Beers Criteria - Criteria 5
Beers Criteria (Criteria 5)
NAV Top A B C D E F G I K L M N O P R S T

American Geriatrics Society 2023 updated AGS Beers Criteria®
for potentially inappropriate medication use in older adults. Reference Back to All Criteria View
Criteria 5: Medications that should be avoided or have their dosage reduced with varying levels of kidney function in older adults. (Table 6)
 A
 aMILoride (Midamor)
CrCl (mL/min) at which action is required <30
Rationale Hyperkalemia and hyponatremia
Recommendation Avoid
 Quality of evidence: Moderate, Strength of Recommendation: Strong
Suggested Alt.Tx aspirin
Comments > 325 mg/day
CrCl (mL/min) at which action is required <30
Rationale NSAIDs (oral and parenteral) may increase the risk of acute kidney injury and a further decline in kidney function.
Recommendation Avoid
 Quality of evidence: Moderate, Strength of Recommendation: Strong
Suggested Alt.Tx aspirin-dipyridamole (Aggrenox)
aspirin > 325 mg/day
 
CrCl (mL/min) at which action is required <30
Rationale NSAIDs (oral and parenteral) may increase the risk of acute kidney injury and a further decline in kidney function.
Recommendation Avoid
 Quality of evidence: Moderate, Strength of Recommendation: Strong
 B
Suggested Alt.Tx baclofen (Lioresal)
CrCl (mL/min) at which action is required eGFR <60
Rationale Increased risk of encephalopathy requiring hospitalization in older adults with eGFR <60 mL/min or who require chronic dialysis.
Recommendation Avoid baclofen in older adults with impaired kidney function (eGFR <60 mL/min). When baclofen cannot be avoided, use the lowest effective dose and monitor for signs of CNS toxicity, including altered mental status.
 Quality of evidence: Moderate, Strength of Recommendation: Strong
 C
 celecoxib (CeleBREX)
CrCl (mL/min) at which action is required <30
Rationale NSAIDs (oral and parenteral) may increase the risk of acute kidney injury and a further decline in kidney function.
Recommendation Avoid
 Quality of evidence: Moderate, Strength of Recommendation: Strong
 cimetidine (Tagamet)
CrCl (mL/min) at which action is required <50
Rationale Mental status changes
Recommendation Reduce dose
 Quality of evidence: Moderate, Strength of Recommendation: Strong
 ciprofloxacin (Cipro)
CrCl (mL/min) at which action is required <30
Rationale Increased risk of CNS effects (e.g., seizures, confusion) and tendon ruPture.
Recommendation Dosages used to treat common infections typically require reduction when CrCl <30 mL/min.
 Quality of evidence: Moderate, Strength of Recommendation: Strong
 colchicine (Colcrys, Mitigare)
CrCl (mL/min) at which action is required <30
Rationale GI, neuromuscular, and bone marrow toxicity
Recommendation Reduce dose; monitor for adverse effects.
 Quality of evidence: Moderate, Strength of Recommendation: Strong
 D
 dabigatran (Pradaxa)
CrCl (mL/min) at which action is required <30
Rationale Lack of evidence for efficacy and safety in individuals with a CrCl <30 mL/min. Label dose for patients with CrCl 15-30 mL/min based on pharmacokinetic data.
Recommendation Avoid when CrCl <30 mL/min; dose adjustment is advised when CrCl >30 mL/min in the presence of drug-drug interactions.
 Quality of evidence: Moderate, Strength of Recommendation: Strong
Suggested Alt.Tx diclofenac (Cambia, Cataflam, Voltaren)
CrCl (mL/min) at which action is required <30
Rationale NSAIDs (oral and parenteral) may increase the risk of acute kidney injury and a further decline in kidney function.
Recommendation Avoid
 Quality of evidence: Moderate, Strength of Recommendation: Strong
Suggested Alt.Tx diflunisal (Dolobid)
CrCl (mL/min) at which action is required <30
Rationale NSAIDs (oral and parenteral) may increase the risk of acute kidney injury and a further decline in kidney function.
Recommendation Avoid
 Quality of evidence: Moderate, Strength of Recommendation: Strong
 dofetilide (Tikosyn)
CrCl (mL/min) at which action is required <60
Rationale QTc prolongation and torsades de pointes.
Recommendation Reduce dose if CrCl is 20-59 mL/min.
Avoid if CrCl <20 mL/min.
 Quality of evidence: Moderate, Strength of Recommendation: Strong
 DULoxetine (Cymbalta)
CrCl (mL/min) at which action is required <30
Rationale Increased GI adverse effects (nausea, diarrhea)
Recommendation Avoid
 Quality of evidence: Moderate, Strength of Recommendation: Weak
 E
 edoxaban (Savaysa)
CrCl (mL/min) at which action is required 15-50
<15 or > 95
Rationale Lack of evidence of efficacy or safety in patients with CrCl <30 mL/min.
Recommendation Reduce dose if CrCl is 15-50 mL/min.
Avoid if CrCl <15 or > 95 mL/min.
 Quality of evidence: Moderate, Strength of Recommendation: Strong
 enoxaparin (Lovenox)
CrCl (mL/min) at which action is required <30
Rationale Increased risk of bleeding
Recommendation Reduce dose
 Quality of evidence: Moderate, Strength of Recommendation: Strong
Suggested Alt.Tx etodolac (Lodine)
CrCl (mL/min) at which action is required <30
Rationale NSAIDs (oral and parenteral) may increase the risk of acute kidney injury and a further decline in kidney function.
Recommendation Avoid
 Quality of evidence: Moderate, Strength of Recommendation: Strong
 F
 famotidine (Pepcid)
CrCl (mL/min) at which action is required <50
Rationale Mental status changes
Recommendation Reduce dose
 Quality of evidence: Moderate, Strength of Recommendation: Strong
Suggested Alt.Tx flurbiprofen (Ansaid, Ocufen)
CrCl (mL/min) at which action is required <30
Rationale NSAIDs (oral and parenteral) may increase the risk of acute kidney injury and a further decline in kidney function.
Recommendation Avoid
 Quality of evidence: Moderate, Strength of Recommendation: Strong
 fondaparinux (Arixtra)
CrCl (mL/min) at which action is required <30
Rationale Increased risk of bleeding
Recommendation Avoid
 Quality of evidence: Moderate, Strength of Recommendation: Strong
 G
Suggested Alt.Tx gabapentin (Neurontin)
CrCl (mL/min) at which action is required <60
Rationale CNS adverse effects
Recommendation Reduce dose
 Quality of evidence: Moderate, Strength of Recommendation: Strong
 I
Suggested Alt.Tx ibuprofen (Caldolor, Motrin)
CrCl (mL/min) at which action is required <30
Rationale NSAIDs (oral and parenteral) may increase the risk of acute kidney injury and a further decline in kidney function.
Recommendation Avoid
 Quality of evidence: Moderate, Strength of Recommendation: Strong
Suggested Alt.Tx indomethacin (Indocin)
CrCl (mL/min) at which action is required <30
Rationale NSAIDs (oral and parenteral) may increase the risk of acute kidney injury and a further decline in kidney function.
Recommendation Avoid
 Quality of evidence: Moderate, Strength of Recommendation: Strong
 K
Suggested Alt.Tx ketorolac (Toradol)
CrCl (mL/min) at which action is required <30
Rationale NSAIDs (oral and parenteral) may increase the risk of acute kidney injury and a further decline in kidney function.
Recommendation Avoid
 Quality of evidence: Moderate, Strength of Recommendation: Strong
 L
 levETIRAcetam (Keppra)
CrCl (mL/min) at which action is required ≤80
Rationale CNS adverse effects
Recommendation Reduce dose
 Quality of evidence: Moderate, Strength of Recommendation: Strong
 M
Suggested Alt.Tx magnesium salicylate (Doan's)
CrCl (mL/min) at which action is required <30
Rationale NSAIDs (oral and parenteral) may increase the risk of acute kidney injury and a further decline in kidney function.
Recommendation Avoid
 Quality of evidence: Moderate, Strength of Recommendation: Strong
Suggested Alt.Tx meloxicam (Mobic)
CrCl (mL/min) at which action is required <30
Rationale NSAIDs (oral and parenteral) may increase the risk of acute kidney injury and a further decline in kidney function.
Recommendation Avoid
 Quality of evidence: Moderate, Strength of Recommendation: Strong
 N
Suggested Alt.Tx nabumetone (Relafen)
CrCl (mL/min) at which action is required <30
Rationale NSAIDs (oral and parenteral) may increase the risk of acute kidney injury and a further decline in kidney function.
Recommendation Avoid
 Quality of evidence: Moderate, Strength of Recommendation: Strong
Suggested Alt.Tx naproxen (Aleve, Anaprox, Naprelan, Naprosyn)
CrCl (mL/min) at which action is required <30
Rationale NSAIDs (oral and parenteral) may increase the risk of acute kidney injury and a further decline in kidney function.
Recommendation Avoid
 Quality of evidence: Moderate, Strength of Recommendation: Strong
 nitrofurantoin (Furadantin, Macrobid, Macrodantin)
CrCl (mL/min) at which action is required <30
Rationale Potential for pulmonary toxicity, hepatoxicity, and peripheral neuropathy, especially with long-term use. (See also Table 2).
Recommendation Avoid if CrCl <30 mL/min
 Quality of evidence: Low, Strength of Recommendation: Strong
 nizatidine (Axid)
CrCl (mL/min) at which action is required <50
Rationale Mental status changes
Recommendation Reduce dose
 Quality of evidence: Moderate, Strength of Recommendation: Strong
 O
Suggested Alt.Tx oxaprozin (Daypro)
CrCl (mL/min) at which action is required <30
Rationale NSAIDs (oral and parenteral) may increase the risk of acute kidney injury and a further decline in kidney function.
Recommendation Avoid
 Quality of evidence: Moderate, Strength of Recommendation: Strong
 P
Suggested Alt.Tx piroxicam (Feldene)
CrCl (mL/min) at which action is required <30
Rationale NSAIDs (oral and parenteral) may increase the risk of acute kidney injury and a further decline in kidney function.
Recommendation Avoid
 Quality of evidence: Moderate, Strength of Recommendation: Strong
Suggested Alt.Tx pregabalin (Lyrica)
CrCl (mL/min) at which action is required <60
Rationale CNS adverse effects
Recommendation Reduce dose
 Quality of evidence: Moderate, Strength of Recommendation: Strong
 probenecid (Benemid)
CrCl (mL/min) at which action is required <30
Rationale Loss of effectiveness
Recommendation Avoid
 Quality of evidence: Moderate, Strength of Recommendation: Strong
 R
Suggested Alt.Tx rivaroxaban (Xarelto)
CrCl (mL/min) at which action is required <50
Rationale Lack of efficacy or safety evidence in people with CrCl <15 mL/min; limited evidence for CrCl 15-30 mL/min.
Recommendation Avoid if CrCl <15 mL/min.
Reduce the dose if CrCl is 15-50 mL/min following manufacturer dosing recommendations based on indication-specific dosing.
 Quality of evidence: Moderate, Strength of Recommendation: Strong
 S
 spironolactone (Aldactone)
CrCl (mL/min) at which action is required <30
Rationale Hyperkalemia
Recommendation Avoid
 Quality of evidence: Moderate, Strength of Recommendation: Strong
 spironolactone-hydroCHLOROthiazide (Aldactazide)
CrCl (mL/min) at which action is required <30
Rationale Hyperkalemia
Recommendation Avoid
 Quality of evidence: Moderate, Strength of Recommendation: Strong
Suggested Alt.Tx sulindac (Clinoril)
CrCl (mL/min) at which action is required <30
Rationale NSAIDs (oral and parenteral) may increase the risk of acute kidney injury and a further decline in kidney function.
Recommendation Avoid
 Quality of evidence: Moderate, Strength of Recommendation: Strong
 T
Suggested Alt.Tx traMADol (Ultram)
CrCl (mL/min) at which action is required <30
Rationale CNS adverse effects
Recommendation Immediate release: reduce dose
Extended-release: avoid
 Quality of evidence: Low, Strength of Recommendation: Weak
 triamterene (Dyrenium)
CrCl (mL/min) at which action is required <30
Rationale Hyperkalemia and hyponatremia
Recommendation Avoid
 Quality of evidence: Moderate, Strength of Recommendation: Strong
 triamterene-hydroCHLOROthiazide (Dyazide, Maxzide)
CrCl (mL/min) at which action is required <30
Rationale Hyperkalemia and hyponatremia
Recommendation Avoid
 Quality of evidence: Moderate, Strength of Recommendation: Strong
 trimethoprim-sulfamethoxazole (Bactrim, Septra)
CrCl (mL/min) at which action is required <30
Rationale Increased risk of worsening of kidney function and hyperkalemia; risk of hyperkalemia especially prominent with concurrent use of an ACE, ARB, or ARNI.
Recommendation Reduce dosage if CrCl is 15-29 mL/min.
Avoid if CrCl <15 mL/min.
 Quality of evidence: Moderate, Strength of Recommendation: Strong

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