The edition · Internal Medicine
ACP puts hormone therapy first for menopausal hot flushes
A physician guideline ranks the drug options for vasomotor symptoms; a randomised trial says not to pause biologics for vaccination; and the fracture-treatment gap persists.
The edition in brief
The American College of Physicians has issued a guideline on drug treatment for menopausal vasomotor symptoms in outpatient care: oestrogen with a progestogen, or oestrogen alone after hysterectomy, as first line on high-certainty evidence; venlafaxine or desvenlafaxine second; and escitalopram, paroxetine, gabapentin or a neurokinin receptor antagonist third. The COVER trial randomised 840 people with inflammatory arthritis to continue or pause biologic or JAK inhibitor therapy for two weeks after a COVID-19 booster: pausing did not improve antibody response but more than doubled the odds of a flare. A US claims cohort of nearly 468,000 women found a one-in-five risk of a second fracture within two years of the first, yet only 17.5% started osteoporosis treatment. A single-centre study suggests the cirrhosis threshold of 250 neutrophils is a poor guide to bacterial peritonitis in malignant ascites. In 21 veterans' hospitals, 42% of medical inpatients were medically ready to leave on a given day and 18% had waited a week or more, mostly for long-term care. The pearl covers the fracture that should trigger treatment.
Do not pause biologics for a vaccine dose
Keep patients on their biologic or JAK inhibitor when they receive a COVID-19 booster.
After the first fragility fracture, few women start treatment
Treat a fragility fracture as an indication to start bone protection before the patient leaves hospital.
Bacterial peritonitis in malignant ascites needs its own threshold
In malignant ascites, interpret the neutrophil count cautiously and rely on culture and clinical context.
Two in five medical inpatients were ready to go home
Start discharge planning at admission for patients likely to need placement.
The fracture that should trigger treatment
A low-trauma fracture after 50 warrants an osteoporosis plan, written into the discharge summary.
ACP guideline: drug treatment for menopausal vasomotor symptoms
For bothersome hot flushes without contraindications, hormone therapy is the first-line choice.
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