Potentially Harmful Drugs: Beers Criteria

The “Beers Criteria” is intended for use in outpatient and inpatient settings (but NOT end-of-life care) to improve the care of patients ≥65 years of age.1 It includes medications that should generally be avoided in all elderly, used with caution, or used with caution or avoided in certain elderly.1There is also a list of potentially harmful drug-drug interactions in seniors, as well as a list of medications that may need to be avoided or have their dosage reduced based on kidney function.1 This information is not comprehensive; medications and interactions were chosen for inclusion based on potential harm vs benefit in the elderly, and availability of alternatives with a more favorable risk/benefit ratio.1 Use of the Beers Criteria has not been convincingly shown to reduce morbidity, mortality, or cost but is often used by organizations as quality measures. Use the criteria to identify red flags that might require intervention or close monitoring, not the final word on medication appropriateness.2 Medication use decisions must be individualized.2 Continuing a medication tolerated by the patient may not pose the same risk as initiating the medication.1 If the decision is made to stop a potentially inappropriate medication, tapering may be needed.2 The chart below summarizes the 2023 Beers Criteria, potential therapeutic alternatives, and other considerations.

A = avoid in most elderly (does not apply to end-of-life patients)

C = use with caution in elderly

H= high-risk meds in the elderly per Centers for Medicare & Medicaid Services (https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_238_MIPSCQM.pdf)

--Information in table is from references 1 and 4, unless otherwise specified.--

Drug or Drug Class

Concern(s)

Other Considerations (e.g., special concerns, alternatives)b

Analgesics (also see NSAIDs, below)

Meperidine (A,H) (also see Opioids)
  • Neurotoxicity, delirium, poor efficacy (orally).

Opioids in patients with a history of fall or fracture;delirium or at high risk of delirium;with gabapentinoids; with benzodiazepines; or with two or more other CNS-active drugs.
  • Unsteady gait, psychomotor impairment, syncope.
  • Associated with delirium.
  • With benzodiazepines or gabapentinoids, increased risk of sedation, respiratory depression, and death.
  • Acceptable for acute severe pain.
  • Use multimodal analgesia to limit opioid use.
  • Emerging data suggest an association with delirium. But be aware that uncontrolled pain can also cause delirium.25
  • Consider reducing other concomitant medication(s) that can cause falls. Employ fall-prevention strategies.
  • Avoid with gabapentinoids except when transitioning off opioids. Can use combo with caution for an opioid-sparing effect. Adjust dose for kidney function.
  • For alternatives for different types of pain, see our charts, Pharmacotherapy of Neuropathic Pain, Analgesics for Osteoarthritis, Treatment of Chronic Low Back Pain, and Analgesics for Acute Pain in Adults.

Tramadol (C)
  • SIADH. Check sodium when starting or changing dose.
  • Kidney impairment (CrCl <30 mL/min): increased risk of CNS adverse effects.

Antibiotics

Ciprofloxacin in patient taking theophylline, or warfarin, or in patients with CrCl <30 mL/min
  • Risk of theophylline toxicity.
  • Increased bleeding risk with warfarin.
  • CNS effects (seizures, confusion) and tendon rupture in kidney impairment.
  • Avoid use of ciprofloxacin with theophylline.
  • If ciprofloxacin and warfarin must be used together, monitor INR closely.
  • Dose reduction generally required for CrCl<30 mL/min.

Macrolides (excluding azithromycin) with warfarin
  • Increased bleeding risk.
  • If a macrolide other than azithromycin must be used with warfarin, monitor INR closely.

Nitrofurantoin in patients with CrCl <30 mL/min (A), or for chronic use (A, H)
  • Pulmonary toxicity, peripheral neuropathy, hepatotoxicity, especially with chronic use.
  • Cohort data suggest nitrofurantoin can be effective and have minimal risk in moderate kidney impairment.14

Trimethoprim/sulfamethoxazole (C)
  • Increased risk of hyperkalemia with ACEI, ARB, or ARNI in patients with kidney insufficiency.
  • CrCl <30 mL/min: risk of worsening kidney function and hyperkalemia.
  • Risk of phenytoin toxicity; avoid concomitant use.
  • If trimethoprim/sulfamethoxazole must be used with warfarin, monitor INR closely.
  • Reduce dose for CrCl 15 to 29 mL/min. Avoid if CrCl <15 mL/min.
  • In patients taking an ACEI, ARB, or ARNI choose a different antibiotic.20 If trimethoprim/sulfamethoxazole is required, use the lowest effective dose, and if treatment must exceed three days, check potassium after four or five days15,18,24

Anticonvulsants

Anticonvulsants in patient with history of fall or fracture, except for seizure or mood disorder (also see individual agents for additional, agent-specific concerns), or with two or more other CNS-active drugs.
  • Unsteady gait, psychomotor impairment, syncope.
  • For new-onset seizures, “newer” agents preferred (e.g., lamotrigine, levetiracetam).5 Also see our chart, Antiseizure Medications.
  • Consider bone protection (e.g., bisphosphonate).5
  • Consider reducing other concomitant medication(s) that can cause falls. Employ fall-prevention strategies.
  • Alternatives for neuropathic pain may include SNRIs, gabapentin, pregabalin, capsaicin, or lidocaine patch (US), depending on etiology and comorbidities. For more help choosing, see our chart, Pharmacotherapy of Neuropathic Pain.

Carbamazepine (C) (also see first row in Anticonvulsants section)
  • SIADH. Check sodium when starting or changing dose.

Gabapentin in patient with CrCl <60 mL/min, or with opioids (also see first row in Anticonvulsants section)
  • Increased risk of central nervous system adverse effects in kidney impairment.
  • With opioids, increased risk of sedation, respiratory depression, and death.
  • Reduce dose in kidney impairment.
  • For alternatives for seizures, see our chart, Antiseizure Medications.
  • Avoid with opioids except when transitioning off opioids. Can use combo with caution for an opioid-sparing effect.
  • Alternatives for neuropathic pain may include SNRIs, pregabalin, capsaicin, or lidocaine patch (US), depending on etiology and comorbidities. For more help choosing, see our chart, Pharmacotherapy of Neuropathic Pain.

Levetiracetam in patient with CrCl ≤80 mL/min

(also see first row in Anticonvulsants section)
  • Increased risk of central nervous system adverse effects. Reduce dose.

Oxcarbazepine (C) (also see first row in Anticonvulsants section)
  • SIADH. Check sodium when starting or changing dose.
  • For alternatives for seizures, see our chart, Antiseizure Medications.
  • Alternatives for neuropathic pain may include SNRIs, gabapentin, pregabalin, capsaicin, or lidocaine patch (US), depending on etiology and comorbidities. For more help choosing, see our chart, Pharmacotherapy of Neuropathic Pain.

Pregabalin in patient with CrCl <60 mL/min, or

with opioids

(also see first row in Anticonvulsants section)
  • Increased risk of central nervous system adverse effects in kidney impairment. Reduce dose.
  • With opioids, increased risk of sedation, respiratory depression, and death.
  • For alternatives for seizures, see our chart, Antiseizure Medications.
  • Avoid with opioids except when transitioning off opioids. Can use combo with caution for an opioid-sparing effect.
  • Alternatives for neuropathic pain may include SNRIs, gabapentin, capsaicin, or lidocaine patch (US), depending on etiology and comorbidities. For more help choosing, see our chart, Pharmacotherapy of Neuropathic Pain.

Antidepressants

Duloxetine in patient with CrCl <30 mL/min

(also see SNRIs)
  • Increased risk of nausea or diarrhea. Avoid.

Mirtazapine (Remeron) (C)
  • SIADH. Check sodium when starting or changing dose.

Paroxetine (A, H) (also see SSRIs)
  • Anticholinergic effects (e.g., confusion, cognitive impairment, delirium, dry mouth, constipation, urinary retention), sedation, and orthostatic hypotension.
  • Of special concern in patients with dementia, cognitive impairment, delirium or high risk of delirium, lower urinary symptoms, or BPH (avoid in men).
  • Avoid combining drugs with anticholinergic effects (risk of cognitive decline).
  • For help choosing an alternate antidepressant, see our chart, Choosing and Switching Antidepressants.

SNRIs (C) (also see Duloxetine)
  • SIADH. Check sodium when starting or changing dose.
  • Of special concern in patients with history of fall or fracture.
  • Avoid combining with two or more other CNS-active drugs (fall risk).
  • Consider reducing other concomitant medication(s) that can cause falls. Employ fall-prevention strategies.
  • For help choosing an alternate antidepressant, see our chart, Choosing and Switching Antidepressants.

SSRIs (C) (also see Paroxetine)
  • SIADH. Check sodium when starting or changing dose.
  • Of special concern in patients with history of fall or fracture.
  • Avoid combining with two or more other CNS-active drugs (fall risk).
  • Consider reducing other concomitant medication(s) that can cause falls. Employ fall-prevention strategies.
  • Increased bleeding risk with warfarin. If an SSRI must be used with warfarin, monitor INR closely.
  • For help choosing an alternate antidepressant, see our chart, Choosing and Switching Antidepressants.

Tricyclic antidepressants

(A,H): amitriptyline, amoxapine (US), clomipramine, desipramine,

doxepin (>6 mg/day),

imipramine, nortriptyline, protriptyline (US), trimipramine
  • Anticholinergic effects (e.g., confusion, cognitive impairment, delirium, dry mouth, constipation, urinary retention).
  • Sedation.
  • Orthostatic hypotension.
  • Of special concern in patients with dementia, cognitive impairment, delirium or high risk of delirium, history of fall or fracture, lower urinary symptoms, or BPH (avoid in men).
  • Tertiary amines (amitriptyline, clomipramine, doxepin, imipramine, trimipramine) of special concern in patients with syncope due to risk of orthostatic hypotension.
  • Avoid combining drugs with anticholinergic effects (risk of cognitive decline).
  • Avoid combining with two or more other CNS-active drugs (fall risk).
  • Consider reducing other concomitant medication(s) that can cause falls. Employ fall-prevention strategies.
  • May cause SIADH. Check sodium when starting or changing dose. (C)
  • Alternatives for depression: SSRI (not paroxetine), SNRI, or bupropion,5 depending on comorbidities.For help choosing an alternate antidepressant, see our chart, Choosing and Switching Antidepressants.
  • Alternatives for neuropathic pain may include SNRIs, gabapentin, pregabalin, capsaicin, or lidocaine patch (US), depending on concomitant conditions. For more help choosing, see our chart, Pharmacotherapy of Neuropathic Pain.
  • Alternatives for insomnia: Consider nonpharmacologic interventions.5 Failing this, consider melatonin, low-dose doxepin (3 to 6 mg), or rameleton.13

Antigout

Colchicine in patient with CrCl <30 mL/min
  • Increased risk of bone marrow toxicity, GI adverse effects, neuromuscular adverse effects. Use reduced dose. Monitor for adverse effects.
  • Alternatives: corticosteroid.12

Probenecid in patient with CrCl <30 mL/min
  • Ineffective. Avoid.
  • Alternative uricosuric agents (only if xanthine oxidase inhibitor not appropriate): fenofibrate, losartan, sulfinpyrazone (Canada).12,17

Antihistamines

Anticholinergic antihistamines (A, H): brompheniramine, carbinoxamine (US), chlorpheniramine, clemastine (US), cyproheptadine, dexchlorpheniramine (US),

diphenhydramine (oral), doxylamine, hydroxyzine

(see CNS section for meclizine)
  • Anticholinergic effects (e.g., confusion, cognitive impairment, delirium, dry mouth, constipation, urinary retention).
  • Elimination reduced in elderly.
  • Tolerance to hypnotic effect.
  • Diphenhydramine may be appropriate in acute treatment of severe allergic reactions.
  • Of special concern in patients with dementia, cognitive impairment, delirium or high risk of delirium, history of fall or fracture, lower urinary symptoms, or BPH (avoid in men).
  • Avoid combining drugs with anticholinergic effects (risk of cognitive decline).
  • Consider reducing other concomitant medication(s) that can cause falls. Employ fall-prevention strategies.
  • Alternatives: for allergy, nasal saline, nasal steroid, 2nd generation antihistamine (e.g., cetirizine, levocetirizine, fexofenadine, loratadine).16
  • Alternatives for insomnia: Consider nonpharmacologic interventions.5 Failing this, consider melatonin, low-dose doxepin (3 to 6 mg), or rameleton.13

Antihypertensives

Alpha-blockers (doxazosin [Cardura], prazosin [Minipress], terazosin) (A)
  • Orthostatic hypotension.
  • Of special concern in patients with syncope, and women with urinary incontinence (especially when combined with a loop diuretic).
  • Alternatives for hypertension: thiazide, ACEI, ARB, long-acting CCB.5For help choosing, see our chart, Treatment of Hypertension.

Amiloride in patient with CrCl <30 mL/min.; or with ACEI, ARB, ARNI, or aliskiren
  • Kidney impairment: increased potassium and decreased sodium. Avoid.
  • Do not routinely combine with ACEI, ARB, ARNI, or aliskiren in patients with stage 3a or higher kidney disease due to risk of hyperkalemia.
  • Alternatives for hypertension: thiazide, ACEI, ARB, long-acting CCB.5 For help choosing, see our chart, Treatment of Hypertension.

Clonidine, as first-line antihypertensive (A)
  • Orthostatic hypotension, bradycardia, CNS adverse effects.

Guanfacine (A, H)

Methyldopa (A, H)(Canada)

Diuretics (C)
  • SIADH or hyponatremia. Check sodium when starting or changing dose.

Nifedipine, short-acting (A, H)
  • Hypotension, myocardial ischemia.
  • Alternative dihydropyridine CCBs: amlodipine, felodipine, nifedipine extended-release.5

Triamterene in patient with CrCl <30 mL/min; or with ACEI, ARB, ARNI, or aliskiren
  • Kidney impairment: increased potassium and decreased sodium. Avoid.
  • Do not routinely combine with ACEI, ARB, ARNI, or aliskiren in patients with stage 3a or higher kidney disease due to risk of hyperkalemia.

Antiplatelet Agents and Anticoagulants

Aspirin for primary CV prevention (A)
  • Bleeding risk seems to outweigh benefit for primary prevention in the elderly.
  • For primary CV prevention, avoid initiation, and consider deprescribing.
  • Generally indicated for patients with cardiovascular disease.
  • See our chart, Aspirin for CV Primary Prevention and More, for information to help estimate risk/benefit in patients without CV disease.

Dabigatran (Pradaxa) for long-term use for A-fib or VTE (C), and in patients with CrCl <30 mL/min
  • For long-term use in A-fib or VTE, higher GI bleeding risk than apixaban or warfarin, and higher major bleeding risk than apixaban.
  • Lack of efficacy/safety evidence in CrCl <30 mL/min. Avoid.
  • Consider appropriately-dosed apixaban or edoxaban (depending on kidney function).6,19
  • See our chart, Comparison of Oral Anticoagulants, for indications and dosing.

Dipyridamole, oral short-acting (A, H)
  • More effective options available, orthostatic hypotension.

Edoxaban (Savaysa, US; Lixiana, Canada) in patients with CrCl <15 mL/min,

15 to 50 mL/min, or >95 mL/min
  • Kidney impairment: Lack of efficacy/safety evidence in CrCl <30 mL/min.
  • CrCl >95 mL/min: potential for reduced efficacy in A-fib.3Avoid.1
  • Reduce dose if CrCl 15 to 50 mL/min. Avoid if CrCl <15 mL/min.
  • Consider appropriately-dosed apixaban.6,19
  • See our chart, Comparison of Oral Anticoagulants, for indications and dosing.

Enoxaparin in patients with CrCl <30 mL/min
  • Bleeding risk. Reduce dose.
  • Consider unfractionated heparin, or dalteparin or tinzaparin (Canada) with anti-factor Xa monitoring.20,21

Fondaparinux in patients with CrCl <30 mL/min
  • Bleeding risk. Avoid.
  • Consider unfractionated heparin, or dalteparin or tinzaparin (Canada) with anti-factor Xa monitoring.20,21

Prasugrel (Effient) (C)
  • Higher bleeding risk than clopidogrel, especially in patients ≥75 years of age.
  • Consider clopidogrel, or dose reduction (5 mg once daily) in patients ≥75 mg daily).
  • Benefit may offset bleeding risk in patients with high cardiac risk (e.g., diabetes, history of heart attack) when used for acute coronary syndrome to be managed with percutaneous intervention.

Rivaroxaban (Xarelto) in patients for long-term use for A-fib or VTE (A), and in patients with CrCl <50 mL/min
  • For long-term use in A-fib or VTE, higher GI bleeding risk and higher major bleeding risk than apixaban, and perhaps dabigatran.
  • Lack of efficacy/safety evidence in CrCl< 15 mL/min. Limited evidence for CrCl 15 to 30 mL/min.
  • Consider appropriately-dosed apixaban or edoxaban (depending on kidney function).6,19
  • Rivaroxaban may be a reasonable DOAC choice in some patients, such as those who require once-daily dosing.
  • If used, reduce dose if CrCl 15 to 50 mL/min. Avoid if CrCl <15 mL/min.
  • See our chart, Comparison of Oral Anticoagulants, for indications and dosing.

Ticagrelor (C)
  • Higher bleeding risk than clopidogrel, especially in patients ≥75 years of age.
  • Consider clopidogrel.

Warfarin for A-fib or VTE (A)
  • Higher bleeding risk (especially intracranial) with possibly lower efficacy than DOACs.
  • Choose a DOAC over warfarin unless DOACs are contraindicated or otherwise cannot be used (e.g., cost). See our chart, Comparison of Oral Anticoagulants, for indications and dosing.
  • If the patient has been tolerating warfarin with good control (e.g., INR in-range >70% of the time), consider continuing warfarin.

Antipsychotics

Antipsychotics (A,H) (any; also see individual agents for additional, agent-specific concerns)
  • Risk of stroke, cognitive decline, and death (especially in dementia).
  • Of special concern in patients with dementia, cognitive impairment, delirium or high risk of delirium, history of fall or fracture, or Parkinson’s disease (except quetiapine, or pimavanserin, or clozapine) (also see individual agents).
  • Nonanticholinergic agents acceptable for bipolar disorder, schizophrenia, antiemetic (short-term), Parkinson’s psychosis (quetiapine, pimavanserin, clozapine), depression (adjunct).
  • Acceptable for dementia- or delirium-related behavioral problems if nondrug therapy has failed or can’t be used, and the patient may harm self or others. Use lowest dose for shortest time possible.
  • May cause SIADH. Check sodium when starting or changing dose. (C)
  • Avoid combining with two or more other CNS-active drugs (fall risk).
  • Consider reducing other concomitant medication(s) that can cause falls. Employ fall-prevention strategies.

Chlorpromazine in patient with syncope or BPH, or with other anticholinergic drugs (also see first row in Antipsychotics section)
  • Anticholinergic effects (e.g., confusion, cognitive impairment, delirium, dry mouth, constipation, urinary retention).
  • Risk of orthostatic hypotension.

Clozapine in patient with BPH,or with other anticholinergic drugs (also see first row in Antipsychotics section)
  • Anticholinergic effects (e.g., confusion, cognitive impairment, delirium, dry mouth, constipation, urinary retention).

Loxapine in patient with BPH, or with other anticholinergic drugs (also see first row in Antipsychotics section)
  • Anticholinergic effects (e.g., confusion, cognitive impairment, delirium, dry mouth, constipation, urinary retention).

Olanzapine in patient with syncope, BPH, or with other anticholinergic drugs

(also see first row in Antipsychotics section)
  • Anticholinergic effects (e.g., confusion, cognitive impairment, delirium, dry mouth, constipation, urinary retention).
  • Risk of orthostatic hypotension.

Perphenazine in patient with BPH, or with other anticholinergic drugs (also see first row in Antipsychotics section)
  • Anticholinergic effects (e.g., confusion, cognitive impairment, delirium, dry mouth, constipation, urinary retention).

Thioridazine (US) in patient with syncope, BPH, or with other anticholinergic drugs (also see first row in Antipsychotics section)
  • Anticholinergic effects (e.g., confusion, cognitive impairment, delirium, dry mouth, constipation, urinary retention).
  • Risk of orthostatic hypotension.

Trifluoperazine in patient with BPH (also see first row in Antipsychotics section)
  • Anticholinergic effects (e.g., confusion, cognitive impairment, delirium, dry mouth, constipation, urinary retention).

Anxiolytics

Benzodiazepines (A,H)
  • Increased sensitivity and impaired metabolism (long-acting agents) increases risk of cognitive impairment, unsteady gait, psychomotor impairment, accidents, and delirium.
  • Risk of misuse and dependence.
  • May be acceptable for seizures, rapid eye movement (REM) sleep disorders, benzodiazepine or alcohol withdrawal, severe generalized anxiety disorder, and periprocedural use.
  • Of special concern in patients with dementia, cognitive impairment, delirium or high risk of delirium, or history of fall or fracture.
  • Avoid combining with two or more other CNS-active drugs (fall risk).
  • Consider reducing other concomitant medication(s) that can cause falls. Employ fall-prevention strategies.
  • Alternatives for anxiety: buspirone, SSRI (not paroxetine), or SNRI, depending on comorbidities.1,5
  • Alternatives for insomnia: Consider nonpharmacologic interventions.5 Failing this, consider melatonin, low-dose doxepin (3 to 6 mg), or rameleton.13

Meprobamate (A, H)
  • Sedation, dependence.
  • Alternatives for anxiety: buspirone, SSRI (not paroxetine), or SNRI, depending on comorbidities.5

Cardiac Drugs

Amiodarone as first-line for atrial fibrillation (unless patient has heart failure or significant left ventricular hypertrophy, and rhythm control is desired) (A), or with warfarin
  • More toxic than other treatments for atrial fibrillation.
  • Amiodarone increases warfarin bleeding risk.

CCBs, nondihydropyridine (diltiazem, verapamil) in HFrEF
  • May worsen heart failure. Avoid.

Cilostazol (US) in heart failure
  • Increased mortality. Avoid.

Digoxin first-line for A-fib or heart failure (A), or in doses >0.125 mg/day. (A, H)
  • A-fib: Safer and more effective agents for rate control.
  • HFrEF: unclear risk/benefit. Strong evidence supports alternatives for reducing mortality and hospitalization.
  • Higher doses and kidney insufficiency pose increased risk of toxicity.

Disopyramide (A, H)
  • Negative inotrope; may cause heart failure.
  • Anticholinergic effects (e.g., confusion, cognitive impairment, delirium, dry mouth, constipation, urinary retention).
  • Of special concern in patients with dementia, cognitive impairment, delirium or high risk of delirium, history of fall or fracture, lower urinary symptoms, or BPH (avoid in men).
  • Avoid combining drugs with anticholinergic effects (risk of cognitive decline).
  • Consider reducing other concomitant medication(s) that can cause falls. Employ fall-prevention strategies.
  • For help choosing an alternative, see our FAQ, Atrial Fibrillation: Focus on Pharmacotherapy.

Dronedarone (A)
  • Worse outcomes in permanent A-fib or severe or recently decompensated heart failure. May increase mortality in HFrEF.
  • Avoid in permanent A-fib or symptomatic or recently decompensated heart failure. May use with caution in asymptomatic heart failure.
  • For help choosing an alternative antiarrhythmic, see our FAQ, Atrial Fibrillation: Focus on Pharmacotherapy.

Spironolactone CrCl <30 mL/min
  • Hyperkalemia. Avoid.

Central Nervous System Agents, misc.

Acetylcholinesterase inhibitors (e.g., donepezil), in patient with syncope
  • Bradycardia.
  • Alternative: memantine.7

Dextromethorphan/quinidine (Nuedexta [US]) for treatment of behavioral symptoms of dementia (C)
  • Limited efficacy.
  • Fall risk.
  • Significant drug interactions.
  • Use acceptable for pseudobulbar affect.
  • Of special concern in heart failure; avoid due to risk of QT prolongation.
  • For alternatives, see our chart, Pharmacotherapy of Dementia Behaviors.

Dimenhydrinate (A,H)
  • Anticholinergic effects (e.g., confusion, cognitive impairment, delirium, dry mouth, constipation, urinary retention), sedation.
  • Elimination reduced in elderly.
  • Of special concern in patients with dementia, cognitive impairment, delirium or high risk of delirium, history of fall or fracture, lower urinary symptoms, or BPH (avoid in men).
  • Avoid combining drugs with anticholinergic effects (risk of cognitive decline).
  • Consider reducing other concomitant medication(s) that can cause falls. Employ fall-prevention strategies.
  • For age-related vestibular dysfunction, consider referral for vestibular rehabilitation.8

Lithium in patient taking ACEI, ARB, ARNI, or loop diuretic
  • Risk of lithium toxicity.

Meclizine (US) (A,H)
  • Anticholinergic effects (e.g., confusion, cognitive impairment, delirium, dry mouth, constipation, urinary retention), sedation.
  • Elimination reduced in elderly.
  • Of special concern in patients with dementia, cognitive impairment, delirium or high risk of delirium, history of fall or fracture, lower urinary symptoms, or BPH (avoid in men).
  • Avoid combining drugs with anticholinergic effects (risk of cognitive decline).
  • Consider reducing other concomitant medication(s) that can cause falls. Employ fall-prevention strategies.
  • For age-related vestibular dysfunction, consider referral for vestibular rehabilitation.8

Diabetes Drugs

Insulin, sliding scale (i.e., sole use of as-needed short- or rapid-acting insulin with no basal insulin) (A)
  • Hypoglycemia; poor efficacy.

Pioglitazone in heart failure
  • Fluid retention may worsen heart failure.
  • Avoid in symptomatic heart failure. May use with caution in asymptomatic heart failure.
  • For alternatives, see our chart, Drugs for Type 2 Diabetes.

SGLT2 inhibitors (C)
  • Genitourinary infections.
  • Euglycemic diabetic ketoacidosis.
  • Monitor patients for genitourinary infections, especially women during the first month of treatment.
  • Monitor for ketoacidosis.

Sulfonylureas: gliclazide (Canada)(A), glimepiride (A,H), glipizide (A), glyburide (glibenclamide)(A, H)
  • Higher risk of hypoglycemia, CV events (CV death, ischemic stroke), and all-cause mortality than other antidiabetics.
  • If a sulfonylurea must be used (e.g., cost concern), use a shorter-acting agent (e.g., glipizide).
  • For alternatives, see our chart, Drugs for Type 2 Diabetes.

Gastrointestinal Drugs

Antispasmodics: atropine (in Lomotil) clidinium (in Librax), dicyclomine, methscopolamine (US), scopolamine (A,H)
  • Anticholinergic effects (e.g., confusion, cognitive impairment, delirium, dry mouth, constipation, urinary retention).
  • Unclear efficacy.
  • Of special concern in patients with dementia, cognitive impairment, delirium or high risk of delirium, history of fall or fracture, lower urinary symptoms, or BPH (avoid in men).
  • Avoid combining drugs with anticholinergic effects (risk of cognitive decline).
  • Consider reducing other concomitant medication(s) that can cause falls. Employ fall-prevention strategies.
  • For alternatives for irritable bowel, see our chart, Irritable Bowel Syndrome (IBS) Drug Comparison.

H2-blocker in patient with

delirium or high risk of delirium, taking theophylline (cimetidine), or CrCl <50 mL/min
  • Has central nervous system effects that can cause or worsen delirium.
  • Cimetidine increases theophylline levels.
  • Kidney impairment: increased risk of mental status changes.
  • Avoid cimetidine in patients taking theophylline.
  • Reduce dose if CrCl <50 mL/min.
  • Alternative: proton pump inhibitor (see Proton Pump Inhibitor listing for caveats).5

Metoclopramide, except for gastroparesis (A)
  • Extrapyramidal side effects, tardive dyskinesia.
  • Duration of use for gastroparesis should generally not exceed 12 weeks.
  • Of special concern in patients with Parkinson’s disease, due to dopamine receptor blockade.
  • Alternatives for nausea/vomiting: serotonin antagonists (e.g., ondansetron).10

Mineral oil, oral (A)
  • Aspiration.

Prochlorperazine in patient with dementia, cognitive impairment, Parkinson’s disease, delirium or high risk of delirium, history of fall or fracture, lower urinary tract symptoms, or BPH
  • Anticholinergic effects (e.g., confusion, cognitive impairment, delirium, dry mouth, constipation, urinary retention).
  • Dopamine-receptor blockade may worsen Parkinson’s disease.
  • Avoid in men.
  • Avoid combining drugs with anticholinergic effects (risk of cognitive decline).
  • Consider reducing other concomitant medication(s) that can cause falls. Employ fall-prevention strategies.
  • Alternatives for nausea/vomiting: serotonin antagonists (e.g., ondansetron).10

Promethazine (A, H)
  • Anticholinergic effects (e.g., confusion, cognitive impairment, delirium, dry mouth, constipation, urinary retention).
  • Of special concern in patients with dementia, cognitive impairment, delirium or high risk of delirium, history of fall or fracture, Parkinson’s disease, lower urinary symptoms, or BPH (avoid in men).
  • Dopamine-receptor blockade may worsen Parkinson’s disease.
  • Avoid combining drugs with anticholinergic effects (risk of cognitive decline).
  • Consider reducing other concomitant medication(s) that can cause falls. Employ fall-prevention strategies.
  • Alternatives for nausea/vomiting: serotonin antagonists (e.g., ondansetron).10

Proton pump inhibitors, scheduled use for >8 weeks (A)
  • Risk of C. difficile, bone loss, fractures, GI cancer.
  • Scheduled use for >8 weeks acceptable for patients with high ulcer risk (e.g., taking corticosteroids or chronic NSAID), erosive esophagitis, Barrett’s esophagus, hypersecretion, confirmed need for maintenance (e.g., drug “holiday,” H2-blocker failure).

Hormones

Corticosteroids (oral, parenteral) in patient with delirium or high risk of delirium
  • May cause or worsen delirium.
  • If needed (e.g., chronic obstructive pulmonary disease [COPD] exacerbation), use lowest effective dose for shortest time necessary.
  • Avoid combining with NSAIDs (GI ulcer/bleed risk). Use combo only with gastroprotection.
  • Alternatives depend on indication. See our toolbox, Corticosteroids: Selection, Tapering, and More.

Estrogen (oral, transdermal), with or without progestin (A, H)
  • Breast cancer, endometrial cancer, not cardioprotective; lacks cognitive protection.
  • Consider deprescribing.
  • Alternatives: low-dose vaginal estrogens acceptable for vaginal symptoms and prevention of lower urinary tract infections.1 For vasomotor symptoms, SSRI (not paroxetine), SNRI, gabapentin, depending on comorbidities.5 For help choosing, see our FAQ, Managing Menopausal Symptoms.

Growth hormone, except for growth hormone deficiency (A)
  • Edema, arthralgia, carpal tunnel syndrome, gynecomastia, insulin resistance; little effect on muscle mass.
  • For treatment of unintentional weight loss in the elderly, address underlying causes (e.g., dental issues, depression, medications).9

Megestrol (A, H)
  • Thrombosis, death; minimal effect on weight.
  • For treatment of unintentional weight loss in the elderly, address underlying causes (e.g., dental issues, depression, medications).9

Testosterone, methyltestosterone (US), except for confirmed symptomatic hypogonadism (A)
  • Prostate cancer, cardiac events.

Thyroid, desiccated (A, H)
  • Cardiac adverse effects.
  • Alternative: levothyroxine.

Hypnotics

Antihistamines (see listing above)

Barbiturates (any) (A, H)
  • Dependence, tolerance, risk of overdose (narrow therapeutic window).
  • For alternatives for seizures, see our chart, Antiseizure Medications.
  • Alternatives for insomnia: Consider nonpharmacologic interventions.5 Failing this, consider melatonin, low-dose doxepin (3 to 6 mg), or rameleton.13

Benzodiazepines (see listing under Anxiolytics)

Nonbenzodiazepine, benzodiazepine receptor agonists (“Z drugs;” eszopiclone, zopiclonea [Canada], zolpidem, zaleplon [US]) (A, H)
  • Same concerns as for benzodiazepines.
  • Unfavorable risk/benefit ratio for insomnia.
  • Of special concern in patients with dementia, cognitive impairment, delirium or high risk of delirium, or history of fall or fracture.
  • Avoid combining with two or more other CNS-active drugs (fall risk).
  • Consider reducing other concomitant medication(s) that can cause falls. Employ fall-prevention strategies.
  • Consider nonpharmacologic interventions.5 Failing this, consider melatonin, low-dose doxepin (3 to 6 mg), or rameleton.13

Musculoskeletal Agents

Baclofen in patients with eGFR <60 mL/min.
  • Risk of encephalopathy.
  • Avoid.
  • If baclofen must be used, use the lowest effective dose, and monitor for mental status changes.

Benztropine (A, H) (oral; US)
  • Anticholinergic effects (e.g., confusion, cognitive impairment, delirium, dry mouth, constipation, urinary retention).
  • Not recommended to prevent/treat antipsychotic-associated extrapyramidal effects; not very effective for Parkinson’s disease.
  • Of special concern in patients with dementia, cognitive impairment, delirium or high risk of delirium, history of fall or fracture, lower urinary symptoms, or BPH (avoid in men).
  • Avoid combining drugs with anticholinergic effects (risk of cognitive decline).
  • Consider reducing other concomitant medication(s) that can cause falls. Employ fall-prevention strategies.
  • Alternative for Parkinson’s disease: levodopa/carbidopa.5

Muscle relaxants (A, H)

carisoprodol (US; Soma),

chlorzoxazone, cyclobenzaprine,

metaxalone (US; Skelaxin),

methocarbamol, orphenadrine
  • Anticholinergic effects (cyclobenzaprine, orphenadrine [e.g., confusion, cognitive impairment, delirium, dry mouth, constipation, urinary retention]), sedation, fracture.
  • Questionable efficacy at doses tolerated in elderly.
  • Cyclobenzaprine and orphenadrine of particular concern in patients with dementia, cognitive impairment, delirium or high risk of delirium, history of fall or fracture, lower urinary symptoms, or BPH (avoid in men).
  • Consider reducing other concomitant medication(s) that can cause falls. Employ fall-prevention strategies.
  • Avoid combining drugs with anticholinergic effects (risk of cognitive decline).
  • Avoid combining with two or more other CNS-active drugs (fall risk).
  • Alternatives: acetaminophen, nonacetylated salicylate, NSAID (ibuprofen or naproxen if no heart or kidney failure, with gastroprotection if used for >7 days).5

Trihexyphenidyl (A, H)
  • Anticholinergic effects (e.g., confusion, cognitive impairment, delirium, dry mouth, constipation, urinary retention).
  • Not recommended to prevent/treat antipsychotic-associated extrapyramidal effects; not very effective for Parkinson’s disease.
  • Of special concern in patients with dementia, cognitive impairment, delirium or high risk of delirium, history of fall or fracture, lower urinary symptoms, or BPH (avoid in men).
  • Avoid combining drugs with anticholinergic effects (risk of cognitive decline).
  • Consider reducing other concomitant medication(s) that can cause falls. Employ fall-prevention strategies.
  • Alternative for Parkinson’s disease: levodopa/carbidopa.5

NSAIDs

Aspirin >325 mg/day (A)
  • GI ulcer, bleeding, and perforation risk.
  • Kidney injury.
  • Hypertension.
  • Of special concern in patients with ulcer history.
  • GI risk factors: age >75 years, systemic corticosteroids, anticoagulants, or antiplatelets.
  • Protect with proton pump inhibitor or misoprostol.
  • Avoid combining with oral or parenteral corticosteroids, anticoagulants, or antiplatelets.

NSAIDs (A) (ketorolac and indomethacin, A, H)
  • GI ulcer, bleeding, and perforation risk.
  • Kidney injury.
  • Hypertension.
  • CNS effects (indomethacin)
  • Of special concern in patients with heart failure, ulcer history, or CrCl <30 mL/min.
  • Avoid in symptomatic heart failure. May use with caution in asymptomatic heart failure.
  • Avoid in CrCl <30 mL/min.
  • GI risk factors: age >75 years, systemic corticosteroids, anticoagulants, antiplatelets.
  • Protect with proton pump inhibitor or misoprostol.
  • Avoid combining with oral or parenteral corticosteroids, anticoagulants, or antiplatelets.
  • Avoid ketorolac (oral and parenteral) and indomethacin.
  • Indomethacin has the most adverse effects.
  • Alternatives: acetaminophen, nonacetylated salicylate, capsaicin, lidocaine patch (US), topical NSAID, SNRI5 (depending on etiology and comorbidities).

COX-2 inhibitors in heart failure or CrCl <30 mL/min
  • Worsening heart failure.
  • Kidney injury.
  • Avoid in symptomatic heart failure. May use with caution in asymptomatic heart failure.
  • Avoid in CrCl <30 mL/min.
  • Alternatives: acetaminophen, SNRI (not duloxetine), topical capsaicin, lidocaine patch (US)5(depending on etiology and comorbidities).

Respiratory Drugs

Homatropine (A)
  • Anticholinergic effects (e.g., confusion, cognitive impairment, delirium, dry mouth, constipation, or urinary retention).
  • Of special concern in patients with dementia, cognitive impairment, delirium or high risk of delirium, history of fall or fracture, lower urinary symptoms, or BPH (avoid in men).
  • Avoid combining drugs with anticholinergic effects (risk of cognitive decline).
  • Consider reducing other concomitant medication(s) that can cause falls. Employ fall-prevention strategies.

Urinary Drugs

Desmopressin (A)
  • Hyponatremia.
  • Alternatives: address underlying cause of nocturia (e.g., hyperglycemia, heart failure, calcium channel blocker, flozin).22,23 Consider a 5-alpha reductase inhibitor or phosphodiesterase-5 inhibitor for BPH.22
  • If desmopressin is indicated, use “low-dose” product (e.g., Nocdurna), and monitor sodium closely (e.g., before starting, within a week and again after a month of starting or dosage increase, then periodically).11

Urinary antimuscarinics (e.g., darifenacin, fesoterodine, flavoxate (US), oxybutynin, solifenacin, tolterodine, trospium) in patient with dementia, cognitiveimpairment, delirium or high risk of delirium, or history of fall or fracture
  • Anticholinergic effects (e.g., confusion, cognitive impairment, delirium, dry mouth, constipation, urinary retention).
  • Avoid combining drugs with anticholinergic effects (risk of cognitive decline).
  • Consider reducing other concomitant medication(s) that can cause falls. Employ fall-prevention strategies.
  • Oxybutynin may have the most CNS effects.

Vasodilators (CNS)

Ergoloid mesylates (A, H)
  • Lack of efficacy.
  • Alternatives: Acetylcholinesterase inhibitors (not in patients with syncope), memantine.5

Abbreviations: ACEI = angiotensin-converting enzyme inhibitor; A-fib = atrial fibrillation; ARB = angiotensin receptor blocker; ARNI = angiotensin receptor-neprilysin inhibitor; BPH = benign prostatic hyperplasia; CCB = calcium channel blocker; CrCl = creatinine clearance; CNS = central nervous system; COX-2 = cyclo-oxygenase-2; CV = cardiovascular; GI = gastrointestinal; HFrEF = heart failure with reduced ejection fraction; NSAID = nonsteroidal anti-inflammatory drug; SGLT2 = sodium-glucose cotransporter-2; SIADH = syndrome of inappropriate antidiuretic hormone secretion; SNRI = selective norepinephrine serotonin reuptake inhibitor; SSRI = selective serotonin reuptake inhibitor; VTE = venous thromboembolism.

  1. Zopiclone (Canada; Imovane, etc) not included in Beers, but prudent to consider same precautions as for eszopiclone.
  2. Alternatives may not be appropriate for all patients.

References

  1. 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.
  2. Steinman MA, Fick DM. Using Wisely: A Reminder on the Proper Use of the American Geriatrics Society Beers Criteria®. J Am Geriatr Soc. 2019 Apr;67(4):644-646.
  3. Product information for Savaysa. Daiichi Sankyo. Basking Ridge, NJ 07920. March 2021.
  4. By the 2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2019 Apr;67(4):674-694.
  5. Hanlon JT, Semla TP, Schmader KE. Alternative Medications for Medications in the Use of High-Risk Medications in the Elderly and Potentially Harmful Drug-Disease Interactions in the Elderly Quality Measures. J Am Geriatr Soc. 2015 Dec;63(12):e8-e18.
  6. Clinical Resource, Appropriate Use of Oral Anticoagulants. Pharmacist’s Letter/Prescriber’s Letter. June 2022.
  7. Clinical Resource, Alzheimer’s Dementia Pharmacotherapy. Pharmacist’s Letter/Prescriber’s Letter. March 2023.
  8. Stanton M, Freeman AM. Vertigo. 2022 Mar 18. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–.
  9. Stajkovic S, Aitken EM, Holroyd-Leduc J. Unintentional weight loss in older adults. CMAJ. 2011 Mar 8;183(4):443-9. Erratum in: CMAJ. 2011 May 17;183(8):935.
  10. Prunty JJ, Prunty LM. An outpatient approach to nausea and vomiting. US Pharmacist 2013;38:24-8.
  11. Johnson TM 2nd, Suvada K, Plantinga LC. Recent Medicare Part D beneficiary claims for desmopressin medications. J Am Geriatr Soc. 2021 Jul;69(7):2030-2032.
  12. FitzGerald JD, Dalbeth N, Mikuls T, et al. 2020 American College of Rheumatology Guideline for the Management of Gout. Arthritis Care Res (Hoboken). 2020 Jun;72(6):744-760. Erratum in: Arthritis Care Res (Hoboken). 2020 Aug;72(8):1187. Erratum in: Arthritis Care Res (Hoboken). 2021 Mar;73(3):458.
  13. Samara MT, Huhn M, Chiocchia V, et al. Efficacy, acceptability, and tolerability of all available treatments for insomnia in the elderly: a systematic review and network meta-analysis. Acta Psychiatr Scand. 2020 Jul;142(1):6-17.
  14. Singh N, Gandhi S, McArthur E, et al. Kidney function and the use of nitrofurantoin to treat urinary tract infections in older women. CMAJ. 2015 Jun 16;187(9):648-656.
  15. Horn JR, Hansten PD. Trimethoprim and potassium-sparing drugs: a risk for hyperkalemia. Pharmacy Times 2011;77(2): https://www.pharmacytimes.com/view/druginteractions-0211. (Accessed June 30, 2023).
  16. Bollmeier SG, Williams DM. Acute and chronic rhinitis. In: Zeind CS, Carvalho MG, editors. Applied Therapeutics: the Clinical Use of Drugs. 11th ed. Philadelphia, PA: Wolters Kluwer Health, 2018: pp. 426-49.
  17. Abhishek A, Roddy E, Doherty M. Gout - a guide for the general and acute physicians. Clin Med (Lond). 2017 Feb;17(1):54-59.
  18. Alappan R, Buller GK, Perazella MA. Trimethoprim-sulfamethoxazole therapy in outpatients: is hyperkalemia a significant problem? Am J Nephrol. 1999;19(3):389-94.
  19. Clinical Resource, Comparison of Oral Anticoagulants, Pharmacist’s Letter/Prescriber’s Letter. March 2023.
  20. Clinical Pharmacology powered by ClinicalKey. Tampa (FL): Elsevier. 2023. http://www.clinicalkey.com. (Accessed July1, 2023).
  21. Product monograph for Innohep. Leo Pharma. Thornhill, ON L3T 7W8. May 2017.
  22. Oelke M, De Wachter S, Drake MJ, et al. A practical approach to the management of nocturia. Int J Clin Pract. 2017 Nov;71(11):e13027.
  23. Krepostman N, Kramer H. Lower Urinary Tract Symptoms Should Be Queried When Initiating Sodium Glucose Co-Transporter 2 Inhibitors. Kidney360. 2021 Feb 3;2(4):751-754.
  24. Alappan R, Perazella MA, Buller GK. Hyperkalemia in hospitalized patients treated with trimethoprim-sulfamethoxazole. Ann Intern Med. 1996 Feb 1;124(3):316-20.
  25. Marcantonio ER. Delirium in Hospitalized Older Adults. N Engl J Med. 2017 Oct 12;377(15):1456-1466.

Cite this document as follows: Clinical Resource, Potentially Harmful Drugs: Beers List. Pharmacist’s Letter/Pharmacy Technician’s Letter/Prescriber Insights. July 2023. [390726]



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