What's New
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Herpes zoster vaccination for immunocompromised persons >=18 years old (October 2021)
Herpes zoster vaccination is indicated for those >=50 years of age to reduce the risk of herpes zoster and postherpetic neuralgia. The US Food and Drug Administration and the European Medicines Agency have now approved the recombinant zoster vaccine (RZV) for use in individuals >=18 years old who are at increased risk of herpes zoster due to immunodeficiency or immunosuppression2,3; RZV has been shown to reduce the incidence of herpes zoster in immunocompromised adults. Specific recommendations from the United States Advisory Committee on Immunization Practices regarding the use of RZV in those >=18 years of age are pending.
Cardiovascular Medicine - Cardiology
Risk of GI bleeding with DOACs (October 2021)
Direct oral anticoagulants (DOACs) are generally preferred over warfarin in individuals with non-valvular atrial fibrillation or venous thromboembolism. A new study evaluated the risk of gastrointestinal (GI) bleeding in over 5000 individuals taking apixaban, rivaroxaban, or dabigatran.4 Higher rates of GI bleeding were seen in individuals taking rivaroxaban (3.2 per 100 patient-years) than with the other agents (2.5 for apixaban and 1.9 for dabigatran). The once-daily dosing of rivaroxaban and higher peak levels may explain the higher bleeding risk; the other agents are dosed twice daily. These results may be a consideration when choosing among DOACs.
Family Medicine - Adult General Internal Medicine
Randomized trial of goal blood pressure in older adults (October 2021)
UpToDate recommends intensive blood pressure lowering in hypertensive older adults, based in part upon findings from the Systolic Pressure Intervention Trial (SPRINT). In the Strategy of Blood Pressure Intervention in the Elderly Hypertensive Patients (STEP) trial, more than 8000 Chinese adults aged 60 to 80 years were randomly assigned to either a more intensive (goal systolic pressure <130 mmHg) or a less intensive (goal systolic pressure <150 mmHg) blood pressure lowering strategy.5 Those assigned to more intensive blood pressure lowering had modestly lower rates of stroke, acute coronary syndrome, and heart failure at approximately three years; major adverse events were similar between the groups. The STEP trial findings are broadly consistent with those from SPRINT and support our recommendation for intensive blood pressure lowering in hypertensive older adults.
Primary Care - Immunizations
Post-COVID-19 symptoms not affected by vaccination (October 2021)
Some patients with persistent symptoms following COVID-19 are concerned that vaccination could exacerbate them. A recent study of 163 patients who had a heavy burden of post-COVID-19 symptoms at eight months reported that most patients' symptoms had either improved or remained unchanged one month after receiving either the BNT162b2 (Pfizer) or ChAdOx1 nCoV-19/AZD1222 (AstraZeneca) vaccine.1 We continue to recommend vaccination in patients following COVID-19, regardless of the presence of persistent symptoms.
1. Arnold DT, Milne A, Samms E, et al Symptoms After COVID-19 Vaccination in Patients With Persistent Symptoms After Acute Infection: A Case Series. Ann Intern Med 2021; 174:1334. [Context Link]
2. US Food and Drug Administration. Shingrix package insert. https://www.fda.gov/downloads/BiologicsBloodVaccines/Vaccines/ApprovedProducts/U (Accessed on September 29, 2021). [Context Link]
3. European Medicines Agency. Shingrix. https://www.ema.europa.eu/en/medicines/human/EPAR/shingrix#authorisation-details (Accessed on September 29, 2021). [Context Link]
4. Ingason AB, Hreinsson JP, Agustsson AS, et al Rivaroxaban Is Associated With Higher Rates of Gastrointestinal Bleeding Than Other Direct Oral Anticoagulants: A Nationwide Propensity Score-Weighted Study. Ann Intern Med 2021. [Context Link]
5. Zhang W, Zhang S, Deng Y, et al Trial of Intensive Blood-Pressure Control in Older Patients with Hypertension. N Engl J Med 2021; 385:1268. [Context Link]
Disclaimer: This content is provided for reference purposes only and represents a portion of the UpToDate topic. Readers should not rely on the content or any information cited here as being applicable to specific patient circumstances. All topics are updated as new evidence becomes available and our peer review process is complete.