Is Tizanidine on the Beers List?
No, tizanidine is NOT included on the 2019 American Geriatrics Society Beers Criteria® for potentially inappropriate medications in older adults. However, recent evidence from 2025 suggests this exclusion may need reconsideration.
Current Beers Criteria Status
The 2019 AGS Beers Criteria® specifically lists skeletal muscle relaxants (SMRs) as potentially inappropriate medications to avoid in older adults, but tizanidine and baclofen are explicitly excluded from this recommendation 1. The muscle relaxants that ARE on the Beers list include:
- Cyclobenzaprine
- Carisoprodol
- Chlorzoxazone
- Metaxalone
- Methocarbamol
- Orphenadrine
These medications are flagged due to their anticholinergic effects, sedation risk, and questionable effectiveness at tolerated dosages in older adults 1.
Important Clinical Caveat: Emerging Safety Concerns
Despite tizanidine's exclusion from the 2019 Beers Criteria, a 2025 retrospective cohort study of 87,896 older adults found that tizanidine carries a 34% greater risk of serious injury events (fractures, falls leading to fracture, brain injury, and dislocations) compared to cyclobenzaprine, which IS on the Beers list 2. Baclofen performed even worse, with a 69% greater injury risk 2.
Key Safety Data:
- Adjusted Hazard Ratio for tizanidine: 1.34 (95% CI 1.11-1.62) compared to cyclobenzaprine
- Both tizanidine and baclofen demonstrated lower injury-free probabilities over time
- The authors explicitly recommend including both tizanidine and baclofen on future Beers Criteria updates 2
Clinical Implications
While tizanidine is technically not on the current Beers list, you should exercise significant caution when prescribing it to older adults, particularly given:
Pharmacokinetic concerns in elderly: Elderly patients clear tizanidine four times slower than younger patients, and clearance is reduced by >50% in those with renal insufficiency (CrCl <25 mL/min) 3
Cardiovascular risks: Tizanidine can cause hypotension, bradycardia, and QT prolongation 3
CNS effects: Sedation is common and additive with other CNS depressants including alcohol and benzodiazepines 3
Drug interactions: Clearance is reduced by 50% in women taking oral contraceptives; interactions with rofecoxib can cause hallucinations, psychosis, and cardiovascular effects 3
Practical Recommendation
Given the 2025 safety data showing increased injury risk, consider tizanidine as functionally equivalent to a Beers Criteria medication when prescribing for older adults with musculoskeletal complaints. If you must use it:
- Start with the lowest possible dose
- Monitor closely for sedation, hypotension, and falls
- Reduce doses in renal impairment rather than increasing frequency
- Avoid in patients on oral contraceptives or with cardiovascular disease
- Consider non-pharmacologic alternatives first 4
The discrepancy between the 2019 Beers Criteria (which excludes tizanidine) and the 2025 safety data (which suggests it should be included) represents an evolving understanding of this medication's risk profile in older adults. The most recent, highest-quality evidence suggests tizanidine poses significant harm risk in this population 2.