What medications does the American Geriatric Society say are problematic for our elderly patients?
The 2023 AGS Beers List provides many resources to assist in the rational prescribing of medications for our elderly patients. The AGS panel properly encourages us to use these resources judiciously, and to use them to aid shared decision-making. (LOE = 5)
This POEM aligns with the Canadian Geriatric Society’s Choosing Wisely Canada recommendation: Don’t prescribe a medication without conducting a medication reconciliation review, and consider opportunities for deprescribing at interfaces of care.
Self-funded or unfunded
The American Geriatric Society (AGS) convened a 12-person panel to evaluate systematic reviews and other evidence to update the 2019 AGS Beers Criteria® (I dislike the word "criteria" here; it sounds like a mandate). The panel used an iterative voting process to develop their final recommendations. One decision, taken to simplify the list, was to eliminate medications from the previous list that are rarely prescribed in the United States or are no longer on the market (such as flurazepam or reserpine). The list is fairly exhaustive, but the panel calls out a few noteworthy changes. For example, in their recommendations on using anticoagulants — always a challenge in balancing benefits and harms — the authors recommend not using warfarin as initial therapy for adults with nonvalvular atrial fibrillation or for treating venous thromboembolic phenomena. Additionally, the panel recommends avoiding anticholinergic drugs, oral and transdermal estrogen, sulfonylureas, and aspirin for the primary prevention of cardiovascular disease. The panel also expanded the sections on drug–disease and drug–drug interactions. Scattered throughout are recommendations for deprescribing medications on the list that patients already take. The panel attempted to address many limitations to their list. In my mind, the most significant limitation is the inability to distinguish between the very real potential harms in the frail patient and the potential harms, as well as benefits, in the healthy elderly patient. This means that clinicians should use this list as a guide to therapeutic decisions, but not as an absolute mandate. Now if only our e-prescribing systems could stop nagging us when we make reasonable decisions.
Henry C. Barry, MD, MS
Michigan State University
East Lansing, MI