The edition · Internal Medicine
Most penicillin allergy labels are wrong, and a direct oral challenge can remove them on the ward
A JGIM review sets out how PEN-FAST and an oral challenge turn delabelling into routine inpatient work. Also: KDIGO's 2026 anaemia-in-CKD guideline, a hybrid CGM protocol that replaced half of ward fingersticks, why a low vitamin D rarely means osteomalacia, and the alcohol treatment gap in fatty liver.
The edition in brief
About 10% of patients carry a penicillin allergy label, most of them wrongly; a JGIM narrative review sets out how the PEN-FAST score identifies low-risk patients and how, after the PALACE trial, a direct oral penicillin challenge can replace skin testing for them. The KDIGO 2026 guideline on anaemia in CKD, summarised in Annals, uses transferrin saturation and ferritin to guide iron, prefers intravenous iron in haemodialysis, puts ESAs ahead of HIF-PH inhibitors as first line, and caps maintenance haemoglobin below 11.5 g/dL. A hybrid inpatient CGM protocol in 54 general medicine and renal patients achieved a mean absolute relative difference of 10-12% against fingerstick glucose and replaced 53% of point-of-care tests. In 423 Norwegians with a mean 25-hydroxyvitamin D of 34 nmol/L, none had the full biochemical pattern of osteomalacia. Among 608 veterans with steatotic liver disease who drank, fewer than one in seven received any alcohol treatment over two years.
KDIGO 2026 on anaemia in CKD: iron first, ESA before HIF-PH inhibitors, haemoglobin below 11.5
In CKD anaemia, correct iron and other causes first, use an ESA before a HIF-PH inhibitor, and keep haemoglobin below 11.5 g/dL on treatment.
A hybrid CGM protocol on medical and renal wards replaced half of fingerstick glucose tests
Where a hospital has a hybrid CGM protocol, it can safely take over about half of ward fingersticks, with confirmation for low or discordant readings.
A low vitamin D level rarely came with the biochemistry of osteomalacia
Treat a low vitamin D as a level to correct, not a bone diagnosis; look for osteomalacia only when calcium, phosphate, ALP and symptoms point to it.
Fewer than one in seven drinkers with fatty liver received any alcohol treatment
When a patient with fatty liver screens positive for alcohol, offer treatment — screening alone changed nothing for six in seven.
Ask what actually happened before accepting a drug allergy label
Before accepting an allergy label, ask what the reaction was, when, and whether the drug has been taken since.
Penicillin allergy labels: use PEN-FAST, and remove low-risk ones with a direct oral challenge
For inpatients with a low-risk penicillin allergy label on PEN-FAST, offer a supervised direct oral challenge and remove the label if it is tolerated.
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