Beers Criteria for Potentially Inappropriate Medication Use in Older Adults
Disclaimer for the 2023 American Geriatrics Society Updated Beers Criteria Guideline Summary
Drug-Disease or Drug-Syndrome Interactions That May Exacerbate the Disease or Syndrome
Drug-Drug Interactions That Should Be Avoided in Older Adults
Medications/Criterion Added, Removed or Modified Since 2019
Select Highlights for Medications to Avoid, Adjust Dosage for or Use with Caution
Drug Table 2023
Medication | Comments |
Alprazolam | Avoid |
Amiloride | Avoid if CrCl <30 mL/min |
Amiodarone | Avoid as first-line therapy for atrial fibrillation for most patients |
Amitriptyline | Avoid; has strong anticholinergic properties |
Amobarbital | Removed from 2023 versiom - per 2019, Avoid |
Amoxapine | Avoid; has strong anticholinergic properties |
Androgens | Avoid unless indicated for symptomatic hypogonadism |
Apixaban | Per 2023, Emerging evidence and clinical experience supporting safe use at lower levels of renal function, Per 2019, Avoid if CrCl <25 mL/min |
Aripiprazole | Avoid, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy) |
Asenapine | Avoid, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy) |
Aspirin | Avoid initiating aspirin for primary prevention of cardiovascular disease. Consider deprescribing aspirin in older adults already taking it for primary prevention.; Use with caution in adults ≥70 years; Avoid in most patients with history of gastric or duodenal ulcers; avoid chronic use with >325 mg/day |
Atropine (excludes ophthalmic) | Avoid; has strong anticholinergic properties |
Baclofen | Avoid in older adults with impaired kidney function (eGFR <60 mL/min); If cannot be avoided, use the lowest effective dose and monitor for signs of CNS toxicity, including altered mental status |
Belladonna alkaloids | Avoid; has strong anticholinergic properties |
Benztropine (oral) | Avoid; has strong anticholinergic properties |
Brexpiprazole | Avoid, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy) |
Brompheniramine | Avoid; has strong anticholinergic properties |
Butobarbital | Removed from 2023 versiom - per 2019, Avoid |
Butalbital | Avoid |
Canigliflozin | Use with caution. Monitor patients for urogenital infections and ketoacidosis. |
Carbamazepine | Use with caution |
Carbinoxamine | Removed from 2023 versiom - per 2019, Avoid; has strong anticholinergic properties |
Cariprazine | Avoid, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy) |
Carisoprodol | Avoid |
Chlordiazepoxide (alone or in combination with amitriptyline or clidinium) | Avoid |
Chlorpheniramine | Avoid; has strong anticholinergic properties |
Chlorpromazine | Avoid, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy); has strong anticholinergic properties |
Chlorpropamide | Avoid |
Chlorzoxazone | Avoid |
Cilostazol | Avoid for most patients; Use with caution in patients with heart failure |
Cimetidine | Reduce dose if CrCl <50 mL/min; avoid in patients with delirium |
Ciprofloxacin | Reduce dose if CrCl <30 mL/min |
Citalopram | Use with caution |
Clemastine | Removed from 2023 versiom - per 2019, Avoid; has strong anticholinergic properties |
Clidinium-chlordiazepoxide | Avoid; has strong anticholinergic properties |
Clomipramine | Avoid; has strong anticholinergic properties |
Clonazepam | Avoid |
Clonidine for first-line treatment | Avoid as an antihypertensive |
Clorazepate | Avoid |
Clozapine | Avoid*, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy); has strong anticholinergic properties |
Colchicine | Reduce dose if CrCl <30 mL/min and monitor |
Cyclobenzaprine | Avoid; has strong anticholinergic properties |
Cyproheptadine | Avoid; has strong anticholinergic properties |
Dabigatran | Use with caution for treatment of VTE or atrial fibrillation in adults ≥75 years; Avoid; dose adjustment advised when CrCl >30 mL/min in the presence of drug-drug interactions |
Dapagliflozin | Use with caution. Monitor patients for urogenital infections and ketoacidosis. |
Darifenacin | Has strong anticholinergic properties |
Desiccated thyroid | Avoid |
Desipramine | Avoid; has strong anticholinergic properties |
Desmopressin | Avoid for nocturia or nocturnal polyuria |
Desvenlafaxine | Use with caution |
Dexbrompheniramine | Avoid; has strong anticholinergic properties |
Dexchlorpheniramine | Removed from 2023 versiom - per 2019, Avoid; has strong anticholinergic properties |
Dexlansoprazole | Avoid scheduled use for >8 weeks for most patients |
Dextromethorphan/quinidine | Use with caution |
Diazepam | Avoid |
Diclofenac | Avoid chronic use |
Dicyclomine | Has strong anticholinergic properties; Avoid in men with lower urinary tract symptoms, benign prostatic hyperplasia |
Dicyclomine Homatropine (excludes opthalmic) | Avoid |
Diflunisal | Avoid chronic use |
Digoxin | Avoid as first line therapy for atrial fibrillation and for heart failure; if used for atrial fibrillation or heart failure, avoid dosages >0.125 mg/day; Avoid as first-line therapy for heart failure |
Diltiazem | Avoid for most patients; Use with caution in patients with heart failure |
Dimenhydrinate | Avoid; has strong anticholinergic properties |
Diphenhydramine (oral) | Avoid; has strong anticholinergic properties |
Dipyridamole, oral short acting | Avoid |
Disopyramide | Removed from 2023 versiom - per 2019, Avoid; has strong anticholinergic properties |
Diuretics | Use with caution |
Dofetilide | Reduce dose if CrCl 20-59 mL/min; Avoid if CrCl <20 mL/min |
Doxazosin | Avoid use as an antihypertensive; Avoid in patients with syncope and in females with urinary incontinence |
Doxepin (>6 mg / day) | Avoid; has strong anticholinergic properties |
Doxylamine | Avoid; has strong anticholinergic properties |
Dronedarone | Avoid in individuals with permanent atrial fibrillation or some types of heart failure; Use caution in patients with HFrEF with less severe symptoms (NYHA class I or II) |
Duloxetine | Use with caution; Avoid if CrCl <30 mL/min |
Edoxaban | Reduce dose if CrCl 15-50 mL/min; Avoid if CrCl <15 or >95 mL/min |
Emplaglifozin | Use with caution. Monitor patients for urogenital infections and ketoacidosis. |
Enoxaparin | Reduce dose if CrCl <30 mL/min |
Ergoloid mesylates (dehydrogenated ergot alkaloids) | Avoid |
Ertuglifozin | Use with caution. Monitor patients for urogenital infections and ketoacidosis. |
Escitalopram | Use with caution |
Esomeprazole | Avoid scheduled use for >8 weeks for most patients |
Estazolam | Avoid |
Estrogens with or without progestins | Avoid systemic estrogen - consider deprescribing among older women already using this medication; Vaginal cream or vaginal tablets: acceptable to use low-dose intravaginal estrogen for some patients |
Eszopiclone | Avoid |
Etodolac | Avoid chronic use |
Famotidine | Reduce dose if CrCl <50 mL/min; Avoid in patients with delirium |
Fenoprofen | Removed from 2023 versiom - per 2019, Avoid chronic use |
Fesoterodine | Has strong anticholinergic properties |
Flavoxate | Has strong anticholinergic properties |
Fluoxetine | Use with caution |
Fluphenazine | Avoid, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy) |
Flurazepam | Removed from 2023 versiom - per 2019, Avoid |
Fluvoxamine | Use with caution |
Fondaparinux | Avoid if CrCl <30 mL/min |
Gabapentin | Reduce if CrCl <60 mL/min |
Glimepiride | Avoid |
Glyburide (also known as glibenclamide) | Avoid |
Growth hormone | Avoid, except for some patients with growth hormone deficiency |
Guanabenz | Avoid other CNS alpha-agonists as listed |
Guanfacine | Avoid other CNS alpha-agonists as listed |
Haloperidol | Avoid, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy) |
Homatropine (excludes ophthalmic) | Has strong anticholinergic properties; Avoid in men with lower urinary tract symptoms, benign prostatic hyperplasia |
Hydroxyzine | Avoid; has strong anticholinergic properties |
Hyoscyamine | Avoid; has strong anticholinergic properties |
Ibuprofen | Avoid chronic use |
Iloperidone | Avoid, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy) |
Imipramine | Avoid; has strong anticholinergic properties |
Indomethacin | Avoid |
Insulin, sliding scale | Avoid |
Isoxsuprine | Avoid |
Ketoprofen | Removed from 2023 versiom - per 2019, Avoid chronic use |
Ketorolac, includes parenteral | Avoid |
Lansoprazole | Avoid scheduled use for >8 weeks for most patients |
Levetiracetam | Reduce dose if CrCl ≤80 mL/min |
Levomilnacipran | Use with caution |
Lorazepam | Avoid |
Loxapine | Removed from 2023 versiom - per 2019, Avoid, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy); has strong anticholinergic properties |
Lumateperone | Avoid, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy) |
Lurasidone | Avoid, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy) |
Meclizine | Avoid |
Meclofenamate | Removed from 2023 versiom - per 2019, Avoid chronic use |
Mefenamic acid | Removed from 2023 versiom - per 2019, Avoid chronic use |
Megestrol | Avoid |
Meloxicam | Avoid chronic use |
Meperidine | Avoid |
Mephobarbital | Avoid |
Meprobamate | Avoid |
Mesoridazine | Avoid, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy) |
Metaxalone | Avoid |
Methocarbamol | Avoid |
Methscopolamine | Removed from 2023 versiom - per 2019, Avoid; has strong anticholinergic properties |
Methyldopa | Avoid other CNS alpha-agonists as listed |
Methyltestosterone | Avoid unless indicated for symptomatic hypogonadism |
Metoclopramide | Avoid, unless for gastroparesis use less than 12 weeks for most cases; Avoid in patients with Parkinson Disease |
Milnacipran | Use with caution |
Mineral oil, given orally | Avoid |
Mirtazapine | Use with caution |
Molindone | Avoid, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy) |
Nabumetone | Avoid chronic use |
Naproxen | Avoid chronic use |
Nifedipine, immediate release | Avoid |
Nitrofurantoin | Avoid in individuals with creatinine clearance <30 mL/min or for long-term suppression |
Nizatidine | Reduce dose if CrCl <50 mL/min; Avoid in patients with delirium |
Nortriptyline | Avoid; has strong anticholinergic properties |
Olanzapine | Avoid, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy); has strong anticholinergic properties |
Omeprazole | Avoid scheduled use for >8 weeks for most patients |
Omeprazole / sodium bicarbonate | Avoid scheduled use for >8 weeks for most patients |
Orphenadrine | Avoid; has strong anticholinergic properties |
Other 1st and 2nd Generation Antipsychotics | Avoid, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy) |
Other PPIs | Avoid scheduled use for >8 weeks for most patients |
Other SNRIs | Use with caution |
Other SSRIs | Use with caution |
Other TCAs | Use with caution |
Oxaprozin | Avoid chronic use |
Oxazepam | Avoid |
Oxcarbazepine | Use with caution |
Oxybutynin | Has strong anticholinergic properties |
Paliperidone | Avoid, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy) |
Pantoprazole | Avoid scheduled use for >8 weeks for most patients |
Paroxetine | Avoid; has strong anticholinergic properties |
Pentobarbital | Avoid |
Perphenazine | Avoid, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy); has strong anticholinergic properties |
Phenobarbital | Avoid |
Pimavanserin | Avoid*, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy) |
Pioglitazone | Avoid for most patients; Use with caution in patients with heart failure |
Piroxicam | Avoid chronic use |
Prasugrel | Use with caution in adults ≥75 years - If prasugrel is used, consider a lower dose (5 mg) for those 75 years old and older |
Prazosin | Avoid use as an antihypertensive; Avoid in patients with syncope and in females with urinary incontinence |
Pregabalin | Reduce if CrCl <60 mL/min |
Probenecid | Avoid if CrCl <30 mL/min |
Prochlorperazine | Avoid in patients with Parkinson Disease |
Prochlorperazine | Has strong anticholinergic properties; Avoid in men with lower urinary tract symptoms, benign prostatic hyperplasia |
Promethazine | Avoid; has strong anticholinergic properties |
Propantheline | Avoid; has strong anticholinergic properties |
Protriptyline | Removed from 2023 versiom - per 2019, Avoid; has strong anticholinergic properties |
Pyrilamine | Avoid; has strong anticholinergic properties |
Quazepam | Removed from 2023 versiom - per 2019, Avoid; has strong anticholinergic properties |
Quetiapine | Avoid*, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy) |
Rabeprazole | Avoid scheduled use for >8 weeks for most patients |
Ranitidine | Reduce dose if CrCl <50 mL/min; Avoid in patients with delirium |
Reserpine (>0.1 mg/day) | Avoid other CNS alpha-agonists as listed |
Risperidone | Avoid, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy) |
Rivaroxaban | Avoid for long-term treatment of atrial fibrillation or VTE in favor of safer anticoagulant alternatives - see also criteria regarding DOACs; Avoid if CrCl <15 mL/min and reduce the dose if CrCl is 15–50 mL/min following manufacturer dosing recommendations based on indication-specific dosing |
Rosiglitazone | Avoid for most patients; Use with caution in patients with heart failure |
Scopolamine (excludes ophthalmic) | Avoid; has strong anticholinergic properties |
Secobarbital | Avoid |
Sertraline | Use with caution |
Solifenacin | Has strong anticholinergic properties |
Spironolactone | Avoid if CrCl <30 mL/min |
Sulindac | Avoid chronic use |
Temazepam | Avoid |
Terazosin | Avoid use as an antihypertensive; Avoid in patients with syncope and in females with urinary incontinence |
Testosterone | Avoid unless indicated for symptomatic hypogonadism |
Thioridazine | Avoid, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy); has strong anticholinergic properties |
Thiothixene | Avoid, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy) |
Ticagrelor | Use with caution, particularly in adults 75 years old and older. If prasugrel is used, consider a lower dose (5 mg) for those 75 years old and older. |
Tolmetin | Avoid chronic use |
Tolterodine | Has strong anticholinergic properties |
Tramadol | Use with caution; If CrCl <30 mL/min, may require reduction with immediate release or avoid with extended release |
Triamterene | Avoid if CrCl <30 mL/min |
Triazolam | Avoid |
Trifluoperazine | Removed from 2023 versiom - per 2019, Avoid, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy); has strong anticholinergic properties |
Trihexyphenidyl | Avoid; has strong anticholinergic properties |
Trimethoprimsulfamethoxazole | Use with caution in patients on ACEI or ARB or ARNI and decreased creatinine clearance; Reduce dosage if CrCl is 15–29 mL/min and avoid if CrCl <15 mL/min |
Trimipramine | Removed from 2023 versiom - per 2019, Avoid; has strong anticholinergic properties |
Triprolidine | Avoid; has strong anticholinergic properties |
Trospium | Has strong anticholinergic properties |
Venlafaxine | Use with caution |
Verapamil | Avoid for most patients; Use with caution in patients with heart failure |
Warfarin | Avoid starting warfarin as initial therapy for the treatment of nonvalvular atrial fibrillation or VTE unless alternative options (i.e., 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. See also criteria regarding DOACs. |
Zaleplon | Avoid |
Ziprasidone | Avoid, except in some situations (e.g. bipolar disorder, schizophrenia, short-term chemotherapy) |
Zolpidem | Avoid |
This table is not intended as a replacement for or comprehensive summary of the whole or of any part of the AGS 2023 Beers Criteria. For a full and complete listing of medications, along with recommendations, rationale and grading, please refer to the full text Beers Criteria guideline here.
Additional Comment
- 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.
Recommendation Grading
Overview
Title
AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults
Authoring Organization
American Geriatrics Society
Publication Month/Year
May 4, 2023
Last Updated Month/Year
April 1, 2024
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
With more than 90% of older people using at least one prescription and more than 66% using three or more in any given month, the AGS Beers Criteria® plays a vital role in helping health professionals, older adults, and caregivers work together to ensure medications are appropriate. 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 regulators. Since 2011, the AGS has been the steward of the criteria and has produced 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 criteria, 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 hospice 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 clinical decision-making.
Target Patient Population
Older adults taking one or more medications
Target Provider Population
All healthcare providers that care for older patients
Inclusion Criteria
Male, Female, Older adult
Health Care Settings
Ambulatory, Home health, Hospital, Long term care, Outpatient
Intended Users
Healthcare business administration, nurse, nurse practitioner, community pharmacist, health systems pharmacist, pharmacy technician, physician, physician assistant
Scope
Treatment, Management, Prevention
Diseases/Conditions (MeSH)
D008508 - Medication Errors, D000067561 - Potentially Inappropriate Medication List, D054539 - Medication Therapy Management
Keywords
Beers Criteria, beers, Beer's, Beer's Criteria, beers list, medication use, beer criteria
Source Citation
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 May 4. doi: 10.1111/jgs.18372. Epub ahead of print. PMID: 37139824.