Updated criteria from the American Geriatrics Society (AGS) identify a wide range of potentially risky medications that may cause serious side effects and other adverse drug events (ADEs) in adults 65 and older. These persons run a particularly high risk of ADEs, in part because age-related physiological changes and multiple health problems can make them more vulnerable. Foremost among the concerns might be pain relievers taken by these patients and the new AGS criteria include a significant number of analgesics to avoid.
The medication listings from the AGS — known as the “Beers Criteria for Potentially Inappropriate Medication Use in Older Adults (2012)” —along with additional professional and patient education material, are [available online here]. The criteria are named for the late Mark H. Beers, MD, a geriatrician and editor of The Merck Manuals and The Merck Manual of Geriatrics. He first published the medications-of-concern listing in 1991 and it was last revised in 2003. Most recently, in 2011, the AGS convened a panel of experts in geriatrics and pharmacotherapy to revise and expand the criteria based on the latest research.
The new edition of Beers Criteria includes 53 medications and classes of medications as potentially problematic in older persons. Within the pain medications category, only 2 opioid agents are listed — Meperidine and Pentazocine — primarily because of their potential for neurotoxic adverse effects and the availability of many safer opioid alternatives. No other opioid analgesics are on the list.
Meanwhile, there is a long list of non-COX-selective NSAIDs to avoid, including: Aspirin (>325 mg/day), Diclofenac, Diflunisal, Etodolac, Fenoprofen, Ibuprofen, Indomethacin, Ketoprofen, Ketorolac, Meclofenamate, Mefenamic acid, Meloxicam, Nabumetone, Naproxen, Oxaprozin, Piroxicam, Sulindac, and Tolmetin. A primary concern is risk of gastrointestinal (GI) bleeding and peptic ulcer disease; although, many of the agents also have been implicated as increasing risks of adverse cardiovascular events — for example see prior UPDATES here, here, here, and most recently here. Indomethacin is noted in the Beers Criteria among all NSAIDs as having the greatest potential risks of adverse effects.
Skeletal muscle relaxants, often used as adjunctive therapy for musculoskeletal pain conditions, also are noted as being poorly tolerated by older adults due to anticholinergic adverse effects, sedation, and increased risks of falls/fractures. Those listed include: Carisoprodol, Chlorzoxazone, Cyclobenzaprine, Metaxalone, Methocarbamol, and Orphenadrine.
COMMENTARY: The AGS received funding from the John A. Hartford Foundation of New York and the Robert Wood Johnson Foundation to help support the development and dissemination of the Beers Criteria to the broadest possible audience of clinicians. The society plans to update the criteria every 3 years.
By identifying medications that are potentially harmful for older adults, the 2012 AGS Beers Criteria may help clinicians more safely prescribe for older patients. However, the AGS notes in a press release that responses to drugs vary significantly among older people; and, for some individuals, medications on the list may be the only option. These criteria alone should never dictate prescribing, nor should the list be used punitively to deny patients therapy that may be best suited to their individual needs.
It also is important to observe that opioid analgesics are almost entirely absent from the Beers Criteria, and the AGS has long recommended opioids as a preferred therapy for moderate to severe pain in older persons. However, with growing concerns about alleged risks of long-term opioids, including newly enacted regulations in some states to restrict the prescribing of these medications, elderly patients may be increasing exposed to alternate analgesics, such as NSAIDs, that may be inadequate for relief of their pain and/or do them more harm than good.
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