What medication should be avoided in individuals over 65 years of age according to the American Geriatric Society Beers Criteria?

Glyburide Should Be Avoided in Individuals > 65 Years of Age According to the American Geriatrics Society Beers Criteria

According to the American Geriatrics Society Beers Criteria, glyburide should be avoided in older adults over 65 years of age due to its high risk of severe prolonged hypoglycemia. 1

Rationale for Avoiding Glyburide in Older Adults

Glyburide (also known as glibenclamide) is specifically identified in the Beers Criteria as a potentially inappropriate medication for older adults for several important reasons:

• Higher Risk of Hypoglycemia: Glyburide carries a significantly higher risk of severe and prolonged hypoglycemic events in older adults compared to other sulfonylureas 2
• Accumulation in Kidney Disease: It accumulates in chronic kidney disease, which is more common in older adults, further increasing hypoglycemia risk 1
• Prolonged Duration of Action: Its long half-life and active metabolites can cause sustained hypoglycemia, particularly dangerous in older adults who may have impaired counter-regulatory responses

Comparison with Other Antidiabetic Medications in the Question

When comparing the medications listed in the question:

1. Glyburide: Should be avoided in older adults due to high hypoglycemia risk
2. Metformin: Generally considered first-line therapy for older adults with diabetes when not contraindicated by kidney function
3. Sitagliptin: A DPP-4 inhibitor with low hypoglycemia risk that is generally considered appropriate for older adults
4. Liraglutide: A GLP-1 receptor agonist that has a relatively favorable safety profile in older adults, though may cause gastrointestinal side effects

Evidence of Implementation of Beers Criteria Regarding Glyburide

Research has shown that glyburide use has significantly decreased following its addition to the Beers Criteria. A study examining pharmacy claims data found that glyburide use decreased from 35.8% in 2011 to just 4.2% in 2015 after its inclusion in the 2012 AGS Beers Criteria update, demonstrating successful adoption of this recommendation 2.

Practical Considerations for Diabetes Management in Older Adults

When managing diabetes in older adults:

• Avoid sulfonylureas with higher hypoglycemia risk, particularly glyburide
• Consider alternative agents with lower hypoglycemia risk (metformin, DPP-4 inhibitors, GLP-1 agonists) when appropriate
• Set less stringent glycemic targets for frail older adults to reduce hypoglycemia risk
• Monitor renal function regularly as many diabetes medications require dose adjustment or avoidance with declining kidney function

Broader Context of the Beers Criteria

The Beers Criteria serve as a guide to identify medications with unfavorable risk-benefit profiles in older adults. They are updated regularly (most recently in 2019) and include:

• Medications to avoid in older adults regardless of conditions
• Medications to avoid with specific diseases or syndromes
• Medications to use with caution
• Drug-drug interactions to avoid
• Medications requiring dose adjustment based on kidney function

The goal is to reduce adverse drug events, improve patient outcomes, and guide appropriate prescribing in the geriatric population.