The American Geriatrics Society has released its 2023 revision of the Beers Criteria with detailed discussions of anticoagulant use in adults aged 65 years or older, drug-drug and drug-disease interactions presenting special problems in this age group, and dose adjustments needed in patients with reduced kidney function. The last revision was released in 2019.
The criteria expand the “avoid” recommendation for sulfonylureas, which “previously focused on long-acting sulfonylureas but now includes all medications in this class (in particular, avoiding them as first- or second-line therapy, while still advising that if a sulfonylurea is used, shorter-acting ones pose less risk of hypoglycemia than longer-acting ones),” the expert panel writes. “In addition to changes made based on available evidence, the panel decided on several modifications to improve the clarity and usability of the AGS Beers Criteria®. The panel changed the order and wording of certain criteria, recommendations, and rationale statements to improve clarity, avoid possible misinterpretations, and maintain consistency of formatting. The order of drugs and categories listed in [a key table] was also modified for similar reasons. To enhance usability, where feasible we have listed individual drugs that belong to a specified drug class, not including agents that are rarely or never used in the United States (as defined using the methods described immediately below). Note that when such drug class labels are used, the general intent is that the criteria apply to all drugs within that class except when specified otherwise.”
For the anticoagulants, the new guidelines make these recommendations:
• Warfarin: Avoid starting warfarin as initial therapy for the treatment of venous thromboembolism (VTE) or nonvalvular atrial fibrillation unless alternative options (e.g., DOACs) are contraindicated or there are substantial barriers to their use. For older adults who have been using warfarin long-term, it may be reasonable to continue this medication, particularly among those with well-controlled INRs (i.e., >70% time in the therapeutic range) and no adverse effects.
• Rivaroxaban: Avoid rivaroxaban for long-term treatment of nonvalvular atrial fibrillation or VTE in favor of safer anticoagulant alternatives.
• Dabigatran: Use caution in selecting dabigatran over other DOACs (e.g., apixaban) for long-term treatment of nonvalvular atrial fibrillation or VTE.