Beer(s)

I haven’t written a blog post in a while. Not because I’ve been ill or travelling, but simply because I couldn’t find anything I was interested in writing about. Now, at last, I came upon some appropriate material. Next week I hope to blog about Katy Butler’s new book, The Art of Dying Well. This week I want to say a bit about the “2019 American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.” 

The Beers criteria were first promulgated in 1991 by Mark Beers and published in the Archives of Internal Medicine. The idea of reviewing the literature on adverse drug reactions in the elderly and publicizing a list of the worst offenders was widely applauded—but the methodology used in the original list was severely criticized. The American Geriatrics Society subsequently adopted the project and has been responsible for recent revisions. The newest list was just issued.

As with earlier AGS revisions, the expert panel charged with evaluating medications used evidence-based criteria for its judgments. For every medication about which it makes a recommendation, it indicates the quality of the evidence and the strength of the recommendation. Moreover, the panel distinguishes among three groups of potentially inappropriate medications: 1) those that should be avoided by older people in general, either because of a high risk of adverse effects, limited effectiveness, or the availability of better alternatives; 2) those that should be avoided by people with certain medical conditions (for example, renal failure); and 3) those in which the risks generally outweigh the benefits but which may be useful for particular individuals.

Physicians should keep all the tables on hand as a reference; because the medications are sorted by therapeutic category, i.e. “anti-infective” or “cardiovascular” and only generic names are used, the list is less useful for patients and families. I am going to summarize some of the main points for the general reader.

One group of medications that the AGS strongly recommends avoiding (although interestingly, the quality of the evidence is rated as “moderate”) are the first- generation antihistamines, drugs such as diphenhydramine (benadryl) and hydroxyzine (atarax) that are used against allergies and itching. They cause dry mouth, constipation, and confusion. To a large extent they have been replaced by the second-generation antihistamines (fexofenadine or Allegra, loratadine or Claritin, and cetirizine or Zyrtec) and their isomers, sometimes called third- generation antihistamines (levocetirizine or Xyzal). 

A number of first-generation antidepressants are similarly to be avoided because they, like the antihistamines, are anticholinergic (amitriptyline or Elavil, imipramine or Tofranil, and desipramine or Norpramin)—though in this case the quality of the evidence is high. These drugs have largely been superseded by newer antidepressants such as the selective serotonin reuptake inhibitors (SSRIs including fluoxetine or Prozac, citalopram or Celexa, and sertraline or Zoloft) and serotonin and norepinephrine reuptake inhibitors (SNRIs such as duloxetine or Cymbalta and venlaxafine or Effexor). It’s important to note that all these drugs can cause confusion; a few highly publicized studies notwithstanding, the AGS does not claim that any of these medications actually cause dementia. It’s also worth commenting that while all the antihistamines are available over the counter, so older patients might mistakenly choose one of the first-generation drugs over less toxic agents, the antidepressants are all prescription drugs and the first-generation agents are very seldom prescribed by physicians.

A second group of medications that AGS singles out are the antipsychotics, both the first-generation variety (drugs such as haloperidol or Haldol and fluphenazine or Prolixin) and second-generation agents (olanzapine or Zyprexa, quetiapine or Seroquil, and risperidone or Risperdal). All these drugs are deemed risky and are to be avoided except in people with schizophrenia or in people with dementia who are exhibiting dangerous behavior that has failed to respond to other alternatives. This is important because physicians continue to prescribe antipsychotics for the behavioral manifestations of dementia, despite compelling evidence that they are ineffective and/or risky.

Finally, both the benzodiazepines (used to treat anxiety or sleep disorders) and non-steroidal anti-inflammatory pain medications (drugs such as ibuprofen or Motrin and naproxen or Naprosyn but not celecoxib or Celebrex) receive an “avoid” recommendation, though in both cases the quality of the evidence is moderate but the recommendation is deemed strong. This is noteworthy because both groups of medicines continue to be prescribed by physicians and many of the second group are available over-the-counter.

The newest iteration of the Beers list is not perfect. But at the very least, there should be an awfully good reason for an older person to take any of the drugs the AGS says to avoid.