Internal Medicine Updates

First-ever Cardiovascular-Kidney-Metabolic (CKM) Syndrome guideline

• What: the first multisociety (AHA/ACC/ADA/ASN) guideline on CKM syndrome — the interconnected web of obesity, type 2 diabetes, CKD, and cardiovascular disease (published June 2026).
• Key moves: formal CKM staging (Stages 0–4) across the life course; risk quantified with the PREVENT equations (10- and 30-year); eGFR + UACR to characterize kidney disease; SGLT2 inhibitors, GLP-1–based therapy, and finerenone positioned by stage; obesity reframed as a central, modifiable driver.
• Why it matters: gives internists a common cross-specialty language and a prevention-first, coordinated-care model; replaces the 2013 obesity guideline.

Source: Circulation 2026 (PubMed)

2026 ACC/AHA Dyslipidemia guideline — LDL-C targets return

• First major US cholesterol-guideline update since 2018; retitled from "blood cholesterol" to dyslipidemia to capture triglyceride-rich remnants and lipoprotein(a).
• Restores explicit LDL-C / non-HDL-C treatment goals; recommends at least one lifetime Lp(a) measurement; uses PREVENT for risk; PCSK9 monoclonals no longer require a prior ezetimibe trial.

Source: JACC 2026 (PubMed) · AHA science news

2025 AHA/ACC Hypertension guideline — lower targets, PREVENT

Sets lower blood-pressure goals, replaces the Pooled Cohort Equations with the PREVENT equations for risk, and recommends pharmacotherapy at ≥130/80 mmHg for patients with CVD, diabetes, CKD, or elevated risk. Reassess current patients against the new thresholds.

Source: JACC 2025 (PubMed)

VESALIUS-CV — PCSK9 inhibition for primary prevention

In high-risk patients with established atherosclerosis or diabetes but no prior MI or stroke, evolocumab reduced major cardiovascular events — the first demonstration that PCSK9 inhibition lowers events in primary prevention, not just secondary. Expect pressure to escalate lipid-lowering earlier in selected high-risk patients (pending cost/coverage).

Source: NEJM 2026 (PubMed)

Oral PCSK9 inhibitor enlicitide (CORALreef)

An oral PCSK9 inhibitor lowered LDL-C to a degree comparable to injectable monoclonal antibodies, with a placebo-like safety profile. A pill could substantially improve access and adherence; cardiovascular-outcomes data are still awaited.

Source: NEJM 2026 (PubMed)

STAREE — statins for primary prevention after age 70

In 9,971 community-dwelling adults (mean age 74.7) without cardiovascular disease, atorvastatin cut major cardiovascular events by about 30% over a median 5.9 years (10.9 vs 15.5 events per 1,000 person-years; HR 0.70). It did not extend disability-free survival, the trial's co-primary outcome (HR 0.94, not significant). Serious adverse events were the same in both arms.

Bottom line: the first placebo-controlled evidence in this age group supports offering a statin for event prevention. Frame it for patients as fewer heart attacks and strokes, not a longer or more independent life.

Source: STAREE, NEJM 2026 · added September 2026

Baxdrostat — the first aldosterone synthase inhibitor for hypertension

FDA approved baxdrostat on May 18, 2026 as add-on therapy for adults with hypertension. In the BaxHTN trial (796 patients), the 2 mg dose lowered systolic pressure by 9.8 mmHg more than placebo at week 12. It is a new mechanism for resistant and uncontrolled hypertension. Its key risks are hyperkalemia and hyponatremia, so monitor potassium and sodium.

Source: FDA approval summary, ACC.org · added September 2026

Beta-blockers after MI with preserved EF — you can de-prescribe

• In post-MI patients with preserved LVEF and no heart failure, routine long-term beta-blockade did not reduce events (REBOOT).
• A dedicated discontinuation trial supported safely stopping beta-blockers in stable, low-risk patients without LV dysfunction (SMART-DECISION).
• Bottom line: continue beta-blockers for reduced EF / heart failure; for preserved EF, omission or discontinuation is reasonable via shared decision-making.

Sources: REBOOT, NEJM 2025 (PubMed) · Discontinuation trial, NEJM 2026 (PubMed)

Left atrial appendage closure as first-line in AF — two trials, mixed signal

• CHAMPION-AF: in AF patients eligible for anticoagulation, LAAC was noninferior to a DOAC for efficacy with less non-procedural bleeding.
• CLOSURE-AF: in older, higher-risk patients, LAAC did not meet noninferiority versus physician-directed medical therapy.
• Bottom line: device-first stroke prevention remains a selective, shared-decision choice — not a blanket recommendation.

Sources: CHAMPION-AF, NEJM 2026 (PubMed) · CLOSURE-AF, NEJM 2026 (PubMed)

SINGLE-AF — anticoagulate at intermediate stroke risk

For AF at intermediate stroke risk, a DOAC lowered the composite of stroke, systemic embolism, major bleeding or cardiovascular death at 24 months versus no anticoagulation (0.5% vs 1.5%; HR 0.31). Strokes numbered 3 versus 10 among 1,803 patients (mean age 60). Major bleeding appeared similar.

Bottom line: randomized evidence now favors a DOAC at intermediate risk, where the decision was previously left open. Event counts were small (4 vs 13), so individualize it.

Source: SINGLE-AF, NEJM 2026 · added September 2026

Physiology-guided complete revascularization in STEMI (AIR-STEMI)

In 1,823 patients with STEMI and multivessel disease, complete revascularization guided by functional coronary angiography reduced death, MI, stroke or ischemia-driven revascularization compared with angiography-guided revascularization (8.9% vs 13.7% at a median 17.9 months; HR 0.62). The safety outcome of contrast kidney injury or major bleeding was also lower (4.6% vs 7.1%).

Bottom line: for non-culprit lesions, a physiology-guided strategy outperformed visual assessment on the angiogram.

Source: AIR-STEMI, NEJM 2026 · added September 2026

The Fifth Universal Definition of Myocardial Infarction

• The numbered types (1, 2, 3, 4a–c, 5) are replaced by three clinical settings: primary, secondary and procedure-related MI.
• Primary MI now covers every acute coronary pathology: atherothrombosis, spontaneous coronary artery dissection, embolism, vasospasm, and late stent or graft failure.
• "Type 3 MI" is retired. Procedure-related MI no longer depends on troponin multiples and is defined the same way for PCI and surgery.
• Sex-specific 99th-percentile troponin limits now define myocardial injury, to avoid under-recognizing injury in women.

Source: Fifth UDMI, JACC 2026 · added September 2026

First dedicated ESC guideline on cardiac rehabilitation

• Cardiac rehabilitation is recommended after ACS and in chronic coronary syndromes, with or without PCI or CABG, to reduce cardiovascular death and MI (Class I, Level A).
• Start early: ideally within 14 days of ACS and no later than 30. After CABG, within 28 days and no later than 42 (Class I).
• Telerehabilitation or hybrid programs should be considered as alternatives to center-based rehabilitation (Class IIa). This is the first formal ESC endorsement.

Bottom line: referral at discharge is part of post-MI care, and home-based programs now count.

Source: ESC cardiac rehabilitation guideline, Eur Heart J 2026 · added September 2026

Aficamten in nonobstructive hypertrophic cardiomyopathy (ACACIA-HCM)

In 517 patients with symptomatic nonobstructive HCM, the cardiac myosin inhibitor aficamten improved patient-reported health status (KCCQ clinical summary score +3.0 points versus placebo) and peak oxygen uptake (+0.67 mL/kg/min) at 36 weeks.

Bottom line: myosin inhibition now has randomized benefit beyond obstructive HCM. The gains were modest but statistically significant.

Source: ACACIA-HCM, NEJM 2026 · added September 2026

Eplontersen did not reduce events in ATTR cardiomyopathy (CARDIO-TTRansform)

In 1,432 patients with transthyretin amyloid cardiomyopathy (mean age 76; 91% men), the TTR-silencing antisense drug eplontersen did not lower the composite of cardiovascular death and recurrent cardiovascular events compared with placebo through 140 weeks (rate ratio 0.89, P = 0.28).

Bottom line: a negative outcomes trial worth knowing. The result applies to eplontersen and does not change the evidence for other ATTR-CM therapies.

Source: CARDIO-TTRansform, NEJM 2026 · added September 2026

2026 ESC Heart Failure guideline — two phenotypes, and therapy across the EF range

• Reclassification: heart failure with mildly reduced EF is gone. There are now two phenotypes: HFrEF (LVEF below 50%) and HFpEF (LVEF 50% or more).
• Regardless of EF: an SGLT2 inhibitor (dapagliflozin or empagliflozin) and a mineralocorticoid-receptor antagonist are both recommended for symptomatic heart failure to reduce hospitalization or cardiovascular death (Class I, Level A).
• New: semaglutide or tirzepatide should be considered for symptomatic heart failure with LVEF 45% or more and BMI 30 or more, with or without diabetes, for weight, exercise capacity and quality of life (Class IIa).
• Upgraded: mitral transcatheter edge-to-edge repair for persistent severe secondary MR in selected HFrEF patients (now Class I). Digoxin or digitoxin should be considered for symptomatic HFrEF with LVEF 40% or less despite optimal therapy (now Class IIa).

Source: ESC HF guideline, Eur Heart J 2026 · added September 2026

The Second Universal Definition of Heart Failure

A joint AHA/ACC/ESC/WHF consensus document, not a treatment guideline. It drops fixed LVEF cutoffs in favor of three clinically actionable groups: HF with reduced EF, HFpEF, and HF with improved EF. It reaffirms the Stage A–D framework.

Practice point: heart failure is diagnosed from the accumulation of suggestive features, not a single test. A substantial proportion of people with HFpEF have normal natriuretic peptide levels despite invasive evidence of heart failure, so a normal BNP does not exclude it.

Source: Second Universal Definition of HF, Eur Heart J 2026 · added September 2026

First multisociety Acute Pulmonary Embolism guideline

A de novo guideline from ten societies introduces "Acute PE Clinical Categories" to standardize severity, disposition (home vs. early discharge vs. admission), and use of advanced therapies. It favors DOACs over VKAs and LMWH over UFH, and builds in structured follow-up for persistent dyspnea after anticoagulation.

Source: JACC 2026 (PubMed)

2026 AHA/ASA Acute Ischemic Stroke early-management guideline

• Endorses alteplase or tenecteplase within the 4.5-hour window; expands endovascular therapy to selected large-core and basilar-artery occlusions up to 24 hours.
• Advises against aggressive post-reperfusion BP lowering and tight glucose control; adds the first pediatric AIS recommendations.

Source: Stroke 2026 (PubMed)

2026 Surviving Sepsis Campaign guideline

Updates the 2021 edition with more granular guidance on early recognition, antibiotic optimization, hemodynamic targets (especially in older adults), and de-resuscitation / fluid removal after initial stabilization. It newly emphasizes structured post-ICU recovery and long-term follow-up for sepsis survivors.

Source: Crit Care Med 2026 (PubMed)

Multisociety sepsis position paper — hospital systems, not bedside bundles

Eight societies (IDSA, ACEP, ASM, PIDS, SCCM, SHEA, SHM, SIDP) set out hospital-level strategies to improve sepsis outcomes across six domains: diagnostics, antimicrobial delivery, surveillance, adjunctive therapy, infrastructure and infection prevention. It complements the Surviving Sepsis Campaign rather than replacing its bedside guidance.

• Rapid multiplex molecular testing on positive blood cultures, paired with stewardship.
• Antibiotics within 1 hour for septic shock, with an order-to-infusion time under 30 minutes where feasible.
• Prolonged infusion of antipseudomonal β-lactams after a loading dose; when both are ordered, give the β-lactam before vancomycin.
• Multidisciplinary sepsis governance.

Source: Rhee et al., Clin Infect Dis 2026 · added September 2026

Aspirin alone after hip or knee replacement (EPCAT III)

In 5,429 patients after total hip or knee arthroplasty, aspirin 81 mg daily from day 0 was noninferior to 5 days of rivaroxaban followed by aspirin. Symptomatic proximal DVT or PE at 90 days occurred in 0.48% vs 0.45%, and major or clinically relevant bleeding in 1.66% vs 2.04%. Aspirin continued 9 more days after knee replacement and 30 more after hip replacement.

Bottom line: aspirin monotherapy is a reasonable choice for typical-risk arthroplasty patients. Event rates were low and high-risk patients were not the focus, and the earlier CRISTAL trial found aspirin from day 0 inferior to enoxaparin. It does not replace anticoagulation for high-risk patients.

Source: EPCAT III, NEJM 2026 · added September 2026

ATS 2026 guideline on noninvasive respiratory support

• Acute hypoxemic respiratory failure: high-flow nasal cannula (strong recommendation); NIV or CPAP as a conditional alternative, with close monitoring for escalation.
• Acute hypercapnic respiratory failure: NIV, to reduce mortality and intubation (strong). HFNC only for milder hypercapnia with mild acidemia (for example pH above 7.25), and only if close monitoring and prompt escalation to NIV are available (conditional).

Source: ATS guideline, Am J Respir Crit Care Med 2026 · added September 2026

The first mRNA influenza vaccine (mRNA-1010)

FDA approved an mRNA seasonal influenza vaccine on August 5, 2026: traditional approval for ages 50–64 and accelerated approval for 65 and older. In the pivotal trial (40,703 adults aged 50+), relative efficacy against RT-PCR-confirmed influenza-like illness was 26.6% versus standard-dose vaccine. Injection-site pain and fatigue were more common (pain 65.8% vs 29.8%).

Sources: Pivotal trial, NEJM 2026 · FDA approval report · added September 2026

Bictegravir/lenacapavir — a new single-tablet HIV switch option

FDA approved a once-daily single tablet of bictegravir plus lenacapavir on August 27, 2026 for virologically suppressed adults with HIV, including those on complex multi-tablet regimens (ARTISTRY-1 and ARTISTRY-2). It is a simplification option for primary-care HIV management. Confirm resistance history before switching.

Source: FDA approval summary (UCLA CHIPTS) · added September 2026

Staphylococcus aureus bacteremia — IDSA/ESCMID consensus (Part 1)

This replaces the old "complicated versus uncomplicated" split with risk stratification for deep-seated or metastatic infection and relapse. The panel's suggestions:

• Follow-up blood cultures: at least 2 sets at 48 hours, then every 24–48 hours until negative.
• Echocardiography: TTE in all adults with SAB, because no truly low-risk group could be defined. Follow with TEE after a negative TTE when risk features are present.
• Unknown focus in higher-risk patients: whole-body imaging (such as FDG-PET/CT) or a combination of imaging modalities.
• Duration without deep-seated or metastatic foci: 14 days, rather than shorter or longer courses.

Antibiotic choice for MSSA and MRSA will be covered in later parts.

Source: IDSA/ESCMID statement (Sept 2026) · added September 2026

Infective endocarditis — new AHA scientific statement

The first AHA update since 2015. By design it offers management suggestions rather than graded recommendations.

• Partial oral therapy (the POET approach) is an option for selected stabilized patients with streptococcal, E. faecalis, MSSA or coagulase-negative staphylococcal endocarditis. It is not considered second-line therapy.
• Imaging: TEE for prosthetic valves or cardiac devices even if TTE is negative. With native valves, a high-quality negative TTE may suffice when pretest probability is low.
• Surgery: when indicated, early surgery within 48–72 hours is favored, unless there has been a major stroke or intracranial hemorrhage, which usually delays surgery by 2–4 weeks.
• Cardiac device infection requires complete device extraction. Adding gentamicin or rifampin for staphylococcal prosthetic-valve endocarditis showed no benefit in recent studies and added toxicity.

Source: AHA scientific statement, Circulation 2026 · added September 2026

IDSA guidance on antimicrobial-resistant gram-negative infections (2026)

The updated living guidance gives preferred and alternative agents for ESBL-producing and AmpC-producing Enterobacterales, carbapenem-resistant Enterobacterales, difficult-to-treat Pseudomonas aeruginosa, carbapenem-resistant Acinetobacter baumannii and Stenotrophomonas maltophilia. It also covers empiric therapy, oral step-down and treatment duration. It is current as of March 1, 2026, gives adult dosing, and is updated online at idsociety.org, so check there before prescribing.

Source: IDSA AMR guidance, Clin Infect Dis 2026 · added September 2026

Vaccinating immunocompromised patients — IDSA guideline

• Age-appropriate COVID-19 and influenza vaccination for immunocompromised adults and children, and RSV vaccination for immunocompromised adults and adolescents (each a strong recommendation, moderate certainty).
• High-dose or adjuvanted influenza vaccines give a more robust response. Live attenuated influenza vaccine is contraindicated.
• Timing: ideally at least 2 weeks before immunosuppressive treatment. After B-cell depletion, consider waiting 3–6 months after the last infusion, but vaccinate during treatment if optimal timing is not possible.
• Giving the vaccines together is appropriate, and household contacts should be up to date.

Source: IDSA guideline, Clin Infect Dis 2026 · added September 2026

ADA Standards of Care in Diabetes — 2026

• Continuous glucose monitoring positioned at or near diagnosis; automated insulin delivery preferred for insulin users.
• GLP-1–based therapy supported for type 1 diabetes with obesity for the first time; lower systolic BP target for high CV/renal risk; individualized (not maximal) obesity pharmacotherapy dosing.

Source: Diabetes Care 2026 (PubMed) · Standards of Care

Next-generation incretins — an oral GLP-1 and triple agonists

• Orforglipron, an oral non-peptide GLP-1 receptor agonist, advanced through phase 3 (e.g., ACHIEVE-5) — a pill with no food/water timing restrictions could broaden access in primary care.
• Survodutide (glucagon/GLP-1 agonist) produced large phase-3 weight loss in adults with obesity; the GIP/GLP-1/glucagon triple agonist retatrutide reported topline phase-3 obesity results (still investigational).

Sources: Orforglipron (ACHIEVE-5), JAMA 2026 (PubMed) · Survodutide, NEJM 2026 (PubMed)

Semaglutide for MASH (ESSENCE) — a GLP-1 for liver disease

In patients with metabolic dysfunction–associated steatohepatitis and F2–F3 fibrosis, semaglutide 2.4 mg improved MASH resolution and fibrosis versus placebo — supporting a GLP-1 option for non-cirrhotic MASH. Screen at-risk patients (e.g., type 2 diabetes) with FIB-4.

Source: NEJM 2025 (PubMed)

Tirzepatide gains a cardiovascular indication — read the trial carefully

On August 28, 2026 FDA added a cardiovascular risk-reduction indication to tirzepatide for adults with type 2 diabetes and established cardiovascular disease, based on SURPASS-CVOT (13,299 patients). Against an active comparator, dulaglutide, major adverse cardiovascular events occurred in 12.2% vs 13.1% (HR 0.92). That result met noninferiority but not superiority.

Bottom line: tirzepatide is now labeled for CV protection, but the trial showed it protects about as well as a GLP-1 receptor agonist already known to reduce events. It did not show that it does better.

Sources: SURPASS-CVOT, NEJM 2025 · FDA label expansion (Lilly) · added September 2026

Efsitora alfa — a second once-weekly basal insulin

FDA approved efsitora alfa on September 24, 2026, based on four phase 3 QWINT trials. It is the second once-weekly basal insulin in the US, after insulin icodec. Weekly basal insulin may help patients with type 2 diabetes who struggle with daily injections. A weekly dose will need its own approach to hypoglycemia and to perioperative and inpatient dosing.

Source: FDA approval (Lilly) · added September 2026

ACP living guideline on obesity medications

For nonpregnant adults with obesity, or overweight with comorbidity, ACP ranks pharmacotherapy (with lifestyle modification) in this order:

1. Semaglutide or tirzepatide
2. Phentermine-topiramate
3. Liraglutide
4. Naltrexone-bupropion

It is a living guideline and will be updated as the evidence changes.

Source: ACP guideline, Ann Intern Med 2026 · added September 2026

ACG diverticulitis guideline — fewer antibiotics, no episode-count surgery

• Antibiotics: not routinely for low-risk acute uncomplicated diverticulitis. Use them for high-risk features, immunocompromise, frailty, or when safe outpatient care cannot be ensured (conditional, moderate certainty).
• Surgery: the number of episodes no longer determines the need for colectomy, and neither does young age alone. When recurrent disease significantly impairs quality of life, refer to discuss the risks and benefits of elective resection.
• Colonoscopy: after complicated diverticulitis (strong). After uncomplicated disease, only with alarm features or if screening is not current. Wait 6–8 weeks.
• Prevention: not mesalamine (strong recommendation against), rifaximin or probiotics. Lifestyle measures are advised instead. Nuts, corn, seeds and popcorn need not be avoided.

Source: ACG guideline, Am J Gastroenterol 2026 · added September 2026

C. difficile infection — AGA clinical practice updates

• Fidaxomicin (200 mg twice daily for 10 days) is favored first-line for non-fulminant infection because recurrence is lower. Oral vancomycin (125 mg four times daily for 10 days) remains acceptable.
• Metronidazole should not be used outside fulminant disease.
• Bile-acid binders such as cholestyramine should not be used alone or alongside oral vancomycin or fidaxomicin.
• A companion update addresses C. difficile in inflammatory bowel disease.

Sources: AGA update (adults), Clin Gastroenterol Hepatol 2026 · AGA update (IBD), Gastroenterology 2026 · added September 2026

ACG hepatic encephalopathy guideline — stop ordering ammonia

• Serum ammonia should not be used alone to diagnose HE or to guide treatment (conditional, very low certainty).
• Lactulose for overt HE (strong), titrated to 2–3 soft stools a day as first-line prevention after a first episode (strong, high certainty). Add rifaximin for recurrence despite lactulose (strong, high certainty).
• Nutrition: protein 1.2–1.5 g/kg/day for outpatients (strong); no protein restriction.
• Start rifaximin 14 days before elective TIPS and continue at least 6 months (strong).

Source: ACG guideline, Am J Gastroenterol 2026 · added September 2026

SGLT2 inhibitors benefit all CKD stages (SMART-C meta-analysis)

An individual-patient-data meta-analysis showed SGLT2 inhibitors slowed CKD progression across the range of eGFR and albuminuria — including low-grade albuminuria and advanced CKD. Consider an SGLT2 inhibitor for nearly all eligible CKD patients.

Source: JAMA 2026 (PubMed)

FIND-CKD — finerenone in non-diabetic CKD

In adults with non-diabetic CKD already on maximally tolerated RAS blockade, finerenone slowed eGFR decline — extending the nonsteroidal MRA story beyond diabetic kidney disease and pointing toward a RAS-inhibitor + SGLT2i + finerenone foundation for proteinuric CKD.

Source: NEJM 2026 (PubMed)

Semaglutide protects the kidney across cardio-kidney-metabolic disease (pooled SELECT, FLOW, SOUL)

Pooling three phase 3 trials (30,787 participants, with and without diabetes), semaglutide reduced a major kidney composite by 16% versus placebo (HR 0.84). A narrower kidney-specific composite fell by 20% (HR 0.80), with safety in line with the drug class.

Bottom line: kidney protection is a class-level reason to use semaglutide in cardio-kidney-metabolic disease, alongside RAS blockade, an SGLT2 inhibitor and, where indicated, finerenone.

Source: Pooled analysis, Lancet Diabetes Endocrinol 2026 · added September 2026

Atacicept — a new IgA nephropathy therapy

FDA granted accelerated approval on July 7, 2026 to atacicept, the first dual BAFF/APRIL inhibitor, to reduce proteinuria in adults with primary IgA nephropathy. In ORIGIN 3, proteinuria fell 42% more than with placebo at 36 weeks. Accelerated approval rests on proteinuria, and confirmation of eGFR benefit is pending.

Source: FDA announcement · added September 2026

Finerenone approved for CKD in type 1 diabetes (FINE-ONE)

FDA approved finerenone for CKD associated with type 1 diabetes on September 17, 2026. In FINE-ONE (242 adults), albuminuria fell 28% versus placebo at 6 months. Hyperkalemia occurred in 10.1% versus 3.3%, so check potassium as with any mineralocorticoid-receptor antagonist.

Bottom line: the first new kidney-protective option for type 1 diabetes in decades. The approval rests on albuminuria, not yet on hard kidney outcomes.

Source: FDA approval (Bayer) · added September 2026

First ESC/ERA guideline on cardiovascular disease and CKD

• Screen everyone with cardiovascular disease for CKD using eGFR and albuminuria (Class I).
• In CKD: maximally tolerated ACE inhibitor or ARB (Class I, Level A). An SGLT2 inhibitor with type 2 diabetes and eGFR 20 or more, or without diabetes with eGFR 20 or more and UACR of at least 200 mg/g (Class I, Level A).
• In CKD with type 2 diabetes: finerenone for eGFR 25 or more and UACR of at least 30 mg/g (Class I, Level A). Semaglutide in defined eGFR and albuminuria ranges (Class I, Level A).

Source: ESC/ERA guideline, Eur Heart J 2026 · added September 2026

Biologics enter COPD — dupilumab and mepolizumab

In COPD with type 2 inflammation (blood eosinophils ≥300) on triple therapy, dupilumab (pooled BOREAS/NOTUS) and mepolizumab (MATINEE) reduced exacerbations — now recognized add-on options in GOLD 2026. Check blood eosinophils in exacerbation-prone patients.

Sources: Dupilumab pooled, Lancet Respir Med 2025 (PubMed) · Mepolizumab (MATINEE), NEJM 2025 (PubMed)

GINA 2026 — what changed in asthma

• Step 1: anti-inflammatory reliever therapy with combination ICS-SABA was added to Track 2 for adults and adolescents. ICS-formoterol reliever therapy (Track 1) remains GINA's preferred approach.
• Exacerbations: four new flowcharts. Supplemental oxygen is not recommended unless saturation is below 92%, with an upper target of 95% in those 6 and older. SABA dosing is more conservative, citing over-treatment. Give epinephrine first when anaphylaxis features are present.
• Severe asthma: depemokimab (anti-IL-5 every 26 weeks, ages 12 and up) and an omalizumab biosimilar. A triple ICS-LABA-LAMA inhaler was added at Step 5.

Source: GINA 2026 report · added September 2026

2026 ACR/SAA/SPARTAN axial spondyloarthritis guideline

An update of the 2019 adult treatment guideline, with a first dedicated juvenile companion. The official summary was released June 24, 2026, and the peer-reviewed manuscripts are pending.

• Imaging: sacroiliac radiographs first in adults; MRI without contrast first in children.
• Treatment: NSAIDs first-line. TNF inhibitors and IL-17 inhibitors are equally preferred as the first biologic. JAK inhibitors are recommended, but not first among advanced therapies.
• Recommended against: IL-23 inhibitors for axial disease, and conventional synthetic DMARDs for purely axial disease.

Source: ACR guideline summary (June 2026) · added September 2026

2026 ACR osteoarthritis guideline — GLP-1s for knee OA, methotrexate for erosive hand OA

• New: a GLP-1 receptor agonist to help reach optimal weight, with diet and exercise, in knee OA with obesity (conditional, moderate certainty).
• Changed: methotrexate for erosive hand OA (conditional, low certainty). It is conditionally recommended against in knee and hip OA.
• Strong recommendations against: hydroxychloroquine, bisphosphonates, glucosamine and chondroitin, TNF inhibitors, and PRP or stem-cell injections for knee or hip OA.
• Still strongly recommended: exercise, weight loss where appropriate, topical and oral NSAIDs, and intra-articular glucocorticoids for knee or hip OA.

The official summary is published, and the full manuscript is pending.

Source: ACR guideline summary (Sept 2026) · added September 2026

Avacopan — liver injury and a proposed withdrawal

March 31, 2026: FDA reported 76 cases of drug-induced liver injury with avacopan (Tavneos), used for ANCA-associated vasculitis. Of these, 74 were serious, with 54 hospitalizations, 8 deaths and 7 biopsy-confirmed cases of vanishing bile duct syndrome. FDA advised stopping the drug promptly for specified liver-test abnormalities.

April 27, 2026: FDA proposed withdrawing the drug's approval. The grounds were a lack of substantial evidence of effectiveness and untrue statements in the application, relating to readjudication of pivotal-trial data. Hepatotoxicity was cited as an aggravating factor. The drug remains on the market while the hearing process runs.

Bottom line: monitor liver tests closely in current users, and review whether continued use is warranted.

Sources: FDA safety communication · FDA withdrawal proposal · added September 2026

DESTINY-Breast09 — a new first-line standard for HER2+ breast cancer

Trastuzumab deruxtecan (T-DXd) plus pertuzumab improved progression-free survival versus the taxane-based standard as first-line therapy for HER2-positive metastatic breast cancer. Relevant to internists for awareness, referral, and survivorship; monitor for interstitial lung disease / pneumonitis.

Source: NEJM 2026 (PubMed)

ACP breast cancer screening guidance — and the conflict it creates

• ACP guidance: biennial mammography for average-risk women 50–74; shared decision-making (not routine screening) for ages 40–49.
• Do not use clinical breast exam to screen; discuss discontinuation at ≥75 or limited life expectancy.

Source: Annals of Internal Medicine 2026 (PubMed)

Boxed warning: IV ferric carboxymaltose and hypophosphatemia

On September 1, 2026 FDA added a boxed warning to ferric carboxymaltose (Injectafer) for symptomatic hypophosphatemia and recommended monitoring serum phosphate. It strengthens earlier label warnings.

Bottom line: monitor phosphate in patients receiving ferric carboxymaltose, as the label now directs.

Source: FDA drug safety communication · added September 2026

ASH 2026 ITP guideline — don’t start with steroids alone

• Initial therapy for adults with primary ITP: rituximab plus corticosteroids, or a thrombopoietic agent plus corticosteroids, rather than corticosteroids alone (conditional).
• After corticosteroid failure: a thrombopoietic agent (strong) or rituximab (conditional).

Critical bleeding in ITP is covered by a separate ASH emergency-management guideline.

Source: ASH guideline, Blood Adv 2026 · added September 2026

A reshaped USPSTF

HHS named eight new members to the US Preventive Services Task Force on September 17, 2026, including cardiologists, a radiologist, a gastroenterologist and a pediatric hematologist-oncologist as chair. The Task Force had issued no new final recommendation statements since mid-2025 (its last draft was posted August 5, 2025) and was largely inactive until the new appointments.

Bottom line: existing USPSTF recommendations stand. Watch how the reconstituted panel handles pending topics. Where USPSTF and specialty societies differ, as with breast screening above, document the shared decision.

Source: HHS announcement · added September 2026

The 2026–27 respiratory vaccine season: use the society recommendations

• COVID-19: an updated vaccine for all adults 19 and older, with a second dose at 6 months for those 65 and older.
• Influenza: annual vaccination, with an enhanced product preferred at 65 and older.
• RSV: a one-time dose for everyone 75 and older, and for adults 50–74 at increased risk.
• Pregnancy: maternal RSV vaccination at 32–36 weeks, with the seasonal window extended to September–March (AAFP, ACOG).
• Giving these vaccines at the same visit is endorsed.

For immunocompromised patients, see the IDSA card under Infectious diseases.

Sources: AAFP fall recommendations · ACOG 2026–27 · IDSA · AMA summary of the four societies · added September 2026

Migraine prevention — AAN/AHS guideline (first update since 2012)

• Offer prevention at 4 or more migraine days a month (or moderate-to-severe headache days).
• The highest-confidence tier for episodic migraine puts the CGRP monoclonal antibodies and atogepant alongside propranolol, topiramate and valproate. Newer agents are no longer gated behind the older ones.
• With medication overuse, prefer agents with evidence there: CGRP antibodies, atogepant, onabotulinumtoxinA or topiramate.
• Avoid valproate and topiramate where possible in people of childbearing potential (Level A).
• Allow 8–12 weeks at a tolerated dose to judge an oral preventive, and 24 weeks for onabotulinumtoxinA.

Source: AAN/AHS guideline, Neurology 2026 · added September 2026

Insomnia — CBT-I first; medication is an add-on, not a substitute

The first AASM guideline on combining treatments. Two conditional recommendations, both low certainty:

• If medication is used, add CBT-I rather than using medication alone.
• CBT-I alone is preferred over combination therapy for most patients. Combination is reasonable for those who most value faster gains in total sleep time.

The evidence covers benzodiazepine-receptor agonists and trazodone, not orexin antagonists.

Source: AASM guideline, J Clin Sleep Med 2026 · added September 2026

AHA/ASA 2026 stroke rehabilitation guideline

• Screen routinely and repeatedly for depression and anxiety after stroke.
• Graduated early mobilization starting 24–48 hours after stroke is recommended. Very early, intensive mobilization in the first 24 hours is not.
• Choose a PEG over a prolonged nasogastric tube when dysphagia is expected to persist.
• Avoid overhead pulley exercises for hemiplegic shoulder pain.
• Rehabilitation is a longitudinal process with no fixed endpoint, with early supported discharge and telerehabilitation where appropriate.

Source: AHA/ASA guideline, Stroke 2026 · added September 2026

ACP position paper on AI in medical practice

• AI must support, not weaken, the patient–physician relationship. Efficiency gains should buy better time with patients, not shorter visits.
• AI should inform, not replace, the physician's independent clinical judgment.
• Physicians and health systems must identify and mitigate algorithmic bias, with local AI governance across the full life cycle.
• Physicians and trainees need new competencies in appropriate AI use, alongside the competencies of caring.

Source: ACP position paper, Ann Intern Med 2026 · added September 2026