The edition · Internal Medicine
Hormone therapy first for hot flushes, then a defined ladder: the ACP guideline
A physicians' guideline orders the drug options for menopausal vasomotor symptoms, closed-loop oxygen keeps ward patients in range, and holding biologics for a vaccine dose buys nothing but flares.
The edition in brief
The American College of Physicians guideline on menopausal vasomotor symptoms makes hormone therapy the strong first-line recommendation: oestrogen with a progestogen when the uterus is present, oestrogen alone after hysterectomy. Second line, when hormone therapy is contraindicated or not tolerated, is desvenlafaxine or venlafaxine; third line is escitalopram, paroxetine, gabapentin, or the neurokinin receptor antagonists elinzanetant and fezolinetant. A meta-analysis of seven trials (635 adults) found automated closed-loop oxygen control kept patients within their target saturation range 21 percentage points more of the time than manual titration, most with low-flow oxygen. In the COVER trial of 840 patients with inflammatory arthritis, holding biologics or JAK inhibitors for two weeks after a COVID-19 booster did not improve antibody response but more than doubled the odds of a flare. A single-centre study of 337 paracenteses suggests the cirrhosis threshold of 250 neutrophils per cubic millimetre performs poorly for bacterial peritonitis in malignant ascites. A Korean study of nearly 10 million results found fasting mattered meaningfully for only a few tests, chiefly glucose, triglycerides, GGT and lipase, and nothing was gained beyond 8 to 12 hours. The pearl: recheck a high potassium before treating it if the sample may be haemolysed or delayed.
Closed-loop oxygen keeps ward patients in their saturation range a fifth more of the time
Write a target saturation range on every oxygen prescription and titrate to it; automated control does this better than manual adjustment.
Holding biologics for a COVID-19 booster: no antibody gain, twice the flares
Continue biologics and JAK inhibitors through a COVID-19 booster in inflammatory arthritis; holding them does not improve the response.
Bacterial peritonitis in malignant ascites: the cirrhosis cut-off performs poorly
In malignant ascites, culture the fluid and judge infection clinically; the cirrhosis neutrophil cut-off is unreliable here.
Fasting before blood tests matters for a handful of analytes, not the panel
Ask patients to fast only for the few tests that need it, and never for longer than 8 to 12 hours.
A high potassium on a routine sample: recheck before you treat
Recheck an unexpected high potassium with a clean, promptly processed sample and an ECG before giving potassium-lowering treatment.
ACP guideline on hot flushes: hormone therapy first, then a defined order of alternatives
Offer hormone therapy as first-line treatment for menopausal vasomotor symptoms unless contraindicated, with SNRIs next and SSRIs, gabapentin or neurokinin antagonists after that.
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