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Family Medicine - Adult General Internal Medicine

Psychiatric disorders following recovery from COVID-19 (May 2022)


Patients who recover from acute COVID-19 are at increased risk for psychiatric disorders. In a large retrospective study, incident psychiatric disorders occurred more frequently in patients who survived COVID-19 than in patients without a history of COVID-19 (hazard ratio 1.5).2 Specific disorders included anxiety, depressive, posttraumatic stress, sleep, and substance use disorders. Patients with post-COVID-19 psychiatric disorders should be monitored and may require psychotherapy and/or pharmacotherapy.


Family Medicine - Adult Hematology and Oncology

Surveillance for mental health disorders in adolescent and young adult cancer survivors (May 2022)


Adolescent and young adult (AYA) cancer survivors are at risk for mental health disorders and symptoms. A systematic review of almost 80 studies on mental health surveillance recommendations from the International Late Effects of Childhood Cancer Guideline Harmonization Group determined an elevated risk of mental health disorders and symptoms in this population, low harm of mental health surveillance, and high benefit from referral to mental health support services.3 Based on these data, in all AYA cancer survivors, we now recommend lifelong surveillance at every visit for mental health disorders and symptoms including depression and mood disorders, psychological and cancer-related distress, posttraumatic stress disorder and symptoms, and suicidal ideation.


Family Medicine - Adult Infectious Diseases

Tixagevimab-cilgavimab for pre-exposure prophylaxis against COVID-19 (May 2022)


The monoclonal antibody combination tixagevimab-cilgavimab is a potential option for pre-exposure prophylaxis against COVID-19 for certain immunocompromised individuals who may not benefit maximally from vaccination and for those who have a contraindication to vaccination. In a placebo-controlled, randomized trial of over 5000 unvaccinated adults, a single dose of tixagevimab-cilgavimab reduced the risk of symptomatic infection by 77 percent.4 Overall, serious adverse event rates were similar to those with placebo. However, among individuals with cardiovascular risk, severe cardiac events were rare but more frequent with tixagevimab-cilgavimab. For those who meet eligibility criteria, we individualize the decision to use tixagevimab-cilgavimab, taking into account risk of exposure and severe disease, underlying comorbidities, and patient preference.


Family Medicine - Adult General Internal Medicine

Increased bleeding with apixaban and systemic fluconazole (May 2022)


Direct oral anticoagulants (DOACs) have fewer drug interactions than warfarin, but interactions do occur. In a large series involving nearly 100,000 individuals receiving a DOAC, individuals receiving apixaban plus fluconazole, a moderate inhibitor of the P450 cytochrome CYP3A4, had a 3.5-fold increased risk of bleeding compared with periods when they were receiving apixaban without fluconazole.1 The increase was greatest in gastrointestinal bleeding requiring hospitalization. The risk was only seen with systemic fluconazole plus apixaban; it did not occur with topical fluconazole plus apixaban or systemic fluconazole plus another DOAC. This study highlights the importance of possible drug interactions and of considering alternatives that might be equally effective, such as topical therapy.


1. Holt A, Strange JE, Rasmussen PV, et al Bleeding Risk Following Systemic Fluconazole or Topical Azoles in Patients with Atrial Fibrillation on Apixaban, Rivaroxaban, or Dabigatran. Am J Med 2022; 135:595. [Context Link]


2. Xie Y, Xu E, Al-Aly Z. Risks of mental health outcomes in people with covid-19: cohort study. BMJ 2022; 376:e068993. [Context Link]


3. Marchak JG, Christen S, Mulder RL, et al Recommendations for the surveillance of mental health problems in childhood, adolescent, and young adult cancer survivors: a report from the International Late Effects of Childhood Cancer Guideline Harmonization Group. Lancet Oncol 2022; 23:e184. [Context Link]


4. Levin MJ, Ustianowski A, De Wit S, et al Intramuscular AZD7442 (Tixagevimab-Cilgavimab) for Prevention of Covid-19. N Engl J Med 2022. [Context Link]


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