American Geriatrics Society 2019 Updated AGS Beers . PDF

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CLINICAL INVESTIGATIONAmerican Geriatrics Society 2019 Updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older AdultsBy the 2019 American Geriatrics Society Beers Criteria Update Expert Panel*The American Geriatrics Society (AGS) Beers Criteria (AGS Beers Criteria ) for Potentially Inappropriate Medication (PIM) Use in Older Adults are widely used by clinicians, educators, researchers, healthcare administrators, andregulators. Since 2011, the AGS has been the steward of thecriteria and has produced updates on a 3-year cycle. TheAGS Beers Criteria is an explicit list of PIMs that are typically best avoided by older adults in most circumstances orunder specific situations, such as in certain diseases or conditions. For the 2019 update, an interdisciplinary expertpanel reviewed the evidence published since the last update(2015) to determine if new criteria should be added or ifexisting criteria should be removed or undergo changes totheir recommendation, rationale, level of evidence, orstrength of recommendation. J Am Geriatr Soc 00:1–21, 2019.Key words: medications; drugs; older adults; Beers list;Beers Criteriahe American Geriatrics Society (AGS) Beers Criteria (AGS Beers Criteria ) for Potentially InappropriateMedication (PIM) Use in Older Adults are widely used byclinicians, educators, researchers, healthcare administrators,and regulators. Since 2011, the AGS has been the stewardof the criteria and has produced updates on a 3-year cyclethat began in 2012.1,2 The AGS Beers Criteria are anexplicit list of PIMs that are typically best avoided by olderadults in most circumstances or under specific situations,such as in certain diseases or conditions.TFrom the *American Geriatrics Society, New York, New York.Address correspondence to Mary Jordan Samuel, American GeriatricsSociety, 40 Fulton St, 18th Floor, New York, NY 10038.E-mail: [email protected] related editorial by Michael Steinman et al.DOI: 10.1111/jgs.15767JAGS 00:1–21, 2019 2019 The American Geriatrics SocietyFor the 2019 update, an interdisciplinary expert panelreviewed the evidence published since the last update(2015) to determine if new criteria should be added or ifexisting criteria should be removed or undergo changes totheir recommendation, rationale, level of evidence, orstrength of recommendation. Each of the five types of criteria in the 2015 update were retained in this 2019 update:medications that are potentially inappropriate in most olderadults, those that should typically be avoided in olderadults with certain conditions, drugs to use with caution,drug-drug interactions, and drug dose adjustment based onkidney function.OBJECTIVESThe specific aim was to update the 2015 AGS Beers Criteria using a comprehensive, systematic review and grading of theevidence on drug-related problems and adverse events inolder adults. The strategies to achieve this aim were to: Incorporate new evidence on PIMs included in the 2015 AGSBeers Criteria and evidence regarding new criteria or modifications of existing criteria being considered for the 2019update. Grade the strength and quality of each PIM statement based onthe level of evidence and strength of recommendation. Convene an interdisciplinary panel of 13 experts in geriatriccare and pharmacotherapy who would apply a modified Delphimethod, informed by the systematic review and grading, toreach consensus on the 2019 update. Incorporate exceptions in the AGS Beers Criteria that thepanel deemed clinically appropriate. These exceptions wouldbe designed to make the criteria more individualized to clinicalpractice and be more relevant across settings of care.INTENT OF CRITERIAThe primary target audience for the AGS Beers Criteria is practicing clinicians. The criteria are intended for use inadults 65 years and older in all ambulatory, acute, andinstitutionalized settings of care, except for the hospiceand palliative care settings. Consumers, researchers, pharmacy benefits managers, regulators, and policymakers alsowidely use the AGS Beers Criteria . The intention of theAGS Beers Criteria is to improve medication selection;0002-8614/18/ 15.00

22019 AGS BEERS CRITERIA UPDATE EXPERT PANELeducate clinicians and patients; reduce adverse drug events;and serve as a tool for evaluating quality of care, cost, andpatterns of drug use of older adults.As with previously published AGS Beers Criteria , thegoal of the 2019 update continues to be improving thecare of older adults by reducing their exposure to PIMs thathave an unfavorable balance of benefits and harms compared with alternative treatment options. This is accomplished by using the AGS Beers Criteria as both aneducational tool and a quality measure—two uses that arenot always in agreement—and the panel considered andvigorously deliberated both. The AGS Beers Criteria arenot meant to be applied in a punitive manner. Prescribingdecisions are not always clear-cut, and clinicians must consider multiple factors, including discontinuation of medications no longer indicated. Quality measures must be clearlydefined, easily applied, and measured with limited information and, thus, although useful, cannot perfectly distinguishappropriate from inappropriate care. The panel’s review ofevidence at times identified subgroups of individuals whoshould be exempt from a given criterion or to whom a specific criterion should apply. Such a criterion may not be easily applied as a quality measure, particularly when suchsubgroups cannot be easily identified through structuredand readily accessible electronic health data. As an example, the panel thought that a criterion should not beexpanded to include all adults 65 years and older whenonly certain subgroups have an adverse balance of benefitsvs harms for the medication, or conversely when a sizablesubgroup of older adults may be appropriate candidates fora medication that is otherwise problematic.Despite past and current efforts to translate the criteria into practice, some controversy and myths abouttheir use in practice and policy continue to prevail. Thepanel addressed these concerns and myths by writing acompanion article to the 2015 update of the AGS BeersCriteria and an updated 2019 short piece, which remainsthe best way to advise patients, providers, and health systems on how to use (and not use) the 2019 AGS BeersCriteria .3METHODSMethods used for the 2019 update of the AGS Beers Criteria were similar to those used in the 2015 update, with additionalemphasis on extending the rigor of the evidence review andsynthesis process.2 These methods were based on the Gradingof Recommendations Assessment, Development and Evaluation (GRADE) guidelines for clinical practice guideline development and are consistent with recommendations from theNational Academy of Medicine.4,5Panel CompositionThe AGS Beers Criteria expert update panel comprised13 clinicians and included physicians, pharmacists, andnurses, each of whom had participated in the 2015 update.Panelists had experience in different practice settings,including ambulatory care, home care, acute hospital care,skilled-nursing facility, and long-term care. In addition,the panel included ex-officio representatives from the Centers for Medicare and Medicaid Services, the NationalMONTH 2019–VOL. 00, NO. 00JAGSCommittee for Quality Assurance, and the PharmacyQuality Alliance. Potential conflicts of interest were disclosed at the beginning of the process and before each fullpanel call and are listed in the disclosures section of thisarticle. Panelists were recused from discussion in areas inwhich they had a potential conflict of interest.Literature ReviewLiterature searches were conducted in PubMed and theCochrane Library from January 1, 2015, to September30, 2017. Search terms for each criterion included individual drugs, drug classes, specific conditions, and combinations thereof, each with a focus on “adverse drug events”and “adverse drug reactions.” Medications believed to havelow utilizations (eg, meprobamate and central α-agonistantihypertensives other than clonidine) or no longer available in the United States were excluded from the literaturesearch. Searches targeted controlled clinical trials, observational studies, and systematic reviews and meta-analyses,with filters for human participants, 65 years and older, andEnglish language. Clinical reviews and guidelines were alsoincluded to provide context. Case reports, case series, lettersto the editor, and editorials were excluded.Searches identified 17,627 references; 5403 abstractswere sent to panelists for review, of which 1422 referenceswere selected for full-text review. Among these, 377 articleswere abstracted into evidence tables, including 67 systematicreviews and/or meta-analyses, 29 controlled clinical trials,and 281 observational studies.Development ProcessBetween February 2016 and May 2018, the full panel convened for a series of conference calls and 1 full-day, inperson meeting. In addition, the panel divided into fourwork groups, each assigned a subset of the criteria. Eachwork group led the review and synthesis of evidence for itssubset of the criteria, convening via conference calls andelectronically via e-mail.The development process began by soliciting ideas fromthe panelists about criteria that should be explored for addition, modification, or removal. Suggestions from otherswere also welcomed. To guide the evidence selection,review, and synthesis process, each work group then undertook an exercise to identify a priori which clinical outcomes, indications, and comparison groups were mostrelevant when considering evidence for each criterion(ie, the “desired evidence” for reviewing each criterion).These discussions were not considered binding but providedguidance for keeping the evidence review and synthesisfocused on what was most clinically relevant.Each work group reviewed abstracts from the literaturesearches for the criteria in its purview and collectivelyselected a subset for full-text review. This selection processconsidered the methodologic quality of each study, its relevance to older adults, and its concordance with the desiredevidence noted above. After reviewing the full text of eachselected article, the work group then decided by consensuswhich articles represented the best available evidence, basedon a balance of these same three key criteria (methodologicquality, relevance to older adults, and concordance with

JAGSMONTH 2019–VOL. 00, NO. 00desired evidence). Special emphasis was placed on selectingsystematic reviews and meta-analyses when available,because resource constraints precluded the panel from conducting these types of comprehensive analyses. In general, astudy was considered relevant to older adults if the mean ormedian age of participants was older than 65 years, andespecially relevant if most or all participants were olderthan this age threshold.Articles comprising the best available evidence wereabstracted by AGS staff into evidence tables. These tablessummarized the design, population, and findings of eachstudy, and identified markers of methodologic qualityhighlighted by the GRADE criteria for clinical trials andobservational studies and by A MeaSurement Tool toAssess Systematic Reviews (AMSTAR).6–8 Each work groupthen synthesized evidence for each criterion from the 2015to 2017 literature reviews based on GRADE guidelines andthe American College of Physicians’ evidence gradingframework (Table 1).6,9Using evidence from the 2015 to 2017 literaturereview, evidence findings from previous updates in 2012and 2015, and clinical judgment, each work group presented to the full panel its findings and suggestions forchanges (or no change) to the criteria, with ensuing discussion. For most criteria, a consensus emerged, to leave anexisting criterion from the 2015 update unchanged, to modify it, to remove it entirely, or to add a new criterion. Potential modifications included the drug(s) included in thecriterion, the recommendation, the rationale, the quality ofevidence, and the strength of recommendation. As noted inthe GRADE guidelines, strength of recommendation ratingsincorporate a variety of considerations, including expertopinion and clinical judgment and context, and thus do notalways align with quality of evidence ratings.After discussion of proposed changes, an anonymous Delphi process was used to ascertain panel consensus, using afive-point Likert scale with anchors of “strongly disagree” and“strongly agree.” As a general rule, criteria receiving “agree”or strongly agree ratings from more than 90% of panelistswere included. The remainder were brought back for groupdiscussion, with final decisions resolved through consensus.In addition to changes made on the basis of evidence,the panel decided on several modifications to improve clarity and usability of the AGS Beers Criteria . These includedremoving a number of medications that are used onlyrarely. These removals should not be interpreted as condoning use of these medications but rather are intended to“declutter” the AGS Beers Criteria and not distract frominformation on more commonly used medications. Inselected cases, the panel changed the wording of certain criteria, recommendations, and rationale statements toimprove clarity and avoid potential misinterpretations.The final set of criteria was reviewed by the AGS Executive Committee and Clinical Practice and Models of CareCommittee and subsequently released for public comment.Comments were solicited from the general public and sentto 39 organizations. Comments were accepted over a3-week period from August 13, 2018, until September4, 2018. A total of 244 comments were received from47 individuals (79 comments), 6 pharmaceutical companies(10 comments), and 22 peer organizations (155 comments).All comments were reviewed and discussed by the panel2019 AGS BEERS CRITERIA UPDATE EXPERT PANEL3cochairs. All comments along with proposed changes to thecriteria were shared with the entire panel for final approval.RESULTSNoteworthy Changes to PIMs for Older AdultsTables 2 through 6 show the 2019 criteria. Table 7 liststhose drugs with strong anticholinergic properties that aresometimes referenced in Tables 2 through 6. Comparedwith the 2015 criteria, several drugs were removed fromTable 2 (medications that are potentially inappropriate inmost older adults), Table 3 (medications that are potentiallyinappropriate in older adults with certain conditions), andTable 4 (medications that should be used with caution).These removals are summarized in Table 8 and includeremoval of drugs no longer available in the United States(ticlopidine, oral pentazocine). In other cases, the recommendation was removed entirely because the panel decidedthe drug-related problem was not sufficiently unique toolder adults (eg, using stimulating medications in patientswith insomnia or avoiding medications that can lower theseizure threshold in patients with a seizure disorder). Theseremovals do

From the *American Geriatrics Society, New York, New York. Address correspondence to Mary Jordan Samuel, American Geriatrics Society, 40 Fulton St, 18th Floor, New York, NY 10038. E-mail: [email protected] See related editorial by Michael Steinman et al. DOI: 10.1111/jgs.15767 JAGS 00:1–21, 2019