First-generation antihistamines (diphenhydramine, hydroxyzine, meclizine, promethazine, chlorpheniramine, doxylamine…)

Highly anticholinergic → confusion, dry mouth, constipation, falls, delirium, dementia. (Diphenhydramine OK for acute severe allergic rxn.)

Pulmonary/hepatotoxicity, neuropathy; avoid if CrCl <30 or long-term suppression.

Aspirin for primary prevention of CVD

Bleeding risk rises with age; avoid initiating; consider deprescribing if already on. (Secondary prevention is still indicated.)

Warfarin for new AF/VTE

Higher bleed risk vs DOACs; avoid as initial therapy unless DOAC contraindicated. Box 1

Rivaroxaban (long-term AF/VTE)

Higher major/GI bleed than other DOACs (esp. vs apixaban).

Peripheral α-1 blockers for HTN (doxazosin, prazosin, terazosin)

Orthostatic hypotension; not for routine HTN.

Central α-agonists for HTN (clonidine, guanfacine)

CNS effects, bradycardia, orthostasis.

Nifedipine immediate-release

Hypotension, can precipitate ischemia.

Avoid as first-line for AF unless HF or substantial LVH.

Digoxin (first-line AF/HF)

Safer alternatives exist; if used, avoid doses >0.125 mg/day; reduced renal clearance → toxicity.

Strongly anticholinergic antidepressants / TCAs (amitriptyline, imipramine, nortriptyline, doxepin >6 mg, paroxetine)

Anticholinergic, sedating, orthostasis.

Antipsychotics (typical + atypical)

↑ stroke, cognitive decline, mortality in dementia; avoid for BPSD unless non-drug options failed / risk of harm.

Barbiturates · Benzodiazepines · Z-drugs (zolpidem, zaleplon, eszopiclone) · meprobamate

Dependence, sedation, falls, fractures, cognitive impairment, MVAs.

↑ CV events, all-cause mortality, hypoglycemia. If used, prefer short-acting (glipizide) over glyburide/glimepiride.

Sliding-scale insulin (only short/rapid-acting, no basal)

Hypoglycemia without better glucose control.

Estrogens (oral/transdermal) · androgens · megestrol · growth hormone

Carcinogenic/thrombotic risks; megestrol = thrombosis + minimal weight effect. (Vaginal estrogen OK.)

PPIs >8 weeks (scheduled)

C. diff, pneumonia, fractures, bone loss — unless clear high-risk indication.

Extrapyramidal effects / tardive dyskinesia.

GI antispasmodics (dicyclomine, hyoscyamine, scopolamine)

Strongly anticholinergic, uncertain benefit.

NSAIDs (non-selective, oral) & ASA >325 mg/day

GI bleed/ulcer, ↑BP, kidney injury — esp. with anticoagulants, steroids, age >75.

Poor oral analgesia; neurotoxicity/delirium.

Skeletal muscle relaxants (cyclobenzaprine, methocarbamol, carisoprodol, orphenadrine…)

Anticholinergic, sedating, fractures. (Excludes baclofen/tizanidine for spasticity.)

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642 Beers table 2

Drug/Class	Rationale
First-generation antihistamines (diphenhydramine, hydroxyzine, meclizine, promethazine, chlorpheniramine, doxylamine…)	Highly anticholinergic → confusion, dry mouth, constipation, falls, delirium, dementia. (Diphenhydramine OK for acute severe allergic rxn.)
Nitrofurantoin	Pulmonary/hepatotoxicity, neuropathy; avoid if CrCl <30 or long-term suppression.
Aspirin for primary prevention of CVD	Bleeding risk rises with age; avoid initiating; consider deprescribing if already on. (Secondary prevention is still indicated.)
Warfarin for new AF/VTE	Higher bleed risk vs DOACs; avoid as initial therapy unless DOAC contraindicated. Box 1
Rivaroxaban (long-term AF/VTE)	Higher major/GI bleed than other DOACs (esp. vs apixaban).
Peripheral α-1 blockers for HTN (doxazosin, prazosin, terazosin)	Orthostatic hypotension; not for routine HTN.
Central α-agonists for HTN (clonidine, guanfacine)	CNS effects, bradycardia, orthostasis.
Nifedipine immediate-release	Hypotension, can precipitate ischemia.
Amiodarone	Avoid as first-line for AF unless HF or substantial LVH.
Digoxin (first-line AF/HF)	Safer alternatives exist; if used, avoid doses >0.125 mg/day; reduced renal clearance → toxicity.
Strongly anticholinergic antidepressants / TCAs (amitriptyline, imipramine, nortriptyline, doxepin >6 mg, paroxetine)	Anticholinergic, sedating, orthostasis.
Antipsychotics (typical + atypical)	↑ stroke, cognitive decline, mortality in dementia; avoid for BPSD unless non-drug options failed / risk of harm.
Barbiturates · Benzodiazepines · Z-drugs (zolpidem, zaleplon, eszopiclone) · meprobamate	Dependence, sedation, falls, fractures, cognitive impairment, MVAs.
Sulfonylureas (ALL)	↑ CV events, all-cause mortality, hypoglycemia. If used, prefer short-acting (glipizide) over glyburide/glimepiride.
Sliding-scale insulin (only short/rapid-acting, no basal)	Hypoglycemia without better glucose control.
Estrogens (oral/transdermal) · androgens · megestrol · growth hormone	Carcinogenic/thrombotic risks; megestrol = thrombosis + minimal weight effect. (Vaginal estrogen OK.)
PPIs >8 weeks (scheduled)	C. diff, pneumonia, fractures, bone loss — unless clear high-risk indication.
Metoclopramide	Extrapyramidal effects / tardive dyskinesia.
GI antispasmodics (dicyclomine, hyoscyamine, scopolamine)	Strongly anticholinergic, uncertain benefit.
Desmopressin (for nocturia)	Hyponatremia risk.
NSAIDs (non-selective, oral) & ASA >325 mg/day	GI bleed/ulcer, ↑BP, kidney injury — esp. with anticoagulants, steroids, age >75.
Meperidine	Poor oral analgesia; neurotoxicity/delirium.
Skeletal muscle relaxants (cyclobenzaprine, methocarbamol, carisoprodol, orphenadrine…)	Anticholinergic, sedating, fractures. (Excludes baclofen/tizanidine for spasticity.)

Created by: cakedo6

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