The edition · Top Clinical Updates
Oral menopausal oestrogen raised clot risk at every dose; transdermal did not, in 40,000 Danish cases
A nationwide BMJ case-control study gives the route of HRT a number. Also: SGLT2 inhibitors and GLP-1 agonists protected the kidney only where there was albuminuria, tenecteplase before late basilar thrombectomy added nothing, and 14-day ECG monitoring after unexplained syncope did not reduce further episodes.
The edition in brief
In Danish registries covering women aged 50-69, current oral menopausal oestrogen was associated with higher rates of venous thromboembolism (HR 1.6), ischaemic stroke (1.3) and myocardial infarction (1.2) — one extra VTE per about 1,055 women treated for a year — while transdermal therapy showed no increase, except for myocardial infarction with transdermal combined cyclic regimens. A BMJ target trial emulation in 75,455 people with type 2 diabetes starting second-line therapy after metformin found GLP-1 agonists or SGLT2 inhibitors reduced five-year kidney deterioration against DPP-4 inhibitors in those with albuminuria (RR 0.60) but not in those without (RR 1.10). In ATTENTION LATE, 330 patients with basilar artery occlusion 4.5-24 hours from onset did no better with tenecteplase before thrombectomy (30% vs 30% functionally independent). In ASPIRED, 14-day ambulatory ECG after unexplained syncope in the emergency department did not reduce syncope episodes at a year (IRR 0.89, 0.68-1.18).
In type 2 diabetes, SGLT2 inhibitors and GLP-1 agonists protected the kidney only when albuminuria was present
Measure the urine albumin-creatinine ratio before choosing second-line diabetes therapy; the kidney benefit of SGLT2 inhibitors and GLP-1 agonists was concentrated in people with albuminuria.
Late basilar artery occlusion: tenecteplase before thrombectomy did not improve independence
For basilar artery occlusion presenting 4.5-24 hours after onset at a thrombectomy centre, proceed to thrombectomy without tenecteplase first.
Fourteen-day ECG monitoring after unexplained syncope did not reduce further syncope at a year
Do not order extended ECG monitoring routinely after unexplained syncope; target it at patients with features of an arrhythmic cause.
Ask which route, not just whether, when a patient says she takes HRT
Write down the route, dose and regimen of HRT in every medication history.
Menopausal hormone therapy: oral oestrogen raised clot risk; transdermal showed no increase
When starting menopausal hormone therapy, choose transdermal oestrogen for any woman with a thrombotic risk factor, and keep oral oestradiol doses low.
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