lead to increased risk of toxic effects; further dose reduction may be necessary in clients with stage 4 or 5 chronic kidney disease. | If used for atrial fibrillation or heart failure dosage >0.125 mg/d. | Dosage >0.125 mg/d: moderate | Dosage >0.125 mg/d: strong | |
| Nifedipine, immediate–release | Potential for hypotension; risk of precipitating myocardial ischemia. | Avoid. | High | Strong |
| Amiodarone | Effective for maintaining sinus rhythm but has greater toxicities than other antiarrhythmics used in atrial fibrillation; may be reasonable first-line therapy in clients with concomitant heart failure or substantial left ventricular hypertrophy if rhythm control is preferred over rate control. | Avoid amiodarone as first-line therapy for atrial fibrillation unless client has heart failure or substantial left ventricular hypertrophy. | High | Strong |
| Central Nervous System | ||||
| Antidepressants, alone or in combination Amitriptyline Amoxapine Clomipramine Desipramine Doxepin >6 mg/d Imipramine Nortriptyline Paroxetine Protriptyline Trimipramine | Highly anticholinergic, sedating, and cause orthostatic hypotension; safety profile of low-dose doxepin (≤6 mg/d) comparable with that of placebo. | Avoid. | High | Strong |
| Antipsychotics, first (conventional) and second (atypical) generation | Increased risk of cerebrovascular accident (stroke) and greater rate of cognitive decline and mortality in persons with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless nonpharmacologic options (e.g., behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. | Avoid, except for schizophrenia, bipolar disorder, or for short-term use as antiemetic during chemotherapy. | Moderate | Strong |
| Barbiturates Amobarbital Butabarbital Butalbital Mephobarbital Pentobarbital Phenobarbital Secobarbital | High rate of physical dependence, tolerance to sleep benefits, greater risk of overdose at low dosages. | Avoid. | High | Strong |
| Benzodiazepines Short- and intermediate-acting Alprazolam Estazolam Lorazepam Oxazepam Temazepam Triazolam | Older adults have increased sensitivity to benzodiazepines and decreased metabolism of long-acting agents; in general, all benzodiazepines increase risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes in older adults. | Avoid. | Moderate | Strong |
| Long-acting Clorazepate Chlordiazepoxide (alone or in combination with amitriptyline or clidinium) Clonazepam Clorazepate Diazepam Flurazepam Quazepam | May be appropriate for seizure disorders, rapid eye movement sleep disorders, benzodiazepine withdrawal, ethanol withdrawal, severe generalized anxiety disorder, and periprocedural anesthesia. | |||
| Meprobamate | High rate of physical dependence; sedating. | Avoid. | Moderate | Strong |
| Nonbenzodiazepine, benzodiazepine receptor agonist hypnotics (i.e., “Z-drugs”) Eszopiclone Zaleplon Zolpidem | Nonbenzodiazepine benzodiazepine receptor agonists (i.e., “Z drugs”) have adverse events similar to those of benzodiazepines in older adults (e.g., delirium, falls, fractures); increased | Avoid. | Moderate | Strong |
| Ergoloid mesylates (dehydrogenated ergot alkaloids) Isoxsuprine | Lack of efficacy. | Avoid. | High | Strong |
| Endocrine | ||||
| Androgens Methyltestosterone Testosterone | Potential for cardiac problems; contraindicated in males with prostate cancer. | Avoid unless indicated for confirmed hypogonadism with clinical symptoms. | Moderate | Weak |
| Desiccated thyroid | Concerns about cardiac effects; safer alternatives available. | Avoid. | Low | Strong |
| Estrogens with or without progestins | Evidence of carcinogenic potential (breast and endometrium); lack of cardioprotective effect and cognitive protection in older females. Evidence indicates that vaginal estrogens for the treatment of vaginal dryness are safe and effective; females with a history of breast cancer who do not respond to nonhormonal therapies are advised to discuss the risk and benefits of low-dose vaginal estrogen (dosages of estradiol <25 mcg twice weekly) with their healthcare provider. | Avoid systemic estrogen (e.g., oral and topical patch). Vaginal cream or tablets: acceptable to use low-dose intravaginal estrogen for management of dyspareunia, lower urinary tract infections, and other vaginal symptoms. | Oral and patch: high Vaginal cream or tablets: moderate | Oral and patch: strong Topical vaginal cream or tablets: weak |
| Growth hormone | Impact on body composition is small and associated with edema, arthralgia, carpal tunnel syndrome, gynecomastia, impaired fasting glucose. | Avoid, except for clients rigorously diagnosed by evidence-based criteria with growth hormone deficiency due to an established etiology. | High | Strong |
| Insulin, sliding scale (insulin regimens containing only short- or rapid-acting insulin dosed according to current blood glucose levels without concurrent use of basal or long-acting insulin) | Higher risk of hypoglycemia without improvement in hyperglycemia management regardless of care setting; avoid insulin regimens that include only short- or rapid-acting insulin dosed according to current blood glucose levels without concurrent use of basal or long-acting insulin. This recommendation does not apply to regimens that contain basal insulin or long-acting insulin. | Avoid. | Moderate | Strong |
| Megestrol | Minimal effect on weight; increases risk of thrombotic events and possibly death in older adults. | Avoid. | Moderate | Strong |
| Sulfonylureas, long-acting Chlorpropamide Glimepiride Glyburide (also known as glibenclamide) | Chlorpropamide: prolonged half-life in older adults; can cause prolonged hypoglycemia; causes syndrome of inappropriate antidiuretic hormone secretion. Glimepiride and glyburide: higher risk of severe prolonged hypoglycemia in older adults. | Avoid. | Moderate | Strong |
| Gastrointestinal | ||||
| Metoclopramide | Can cause extrapyramidal effects, including tardive dyskinesia; risk may be greater in frail older adults and with prolonged exposure. | Avoid, unless for gastroparesis with duration of use not to exceed 12 weeks except in rare cases. | Moderate | Strong |
| Mineral oil, given orally | Potential for aspiration and adverse effects; safer alternatives available. | Avoid. | Moderate | Strong |
| Proton pump inhibitors | Risk of Clostridium difficile infection and bone loss and fractures. | Avoid scheduled use for >8 weeks unless for high-risk clients (e.g., oral corticosteroids or chronic | High | Strong |
| Pain Medications | ||||
| Meperidine | Not effective oral analgesic in dosages commonly used; may have higher risk of neurotoxicity, including delirium, than other opioids; safer alternatives available. | Avoid. | Moderate | Strong |
| Non-Cyclooxygenase-Selective | ||||
| Non-cyclooxygenase-selective Aspirin >325 mg/d Diclofenac Diflunisal Etodolac Fenoprofen Ibuprofen Ketoprofen Meclofenamate Mefenamic acid Meloxicam Nabumetone Naproxen Oxaprozin Piroxicam Sulindac Tolmetin | Increased risk of gastrointestinal bleeding or peptic ulcer disease in high-risk groups, including those aged >75 or taking oral or parenteral corticosteroids, anticoagulants, or antiplatelet agents; use of proton pump inhibitor reduces but does not eliminate risk. Upper gastrointestinal ulcers, gross bleeding, or perforation caused by | Avoid chronic use, unless other alternatives are not effective and the client can take gastroprotective agent (proton pump inhibitor or misoprostol). | Moderate | Strong |
| Indomethacin Ketorolac, includes parenteral | Increased risk of gastrointestinal bleeding, peptic ulcer disease, and acute kidney injury in other adults. Indomethacin is more likely than other | Avoid. | Moderate | Strong |
| Skeletal muscle relaxants Carisoprodol Chlorzoxazone Cyclobenzaprine Metaxalone Methocarbamol Orphenadrine | Most muscle relaxants poorly tolerated by older adults because some have anticholinergic adverse effects, sedation, increased risk of fractures; effectiveness at dosages tolerated by older adults questionable. | Avoid. | Moderate | Strong |
| Genitourinary | ||||
| Desmopressin | High risk of hyponatremia; safer alternative treatments. | Avoid for treatment of nocturia or nocturnal polyuria. | Moderate | Strong |
Note: The primary target audience is practicing clinicians. The intentions of the criteria are to improve the selection of prescription drugs by clinicians and clients; evaluate patterns of drug use within populations; educate clinicians and clients on proper drug usage; and evaluate health outcome, quality-of-care, cost, and utilization data.
Source: American Geriatrics Society Beers Criteria® Update Expert Panel. (2019). American Geriatrics Society 2019 Updated
TABLE C.2
2019 AMERICAN GERIATRICS SOCIETY BEERS CRITERIA FOR POTENTIALLY INAPPROPRIATE MEDICATION USE IN OLDER ADULTS DUE TO DRUG–DISEASE OR DRUG–SYNDROME INTERACTIONS THAT MAY EXACERBATE THE DISEASE OR SYNDROME
| Disease or Syndrome | Drug(s) | Rationale | Recommendation | Quality of Evidence | Strength of Recommendation |
|---|---|---|---|---|---|
| Cardiovascular | |||||
| Heart failure | Avoid: cilostazol Avoid in heart failure with reduced ejection fraction: non-dihydropyridine Use with caution in clients with heart failure who are asymptomatic; avoid in clients with symptomatic heart failure; Thiazolidinediones (pioglitazone, rosiglitazone) Dronedarone | Potential to promote fluid retention and/or exacerbate heart failure ( | Avoid or use with caution. | Non-dihydropyridine Thiazolidinediones: high Cilostazol: low Dronedarone: high | Strong |
| Syncope | Nonselective peripheral alpha-1 blockers (e.g., doxazosin, prazosin, terazosin) Tertiary Antipsychotics:
| Nonselective peripheral alpha-1 blockers cause orthostatic blood pressure changes and should be avoided in older adults whose syncope may be due to orthostatic hypotension. Tertiary | Avoid. | Nonselective peripheral alpha-1 blockers: high | Nonselective peripheral alpha-1 blockers, antipsychotics: weak |
| Central Nervous System | |||||
| Delirium | Anticholinergicsa Antipsychoticsb Benzodiazepines Corticosteroids (oral and parenteral)c H2 receptor antagonists:
| Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. Avoid antipsychotics for behavioral problems of dementia and/or delirium unless nonpharmacologic options (e.g., behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. Antipsychotics are associated with greater risk of cerebrovascular accident (stroke) and mortality in persons with dementia. | Avoid. | H2 receptor antagonists: low All others: moderate | Strong |
| Dementia or cognitive impairment | Anticholinergicsa Benzodiazepines Nonbenzodiazepine, benzodiazepine receptor agonist hypnotics:
| Avoid because of adverse Avoid antipsychotics for behavioral problems of dementia or delirium unless nonpharmacologic options (e.g., behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. Antipsychotics are associated with greater risk of cerebrovascular accident (stroke) and mortality in persons with dementia. | Avoid. | Moderate | Strong |
| History of falls or fractures | Antiepileptics Antipsychoticsb Benzodiazepines Nonbenzodiazepine, benzodiazepine receptor agonist hypnotics:
| May cause ataxia, impaired psychomotor function, syncope, additional falls; shorter-acting benzodiazepines are not safer than long-acting ones. If one of the drugs must be used, consider reducing use of other | Avoid unless safer alternatives are not available; avoid antiepileptics except for seizure and mood disorders Opioids: Avoid except for pain management in the setting of severe acute pain (e.g., recent fractures or joint replacement). | Opioids: moderate All others: high | Strong |
| Parkinson disease | Antiemetics:
| Dopamine receptor antagonists with potential to worsen parkinsonian symptoms. Exceptions: Pimavanserin and clozapine appear to be less likely to precipitate worsening of Parkinson disease. Quetiapine has only been studied in low-quality clinical trials with efficacy comparable with that of placebo in five trials and to that of clozapine in two others. | Avoid. | Moderate | Strong |
| Gastrointestinal | |||||
| History of gastric or duodenal ulcers | Aspirin (>325 mg/d) Non- | May exacerbate existing ulcers or cause new/additional ulcers. | Avoid unless other alternatives are not effective and the client can take gastroprotective agent (e.g., proton pump inhibitor or misoprostol). | Moderate | Strong |
| Kidney/Urinary Tract | |||||
| Chronic kidney disease stage IV or higher (creatinine clearance <30 mL/min) | May increase risk of acute kidney injury and further decline of renal function. | Avoid. | Moderate | Strong | |
| Urinary incontinence (all types) in females | Estrogen oral and transdermal (excludes intravaginal estrogen) Peripheral alpha-1 blockers: doxazosin, prazosin, terazosin | Lack of efficacy (oral estrogen) and aggravation of incontinence (alpha-1 blockers). | Avoid in females. | Estrogen: high Peripheral alpha-1 blockers: moderate | Estrogen: strong Peripheral alpha-1 blockers: strong |
| Lower urinary tract symptoms, benign prostatic hyperplasia | Strongly anticholinergic drugs, except antimuscarinics for urinary incontinencea | May decrease urinary flow and cause urinary retention. | Avoid in males. | Moderate | Strong |
Note: The primary target audience is the practicing clinician. The intentions of the criteria are to improve selection of prescription drugs by clinicians and clients; evaluate patterns of drug use within populations; educate clinicians and clients on proper drug usage; and evaluate health outcome, quality-of-care, cost, and utilization data.
aSee Table 7 in full criteria available on geriatricscareonline.org.
bMay be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health conditions but should be prescribed in the lowest effective dose and shortest possible duration.
cExcludes inhaled and topical forms. Oral and parenteral corticosteroids may be required for conditions such as exacerbations of chronic obstructive pulmonary disease but should be prescribed in the lowest effective dose and for the shortest possible duration.
Source: American Geriatrics Society Beers Criteria® Update Expert Panel. (2019). American Geriatrics Society 2019 Updated
TABLE C.3
2019 AMERICAN GERIATRICS SOCIETY BEERS CRITERIA FOR POTENTIALLY INAPPROPRIATE MEDICATIONS TO BE USED WITH CAUTION IN OLDER ADULTS
| Drug(s) | Rationale | Recommendation | Quality of Evidence | Strength of Recommendation |
|---|---|---|---|---|
| Aspirin for primary prevention of cardiovascular disease and colorectal cancer | Risk of major bleeding from aspirin increases markedly in older age. Several studies suggest lack of net benefit when used for primary prevention in older adults with cardiovascular risk factors, but evidence is not conclusive. Aspirin is generally indicated for secondary prevention in older adults with established cardiovascular disease. | Use with caution in adults aged ≥70 years old. | Moderate | Strong |
| Dabigatran Rivaroxaban | Increased risk of gastrointestinal bleeding compared with warfarin and reported rates with other direct oral anticoagulants when used for long-term treatment of | Use with caution for treatment of | Moderate | Strong |
| Prasugrel | Increased risk of bleeding in older adults; benefit in highest risk older adults (e.g., those with prior myocardial infarction or diabetes mellitus) may offset risk when used for its approved indication of acute coronary syndrome to be managed with percutaneous coronary intervention. | Use with caution in adults aged ≥75 years old. | Moderate | Weak |
| Antipsychotics Carbamazepine Diuretics Mirtazapine Oxcarbazepine Tramadol | May exacerbate or cause syndrome of inappropriate antidiuretic hormone secretion or hyponatremia; monitor sodium level closely when starting or changing dosages in older adults. | Use with caution. | Moderate | Strong |
| Dextromethorphan/quinidine | Limited efficacy in clients with behavioral symptoms of dementia (does not apply to treatment of | Use with caution. | Moderate | Strong |
| Trimethoprim-sulfamethoxazole | Increased risk of hyperkalemia when used concurrently with an | Use with caution in clients on | Low | Strong |
Note: The primary target audience is the practicing clinician. The intentions of the criteria are to improve selection of prescription drugs by clinicians and clients; evaluate patterns of drug use within populations; educate clinicians and clients on proper drug usage; and evaluate health outcome, quality-of-care, cost, and utilization data.
Source: American Geriatrics Society Beers Criteria® Update Expert Panel. (2019). American Geriatrics Society 2019 Updated
TABLE C.4
2019 AMERICAN GERIATRICS SOCIETY BEERS CRITERIA FOR POTENTIALLY CLINICALLY DRUG–DRUG INTERACTIONS THAT SHOULD BE AVOIDED IN OLDER ADULTS
| Object Drug and Class | Interacting Drug and Class | Risk Rationale | Recommendation | Quality of Evidence | Strength of Recommendation |
|---|---|---|---|---|---|
| Another | Increased risk of hyperkalemia | Avoid routine use in those with chronic kidney disease stage 3a or higher. | Moderate | Strong | |
| Opioids | Benzodiazepines | Increased risk of overdose | Avoid. | Moderate | Strong |
| Opioids | Gabapentin, pregabalin | Increased risk of severe sedation-related adverse events, including respiratory depression and death | Avoid; exceptions are when transitioning from opioid therapy to gabapentin or pregabalin, or when using gabapentinoids to reduce opioid dose, although caution should be used in all circumstances. | Moderate | Strong |
| Anticholinergic | Anticholinergic | Increased risk of cognitive decline | Avoid, minimize number of anticholinergic drugs. | Moderate | Strong |
| Antidepressants (i.e., Antipsychotics Antiepileptics Benzodiazepines and nonbenzodiazepines, benzodiazepine receptor agonist hypnotics (i.e., “Z-drugs”) Opioids | Any combination of ≥3 of these | Increased risk of falls (all) and of fracture (benzodiazepines and nonbenzodiazepine, benzodiazepine receptor agonist hypnotics) | Avoid total of ≥3 | Combinations including benzodiazepines and nonbenzodiazepine, benzodiazepine receptor agonist hypnotics or opioids: high All other combinations: moderate | Strong |
| Corticosteroids, oral or parenteral | Increased risk of peptic ulcer disease or gastrointestinal bleeding | Avoid; if not possible, provide gastrointestinal protection. | Moderate | Strong | |
| Lithium | Increased risk of lithium toxicity | Avoid, monitor lithium concentrations. | Moderate | Strong | |
| Lithium | Loop diuretics | Increased risk of lithium toxicity | Avoid, monitor lithium concentrations. | Moderate | Strong |
| Peripheral alpha-1 blockers | Loop diuretics | Increased risk of urinary incontinence in older females | Avoid in older females, unless conditions warrant both drugs. | Moderate | Strong |
| Phenytoin | Trimethoprim-sulfamethoxazole | Increased risk of urinary incontinence in older females | Avoid. | Moderate | Strong |
| Theophylline | Cimetidine Ciprofloxacin | Increased risk of theophylline toxicity | Avoid. | Moderate | Strong |
| Warfarin | Amiodarone | Increased risk of bleeding | Avoid when possible; if used together, monitor international normalized ratio closely. | Moderate | Strong |
| Warfarin | Ciprofloxacin | Increased risk of bleeding | Avoid when possible; if used together, monitor international normalized ratio closely. | Moderate | Strong |
| Warfarin | Macrolides (excluding azithromycin) | Increased risk of bleeding | Avoid when possible; if used together, monitor international normalized ratio closely. | Moderate | Strong |
| Warfarin | Trimethoprim-sulfamethoxazole | Increased risk of bleeding | Avoid when possible; if used together, monitor | Moderate | Strong |
| Warfarin | Increased risk of bleeding | Avoid when possible; if used together, monitor for bleeding closely. | High | Strong |
a
Source: American Geriatrics Society Beers Criteria® Update Expert Panel. (2019). American Geriatrics Society 2019 Updated
TABLE C.5
2019 AMERICAN GERIATRICS SOCIETY BEERS CRITERIA FOR MEDICATIONS THAT SHOULD BE AVOIDED OR HAVE THEIR DOSAGE REDUCED WITH VARYING LEVELS OF KIDNEY FUNCTION IN OLDER ADULTS
| Medication Class and Medication | Creatinine Clearance, mL/min, at Which Action Required | Rationale | Recommendation | Quality of Evidence | Strength of Recommendation |
|---|---|---|---|---|---|
| Anti-Infective | |||||
| Ciprofloxacin | <30 | Increased risk of | Doses used to treat common infections typically require reduction when | Moderate | Strong |
| Trimethoprim-sulfamethoxazole | <30 | Increased risk of worsening renal function and hyperkalemia | <15 mL/min: Avoid. | Moderate | Strong |
| Cardiovascular or Hemostasis | |||||
| Amiloride | <30 | Increased potassium, and decreased sodium | Avoid. | Moderate | Strong |
| Apixaban | <25 | Lack of evidence for efficacy and safety in clients with a | Avoid. | Moderate | Strong |
| Dabigatran | <30 | Lack of evidence for efficacy and safety in individuals with a Label dose for clients with a | Avoid; dose adjustment is advised when | Moderate | Strong |
| Dofetilide | <60 | Moderate | Strong | ||
| Edoxaban | 15–50 <15 or >95 | Lack of evidence of efficacy or safety in clients with a | 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 clients with a | Nonvalvular atrial fibrillation: Reduce dose if Venous thromboembolism treatment for | Moderate | Strong |
| Spironolactone | <30 | Increased potassium | Avoid. | Moderate | Strong |
| Triamterene | <30 | Increased potassium and decreased sodium | Avoid. | Moderate | Strong |
| Central Nervous System and Analgesics | |||||
| Duloxetine | <30 | Increased gastrointestinal adverse effects (nausea, diarrhea) | Avoid. | Moderate | Weak |
| Gabapentin | <60 | Reduce dose. | Moderate | Strong | |
| Levetiracetam | ≤80 | Reduce dose. | Moderate | Strong | |
| Pregabalin | <60 | Reduce dose. | Moderate | Strong | |
| Tramadol | <30 | Immediate–release: Reduce dose. Extended–release: Avoid. | Low | Weak | |
| Gastrointestinal | |||||
| Cimetidine | <50 | Mental status changes | Reduce dose. | Moderate | Strong |
| Famotidine | <50 | Mental status changes | Reduce dose. | Moderate | Strong |
| Nizatidine | <50 | Mental status changes | Reduce dose. | Moderate | Strong |
| Ranitidine | <50 | Mental status changes | Reduce dose. | Moderate | Strong |
| Hyperuricemia | |||||
| Colchicine | <30 | Gastrointestinal, neuromuscular, bone marrow toxicity | Reduce dose; monitor for adverse effects. | Moderate | Strong |
| Probenecid | <30 | Loss of effectiveness | Avoid. | Moderate | Strong |
Source: American Geriatrics Society Beers Criteria® Update Expert Panel. (2019). American Geriatrics Society 2019 Updated