Background The potentially inappropriate medications (PIM)-China criteria, published in 2017, require updates to reflect new therapeutic evidence and address limitations such as outdated medications and condition-specific considerations. Aim This study aimed to develop an updated version of the PIM-China criteria through a modified Delphi consensus methodology, ensuring evidence-based and clinically relevant recommendations for older adults in China. Method A literature review of six PIM criteria (Beers, STOPP, FORTA, EU(7)-PIM, Japan and Korea criteria) and relevant literature (2018-2023) informed a preliminary list of PIMs. A multidisciplinary panel of 33 experts, comprising 12 physicians and 21 pharmacists, evaluated 210 candidate criteria over three Delphi rounds. Statistical measures were used to validate consensus, including Kendall's W, coefficient of variation (CV), and expert authority coefficient (Cr). Cr values >= 0.80 indicated high reliability, while Kendall's W > 0.20 signified moderate to strong agreement. Results The updated criteria consist of 154 items, a 57% increase from 2017, including 100 individual medications or drug classes and 54 condition-specific PIMs. Notable additions include recommendations addressing drug-drug interactions, renal function adjustments, and alternative treatments. Consensus improved significantly across rounds, with Kendall's W increasing from 0.145 to 0.271 for individual PIMs and 0.118 to 0.360 for condition-specific PIMs (P < 0.05). Cr reached 0.85, reflecting the panel's high authority. Conclusion The updated 2024 PIM-China criteria enhance prescribing safety and clinical relevance by incorporating new evidence and expert consensus. These criteria are vital for reducing adverse drug events, optimizing prescribing practices, and improving healthcare for older adults in China.