The edition · Top Clinical Updates
Carotid revascularisation did not improve cognition in asymptomatic stenosis, even with poor brain perfusion
A CREST-2 substudy removes a common reason for referral; an oral pyruvate kinase activator reduced transfusion need in thalassaemia; and older recipients gain less from expanded-criteria kidneys.
The edition in brief
CREST-H, a substudy of the CREST-2 trial, tested whether carotid endarterectomy or stenting improves cognition in people with asymptomatic carotid stenosis of 70% or more and impaired blood flow to the affected hemisphere. Among 51 participants with reduced cognition at baseline, revascularisation plus intensive medical management gave no cognitive advantage over medical management alone at one year (adjusted difference -0.15 SD), and the degree of perfusion delay did not change that. In ENERGIZE-T, oral mitapivat reduced transfusion burden by at least half in 30% of adults with transfusion-dependent thalassaemia against 13% on placebo over 48 weeks. A European target trial emulation of 64,036 waitlisted dialysis patients found standard-criteria deceased donor kidneys improved five-year survival at every age, but expanded-criteria kidneys from circulatory death donors gave 75-year-olds no clear survival gain and a threefold higher early mortality. An updated review of 38 trials summarised placebo-subtracted weight loss with GLP-1 receptor agonists and co-agonists in adults without diabetes: about 15% with semaglutide and 19% with tirzepatide, with gastrointestinal effects in three-quarters.
Oral mitapivat reduced transfusion burden in transfusion-dependent thalassaemia
Mitapivat reduced transfusion need in about a third of adults with transfusion-dependent thalassaemia; treat it as a specialist option where it is available.
Expanded-criteria kidneys gave older recipients little clear survival gain over dialysis
For patients over about 75, discuss whether to accept expanded-criteria kidneys, particularly from circulatory death donors, rather than assuming any kidney is better than dialysis.
GLP-1 receptor agonists and co-agonists: the weight loss each delivers without diabetes
Use the drug-specific figures to set realistic weight loss expectations, and warn about gastrointestinal effects before starting.
Screen for thalassaemia trait before labelling microcytosis as iron deficiency
When microcytosis comes with a normal ferritin, test for thalassaemia trait instead of continuing iron.
Carotid revascularisation did not improve cognition in asymptomatic stenosis
Do not offer carotid endarterectomy or stenting for asymptomatic stenosis to improve cognition; make the decision on stroke prevention grounds alone.
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