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Less Is More
May 13, 2019

The Dangers of Ignoring the Beers Criteria—The Prescribing Cascade

Author Affiliations
  • 1Integrative Medicine, Novant Health, Charlotte, North Carolina
JAMA Intern Med. 2019;179(7):863-864. doi:10.1001/jamainternmed.2019.1288

You may be at work on a Friday afternoon thinking about which brew pub you are going to visit after work or over the weekend, a pub where the list of beers may be pages long. You might spend several minutes perusing the characteristics and provenance of each beer and thinking about which beer(s) you are going to try. Are you thinking more about these kinds of beers than about Beers List medications? The Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, commonly referred to as the Beers List, is a list of medications that should be avoided or used with caution in adults 65 years or older. It was originally published in 1991 and has been updated every 3 years since 2011, most recently in January 2019.1 While other lists of medications that may be problematic in elderly patients have been published, the Beers Criteria is the best known and most commonly used.

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9 Comments for this article
Ask: Doc, are you treating me or my condition?
Umbrine Fatima, MD, FACP | Kenmore Mercy Hospital, Buffalo, NY
Thanks for sharing your experience. I am glad your mom survived the errors. There are so many who unfortunately don't. Your mom is also fortunate to have you as the pharmacist, watching over her carefully as docs pour their "treatments" into her.

Given my extensive experience in clinical informatics and EHR development, I can confirm that the EHR vendors can certainly activate the feature to alert users when Beers list medication is prescribed. This is was one of the key feature of Clinical Decision Support (CDS) certification criteria several years ago. You may want to ask your mom's
doctor to reach out to his/her EHR vendor and ask for this feature to be activated / implemented. CDS can be set to trigger alert for predefined demographic groups (for example, all age 65 or older) who are on the medications on the Beers list. The key will be for the vendors to realize the patient safety value in activating this feature.

Meanwhile I am glad that deprescribing is going vogue – there was a recent article from NYACP Geriatric Spotlight: Deprescription, The New Fashion in Prescribing! https://www.nyacp.org/i4a/headlines/headlinedetails.cfm?id=136 . Certainly it has some challenges but what worthy cause doesn’t?

Deprescribing is certainly time consuming and perhaps one of the many reasons why it is easier and faster to right a prescription than to educate, or to deprescribe. And the inherent risk of withdrawal side effects further deter the best of us. Barriers that I have come across include both physician resistance and caregiver/patient resistance to change. Change from what they have been taking for years, for example, is not an easy one to make. A 78-y/o male with severe arthralgia/myalgia on statin for primary prevention does not want to stop his statin because "it is good for the heart". That's the outcome of years of direct to consumer propaganda whereas the messages about its diminished role in primary prevention has not been presented with as much fanfare as the launch of statins was many years ago.

Regardless, we need to increase the awareness of the ADR and need to constantly assess the ongoing need to continue medications. I tell my patients to ask their doctors: "Are you treating me or my condition"? Very often many of us get so focused on GDMT that we forget who we are treating and for what outcome.

Lot more needs to be done to raise the awareness of ADRs and deprescribing. Thank you for your article.
Recurring Themes
Paul Nelson, M.D., M.S. | Family Health Care, P.C.
The Beer's Criteria have existed for a relatively long period of time. And yet, this story continues a recurring theme. If we had a serious strategy to manage polypharmacy, what would it entail? Putting aside the cognitive dissonance occurring from the absence of a broadly endorsed definition of  health, it is likely that we will need a national commitment to assure the equitable availability of enhanced primary healthcare for each citizen, community by community. Without a dedicated coalition between each citizen, the person's pharmacist and primary physician, this problem will only continue to worsen.
/> I suggest that the cost and quality problems of our nation's healthcare must eventually acknowledge this issue. Implementation should learn from the Cooperative Extension Service that has existed for 100+ years within the agriculture Industry. Remember, our nation's agriculture industry is the most efficient and effective in the world. Our nation's healthcare industry is not, by a wide margin. Think worsening maternal mortality.
The underlying problem
I think the real problem here is using the Emergency Department for a problem best assessed by a physician who knows the patient.
Over the last 4 decades, I've observed the health care system degrade. With the replacement of longitudinal with episodic care, my area of practice has blossomed with business at the expense of patient care.
I love what I do and they pay me way too much to do it, but timely access to a primary care physician with an ongoing relationship to the patient and family and access to the needed diagnostics (after a competent history and
physical) would be hugely beneficial to all but the Emergency Department.
The fact that inappropriate prescribing occurs is a simple roof of Dom Berwick's axiom, paraphrased, that every system is precisely designed to achieve exactly the results it gets.
"Benadryl dilemma"
Ron Louie, MD | University of WA, Seattle
Clinical vignettes can be useful, but often highlight problems, whereas salutary effects of some of the Beers Criteria medications don't get much press.

Here's a caregiver's take on the use of diphenhydramine, with references to toxicity, Beers, association with dementia, but also the possible good effects: https://caregivingoldguy.website/2018/10/26/benadryl-tm-dilemma/
BEERS list risk vs alternatives
John Christensen, MD | Illinois Uroligical Institute SC
Sorry to hear about the struggles your mom had. I struggle with an issue I have found with the BEERS list: a lack of relative risk assessment for alternative or no treatment. In specific, for decades we have used nitrofurantoin 50mg daily x 3 months or longer for recurrent UTI prevention. This is now BEERs listed drug, although I have never seen a case of pulmonitis or neuropathy. The problem is, other drugs for RUTI supression have some combination of higher severe allergic reaction rates, more significantly alter GI flora, and higher antibiotic resistance generation rates (example trimethoprim, cipro, tmp/smx, etc). So I feel stuck with the clinical impression NF is still the safest route - and discuss this with patients, document, etc. A comparison of risk of alternative tx would be a helpful part of the BEERs discussion. - John C
The Beers List is a daunting obstacle course.
Jorge Romero, MD | Forensic neurology consultant, retired. Movement disorder and neurophamacology specialist, private practice.
Treating elderly patients effectively and safely often presents particular challenges. I don’t think any practicing physician would deny that the very elderly population is particularly prone side effects of medication. They are also prone to the collateral effects of intercurrent illnesses and conditions.

In the case presented in this article, we were given no information regarding the baseline mental and cognitive status or medical condition of the patient other than her age. Yet, all of the complications have been attributed to medication misuse. Decisions regarding treatment can be very difficult when trying to balance the
risks and benefits of particular treatments, taking into account not only age but also the basic underlying health of the individual.

One of the major weaknesses of the Beers List is that it provides a list of precautions but not a list of alternative treatments. Sometimes the list provides a daunting obstacle course for the effective treatment of problems in the elderly. The number and classes of drugs included in the list is phenomenal, and leaves very little alternative, if any, for intervention in many situations.
Amending Primum Non Nocere or First (above all) Do No Harm to "Do more good than harm"
Stephen Strum, MD, FACP | Community Practice of Hematology & Oncology
The commentary by Kim DeRhodes is right on target. The issue of avoiding drug toxicities is perhaps the most significant factor relating to what many consider the Holy Grail of Medicine. This is the TI (Therapeutic Index), the ratio of Benefits to Patient ÷ Adverse Effects. JAMA published a landmark article over twenty years ago about this topic in an article by Lazarou et al., that indicated that one million deaths per decade occurred due to drug toxicity from medications administered in a hospital setting. (1) A recommendation was made about pharmacists performing a check for drug interactions in the elderly. I believe that this should be mandated by law in all patients, of any age. Look at https://www.drugs.com/drug_interactions.php as an easy to use and free drug interaction checker. Why cannot this be a routine for all pharmacists filling a prescription? How many lives would it save or how much improvement in quality of life would result?

There is little emphasis on selecting drugs that have multiple functions. I call this pharmaceutical multi-tasking. Many drugs have actions that can benefit numerous issues. An example would be a patient with prostate cancer that also has lower urinary tract symptoms (LUTS). A drug such as doxazosin (Cardura®) that belongs to the quinazoline classification has both the ability to induce cancer cell apoptosis as well as improve LUTS (2). And even though Cardura exists in a form called GITS (Gastrointestinal Therapeutic System) that avoids hypotension (3), it is still listed in the Beers List of Medications. The bottom line is that we can fine-tune how we use pharmaceuticals, and we can enhance our ability to not only do no harm but do good. The commentary by DeRhodes was a refreshing read. What is needed is the implementation of many of the ideas presented.

1. Lazarou J1, Pomeranz BH, Corey PN. Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies. JAMA. 279:1200-5, 1998.
2. Kyprianou N, Benning CM: Suppression of human prostate cancer cell growth by alpha1-adrenoceptor antagonists doxazosin and terazosin via induction of apoptosis. Cancer Res 60:5, 2000.
3. Kirby RS, Quinn S, Mallen S, et al.: Doxazosin controlled release vs. tamsulosin in the management of benign prostatic hyperplasia: an efficacy analysis. Int J Clin Pract 58:6-10, 2004.
The real problem
William Reichert, MD | hospital
It is very sad that your mother fell down and hurt her back. But what is even sadder is that apparently she could not get an appointment to see her primary care physician for two weeks and had to go to the ER . Not once but
three times. This is the state of primary care medicine in the USA today. Doctors are too often unavailable to see patients with acute problems. Lots of emphasis on so called "prevention". For acute illness , not so much.
If Medicare for all is passed,
this situation will become even more obvious .
BEERS list meds
Marta Jacenyik, MB BS | Recently Retired primary care MD
One of the ways we made the BEERS list a reminder to ourselves, patient and pharmacist was to have an addition to the automated EHR prescribing that added the common ADVERSE side effect to the prescription LABEL. eg Baclofen 10 mg three times a day as needed for muscle spasm .COMMONLY CAUSES CONFUSION IN ELDERLY PATIENTS.

This wasn’t an override of a box but helped remind us as we WROTE the prescription that we were risking delerium in this patient. Many patients also read the labels and didn’t want to take the medication or their family then remembered
that their parent had been confused before and asked whether it was appropriate .

This is also an area where every person in the chain should do their part eg the pharmacist reminding the doctor and the patient that it is also the ADDITITIVE effect of several medications that puts them at higher risk of side effects.

There are very few BEERs list meds that an ER or urgent care prescriber should prescribe.