1. The Updated 2019 AGS Beers Criteria for Potentially Inappropriate Medication Use
Lisa C Hutchison, PharmD, MPH, BCPS, BCGP, FCCP
Professor, UAMS College of Pharmacy
Dept of Pharmacy Practice
Professor, UAMS College of Medicine
Dept of Geriatrics

2. Objectives Describe the methods used to develop the AGS Beers Criteria
Compare the changes in the 2019 AGS Beers Criteria
Apply the Beers Criteria in patient care and quality improvement

3. Reference
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; 00:1-21. doi.org/ /jgs   ePub ahead of print. (accessed 2019 Mar 19).

4. Outline Development of the Beers Criteria 2019 AGS Beers Criteria
Example Application to Clinical Practice
Questions?

5. How were the Beers Criteria developed?

6. Mark H. Beers, MD
“A ballet-dancing opera critic who hiked the Alps and took up rowing after diabetes cost him his legs”
MD degree, Univ of Vermont
Faculty, UCLA/RAND
First medical student to do a geriatrics elective at Harvard’s new Division on Aging
Co-editor, Merck Manual of Geriatrics
Editor in Chief, Merck Manuals

7. Beers Criteria History
Developed 1991: Nursing home residents
1997 revision: All elderly patients
2003 update
Adoption by NCQA, HEDIS
2012 AGS update
Adoptions by Medicare Part D insurers
2015 AGS update
Added Drug-Drug Ix and Renal Dosing Tables
2019 AGS update

8. Goals of Beers Criteria
Annoy prescribers who prescribe these drugs for their patients and harass pharmacists who fill the scripts
Improve care by decreasing exposure to potentially inappropriate medications
Educational tool
Quality measure
Research tool

9. Purpose of Beers Criteria
Identify drugs to avoid in older adults
Independent of diagnosis
Considering diagnosis
Reduce adverse drug events and drug-related problems by improving medication selection and use
Be useful in any clinical setting

10. Framework: 2019 Expert Panel
Co-chairs:
Donna Fick, PhD, RN & Todd Semla, PharmD
Voting Panelists: 6 MDs, 4 PharmDs, 1 APN
Non-voting Members: CMS, NCQA, PQA
AGS Staff, Non-voting: 2 members
Literature Researcher and Editor, Non-voting

11. Literature Search 25,549 citations 2001-2011
Terms used: Drugs & Drug classes, conditions, and combinations along with: ADE, inappropriate drug use, medication errors, polypharmacy X age/human/English
25,549 citations
258 included in 2012 Beers Criteria
20,748 citations
17,627 citations
17,627 preliminary review
12,224 excluded
1,422 reviewed by panel
377 included in evidence tables

12. Framework: Methods
GRADE criteria for clinical trials and observational studies
AMSTAR for systematic reviews
Each article rated for Risk of Bias
Quality of Evidence for articles supporting recommendation
High---Moderate----Low
Strength of Recommendation based on potential for harm and available alternatives
Strong---Weak---Insufficient
Cochrane Risk of Bias, Jadad Scoring System, American College of Physicians' Guideline Grading System, 2010; AMSTAR, BMC Med Res Methodol, 2007

13. Info included in Recommendations
Therapeutic Category and/or Drug (s)
Recommendation
Avoid
Avoid in
Avoid except in
Rationale
Quality of Evidence
Strength of Recommendation

14. PIMs to Avoid in all Older Adults
Anticholinergics
Antithrombotics*
Anti-infective
Cardiovascular
Central Nervous System
Endocrine*
Gastrointestinal*
Pain Medications*
Genitourinary
PIM = potentially inappropriate medication; * = changes made

15. PIM Table: Antithrombotics
Deleted Ticlopidine
No longer on US market

16. PIM Table Endocrine Agents: Changes
Growth hormone
Avoid except for patients rigorously diagnosed…with GH deficiency…
Insulin, Sliding Scale
Insulin regimens containing only short/rapid-acting insulin without concurrent use of basal or long-acting insulin
Sulfonylureas, long acting
Added Glimepiride as a drug to avoid

17. PIM Table: GI Agents Metoclopramide
Avoid, unless for gastroparesis…duration… not to exceed 12 weeks…

18. PIM Table: Pain Medications
Meperidine
Deleted phrase “especially…with chronic kidney disease”
Pentazocine
Deleted: oral removed from US market

19. Dz/Cn PIMs Interactions Table
Cardiovascular
Central Nervous System*
Delirium
Dementia
Falls/Fracture
Gastrointestinal
Kidney/Urinary Tract
Dz/Cn PIMs = Potentially inappropriate medications due to drug-disease or condition interactions; * = changes made

20. Dz/Cn Table: CNS Deletions
Chronic Seizures or Epilepsy
Removed list of drugs that lower threshold
Insomnia
Removed list of CNS stimulants
Not specific to older adults: Deleting does not mean endorsement of use!

21. Dz/CN PIMs Table CNS Section
Delirium
Evidence level for H2-receptor antagonists changed to LOW (from moderate)
Dementia
Removed H2-receptor antagonists
History of Falls/Fractures:
Added SNRIs
Parkinson disease/Antipsychotics
Replaced aripiprazole with pimavanserin as an exception

22. Use with Caution Table: Increased Bleeding Risk
Aspirin in primary prevention—changed to caution age 70 or older due to major bleeding risk
Added Rivaroxaban to Dabigatran due to GI bleeding risk
Prasugrel remains on list

23. Use with Caution Table:
Increased SIADH or hyponatremia
Deleted chemotherapy drugs from this list
Antidepressants: SSRIs, SNRIs, TCA, Mirtazapine
Antipsychotics; Carbamazepine/Oxcarbazepine
Diuretics
Added Tramadol
Dextromethorphan/Quinidine limited efficacy in behavioral symptoms of dementia
Trim-Sulfa in patients on ACE or ARB with decreased CrCl due to hyperkalemia risk

24. Drug-Drug Interactions
Biggest Changes for 2019
Opioids/Benzos
Increased risk for overdose
Opioids/Gabanoids
Increased risk for respiratory depression/death
Added Anti-infectives
Ciprofloxacin, Macrolides, Trimethoprim-sulfamethoxazole

25. PIMs based on Kidney Function Table
Biggest Changes
Added Anti-infectives: Ciprofloxacin, Trimethoprim-sulfamethoxazole
Modified criteria for level of renal function to take action

26. Outline Development of the Beers Criteria 2019 AGS Beers Criteria
Application to Clinical Practice
Questions?

27. Purpose of Beers Criteria
Identify drugs to avoid in older adults
Independent of diagnosis
Considering diagnosis
Reduce adverse drug events and drug-related problems by improving medication selection and use
Be useful in any clinical setting

28. Even healthy elderly at risk
JAMA Internal Medicine, July 27,2015

29. Part 2

30. Part 3
JAMA Internal Medicine, July 27,2015

31. Clinical Application
Mrs. P, a 74 YO woman, complains of itching that keeps her awake at night now that the winter season is here
What treatment would you provide:
First-generation antihistamines?
Second-generation antihistamines?
Alternative products?
Basic lotions/creams/ointments
Topical steroids
Non-pharmacologic options

32. Clinical Application
88 YO socially active, clear-thinking woman with osteoarthritis that is interfering with her tai chi and yoga classes
What do you do?
Cyclobenzaprine 10mg TID prn pain
Recommend acetaminophen or naproxen short-term (with a PPI) instead
Non-pharmacologic options

33. Beers Criteria for Quality Improvement
Quality Performance Measurement
Looking at populations
Benchmark goals
Requires system-level approaches

34. UAMS EPIC Best Practice Advisory
Implemented in April 2016
An alert fires when providers order selected Beers Criteria medications for patients ≥ 65 years of age
Suggests alternative therapy options

35. QA Study Objective and Design
Pharmacy Resident Project
Did the BPA have desired effect?
Retrospective review of selected Beers Criteria medications prescribed during selected time period
Inclusion criteria: Age ≥ 65 years; Inpatient admission;
Exclusion criteria: Outpatient visit; Palliative care/hospice orders; Unusual frequencies (every 30 days, weekly, code/trauma)
Jul – Dec 2015 Jul-Dec Jul-Dec 2017
Prior 3-9 mo Post 1+ years post
Personal Communication, Meredith Stefanik

36. Prescribing by Year
Personal Communication, Meredith Stefanik

37. Clinic example
Providers in clinic agree to avoid use of meperidine, chlorpropamide, glimepiride, and glyburide (from Beers’ Criteria) in clinic patients >65 YO.
Benchmark of 5 patients
EHRs are searched to find:
Chlorpropamide – 1 patient
Meperidine – 8 patients
Glyburide – 99 patients
Glimepiride – 123 patients

38. QI Cycle Focus on meperidine, glyburide, & glimepiride
Provide education, EHR reminders
Review EHRs for change
Repeat EHR reports to see if usage dropping
Repeat cycle—
Same drug
Different techniques
Choose other drugs

39. AGS Resources Sign up with an account to access (free)
Criteria
Pocket Card
Smartphone App
Available at: GeriatricsCareOnline.org
Sign up with an account to access (free)

40. Outline Questions? Development of the Beers Criteria
2019 AGS Beers Criteria
 Application to Clinical Practice
Questions?