Monthly internal medicine bulletin — October 2, 2026
Colleagues: this issue covers September 2 to October 2, 2026, plus five items from the last days of August (31 to 35 days old) that earn their place: four trials from the European cardiology congress with direct relevance to internists, and this season's COVID-19 vaccines. The month was shaped by the EASD meeting in Milan (September 28 to October 2), with two phase 3 trials in type 2 diabetes, and by two FDA decisions in diabetes. There are 14 verified items; five come from outside North America and Western Europe (Brazil, India, Czech Republic, Australia, and the Dominican Republic). The chronic disease section is short this month: that is stated below rather than padded. Where the journal was behind a paywall, the data come from the scientific society's release or from specialist coverage, and this is noted.
Cardiometabolic
1. Retatrutide in type 2 diabetes with obesity: −20.8% body weight at 80 weeks (TRIUMPH-2)
[Clinical trial] [International]
Phase 3 trial in 1,152 adults with type 2 diabetes and obesity or overweight, randomized to weekly retatrutide (4, 9, or 12 mg) or placebo for 80 weeks. Weight loss: −12.7%, −19.1%, and −20.8% versus −4.0% with placebo. HbA1c fell by 1.4 to 1.6 points from a baseline of 7.7%, versus 0.2 with placebo. Diarrhea in 27.4–33.6% versus 13.2%; treatment discontinuation ranged from 3.8% to 11.6% by dose. Presented at EASD and, according to coverage, published in The Lancet.
Why it matters: this is the largest drug-induced weight loss reported in type 2 diabetes, but the figures use the efficacy estimand (assumes full adherence), the trial is manufacturer-run (Lilly), and there are no cardiovascular outcomes or regulatory approval yet; it does not change practice today, and its likely cost will limit access in the Dominican Republic.
https://europepharmatoday.com/news/lilly-retatrutide-triumph-2-easd-september-2026
https://investor.lilly.com/node/54911/pdf
2. Oral orforglipron versus insulin glargine: cardiovascular safety shown, superiority not shown (ACHIEVE-4)
[Clinical trial] [International]
2,749 adults with type 2 diabetes, overweight or obesity, and elevated cardiovascular risk received daily oral orforglipron or insulin glargine. Four-component major adverse cardiovascular events: HR 0.84 (95% CI 0.59–1.20), meeting noninferiority; three-component: HR 0.77 (0.52–1.13). At 52 weeks, HbA1c −1.6 versus −1.0 points and body weight −8.8% versus +1.7%. Discontinuation due to adverse events: 10.6% with orforglipron. Presented at EASD on September 30; published in The Lancet according to the manufacturer's release.
Why it matters: it establishes safety, not cardiovascular benefit (the intervals cross 1); the mortality reduction highlighted in the press release (HR 0.43) comes from a secondary analysis with few events and should be read as hypothesis-generating. A Lilly trial. For internists, it is an oral option before starting insulin, if price allows.
https://finance.yahoo.com/healthcare/articles/lillys-oral-glp-1-foundayo-220000413.html
3. FDA approves insulin efsitora alfa (Onswik), the first once-weekly basal insulin in the United States
[Regulatory FDA] [United States]
Approved on September 24 for adults with type 2 diabetes. The QWINT program (four phase 3 trials, more than 3,400 patients) showed noninferior HbA1c reduction versus glargine U-100 (QWINT-1 and QWINT-4) and versus degludec U-100 (QWINT-2 and QWINT-3), without superiority. Supplied as U-500 pens (up to 400 units per injection) and U-1,000 pens (up to 800 units). Not indicated in type 1 diabetes because of a higher risk of severe hypoglycemia.
Why it matters: the benefit is convenience (one injection a week), not efficacy; the trials were open-label noninferiority studies. The practical risk lies in dosing errors with high concentrations and in the patient who is admitted, stops eating, or develops kidney failure while on an insulin that lasts a week: inpatient protocols have yet to be written. No date for Latin America.
https://investor.lilly.com/node/54946
4. FDA extends finerenone to chronic kidney disease associated with type 1 diabetes
[Regulatory FDA] [United States]
Decision dated September 17, supported by the FINE-ONE trial: finerenone reduced the urinary albumin-to-creatinine ratio by 22% versus placebo at month 3 and by 28% at month 6.
Why it matters: it fills a real gap, since SGLT2 inhibitors have no indication in type 1 diabetes; but the approval rests on albuminuria, a surrogate outcome, not on hard kidney events, and potassium must be monitored. A Bayer drug; the coverage consulted does not report the trial's sample size.
https://www.ajmc.com/view/5-notable-fda-approvals-from-the-first-half-of-september
5. Brazil: ANVISA registers generic liraglutide for obesity and type 2 diabetes
[Regulatory ANVISA] [Brazil]
The registration was published on September 8 in the Diário Oficial da União: liraglutide 6 mg/mL from the Brazilian company EMS, for weight management and for type 2 diabetes, marketable under the active ingredient name. The report gives no prices.
Why it matters: there are no new clinical data; this is an access story. Generic competition for a GLP-1 agonist in the region's largest market may put pressure on prices across Latin America, although liraglutide is a daily injection and less potent than semaglutide or tirzepatide. (source in Portuguese)
Hospital and critical care medicine
6. Dapagliflozin started during admission for heart failure: slightly faster decongestion (DAPA ACT HF-TIMI 68)
[Clinical trial] [International]
Prespecified analysis of 2,401 patients hospitalized for heart failure, randomized double-blind to dapagliflozin 10 mg or placebo before discharge. At one week: congestion score −0.18 points (p = 0.011), body weight −0.60 kg (p < 0.001), and a lower loop diuretic dose (p = 0.014), with the effect sustained at 2 months. Published in JACC: Heart Failure on August 30 and presented at the European cardiology congress.
Why it matters: the effects are small and the trial's primary outcome (cardiovascular events at 2 months) was neutral; it supports starting the drug during admission for safety and continuity, not for a hard clinical benefit shown here. Generics exist, so it is applicable in our setting.
https://www.pharmacytimes.com/view/in-hospital-dapagliflozin-speeds-decongestion-in-heart-failure
7. Intermediate-high-risk pulmonary embolism: catheter-directed thrombolysis versus anticoagulation alone (PRAGUE-26)
[Clinical trial] [Czech Republic]
558 patients at 11 Czech centers, randomized to catheter-directed thrombolysis with alteplase plus anticoagulation or to standard anticoagulation with heparin. Composite outcome at 7 days (death, recurrence, or cardiorespiratory decompensation): 0.7% versus 6.8% (RR 0.10; 95% CI 0.02–0.44). Bleeding at 7 days: 4.6% versus 5.0%, with two intracranial hemorrhages in the catheter group and none in the control group. Deaths at 7 days: 1 versus 4. Czech public funding.
Why it matters: the benefit is driven by hemodynamic decompensation, not mortality; a single country, 7-day follow-up, and two intracranial hemorrhages call for caution. It requires a catheterization laboratory available around the clock, which in the Dominican Republic limits it to a few centers; it has not yet been replicated outside the region.
8. Tozorakimab cuts COPD exacerbations by about one third (OBERON and TITANIA)
[Clinical trial] [International]
Two replicate 52-week phase 3 trials of tozorakimab 300 mg every four weeks or placebo in patients with at least two moderate or one severe exacerbation in the previous year (about 90% on triple inhaled therapy; just over 2,300 randomized according to coverage). In former smokers, moderate and severe exacerbations fell by 29% and 34% (from about 2.0 to 1.4 per year). By eosinophil count: 23% below 150 cells/µL, 34% at 150 or more, and 43% at 300 or more. Serious adverse events were similar between groups (23% to 32%). Presented at the European respiratory congress on September 8 and published simultaneously in the New England Journal of Medicine.
Why it matters: this is an anti-interleukin-33 antibody with an effect also at low eosinophil counts, where current biologics do not work; but it is an AstraZeneca program, the primary analysis focuses on former smokers, there are no mortality data, and it is not yet approved. Biologic pricing: it does not change practice in our setting in the short term.
9. India: nurse-coordinated collaborative care with mobile support in heart failure (TIME-HF)
[Clinical trial] [India]
Cluster-randomized trial at 22 hospitals in India, with 1,507 adults with an ejection fraction of 40% or less (60% rural): trained nurses, a mobile application, counseling, and adherence support versus usual care, for two years. Survival without hospitalization at two years: 84.0% versus 79.4% (p < 0.001); mortality 22% lower (p = 0.028); quadruple therapy at 24 months: 37.3% versus 22.1%. Published in Circulation; funded by the DBT-Wellcome Trust India Alliance.
Why it matters: this is a low-cost model tested in a middle-income country, more transferable to the Dominican Republic than a new drug. Limitations: fewer than half of eligible patients were recruited, the intervention has several components and it is unclear which one works, there is no cost-effectiveness analysis, and it needs replication outside India.
https://www.tctmd.com/news/nurse-led-care-model-optimizes-outcomes-hfref-time-hf
Infections and emerging diseases in adults
10. IDSA and ESCMID: first seven consensus statements on Staphylococcus aureus bacteremia
[Guideline] [United States and Europe]
Released in September. They replace the "complicated / uncomplicated" classification with low-risk and high-risk stratification. Low risk (clear source, no additional factors): 14 days of therapy. High risk: 14 days may be considered if the diagnostic evaluation is negative and symptoms resolve. Transthoracic echocardiography for essentially all patients; transesophageal according to risk and findings. Antibiotic selection and oral step-down are still pending.
Why it matters: it structures a daily decision for internists and may shorten treatment courses, but it is an initial consensus, not a full guideline with graded evidence; the risk is over-reading the 14 days in high-risk patients. Applicable in our setting where echocardiography is available. Data taken from specialist coverage dated October 1.
11. Hepatitis delta: the antibody brelovitug meets its primary endpoint in phase 3 (AZURE-1)
[Industry] [United States]
Topline results dated September 28 in treatment-naive patients with chronic hepatitis delta. Combined response (virologic plus ALT normalization) at week 24: 56% with 300 mg weekly (n = 59), 45% with 900 mg every four weeks (n = 65), and 0% in the delayed-treatment group (n = 29); p < 0.0001. No grade 3 or higher adverse events and no discontinuations for toxicity. Regulatory submission planned for the first half of 2027.
Why it matters: this is a manufacturer press release (Mirum), not peer reviewed, at 24 weeks, with a surrogate outcome and a small control group. Hepatitis delta is uncommon in the Caribbean, but it is worth remembering delta virus serology in every hepatitis B surface antigen carrier.
12. COVID-19 vaccines 2026-2027: FDA approves XFG-adapted formulas with a restricted indication
[Regulatory FDA] [United States]
On August 27 and 28, Comirnaty, Spikevax, mNEXSPIKE, and Nuvaxovid targeting the XFG subvariant of the JN.1 lineage were approved. The indication is for adults 65 and older and, below that age, only with at least one risk condition (Comirnaty ages 5 to 64; Spikevax 6 months to 64 years; mNEXSPIKE and Nuvaxovid ages 12 to 64).
Why it matters: it sits at the edge of the window (35 days) but defines the season. The approval rests on immunogenicity and nonclinical data, and the sources consulted do not report the vaccine advisory committee's recommendation. In the Dominican Republic, availability depends on public procurement; the reasonable priority is adults over 65 and the immunocompromised.
https://www.cidrap.umn.edu/covid-19/fda-approves-new-covid-vaccines
13. Dominican Republic: dengue low but above 2025, with serotype 2 and influenza A circulating
[Epidemiologic surveillance] [Dominican Republic]
Epidemiological week 35 (reported September 17): 6 confirmed cases in the week and 288 cumulative cases in 2026, 79 more than in the same period of 2025 (209). Serotype DENV-2 was identified and the country remains in the "success zone," with no alert. Malaria: 136 confirmed cases (82% fewer than in 2025). Leptospirosis: 275 cumulative cases. Influenza A virus circulation was detected.
Why it matters: incidence is low, but it exceeds 2025 and DENV-2 is circulating, a serotype associated with severe disease in secondary infections; with the rainy season, it is worth keeping a low threshold for dengue testing and watching for warning signs. The figures come from national press reporting on the Ministry of Public Health bulletin; we did not open the primary bulletin.
Chronic diseases and aging
14. Statin for primary prevention after age 70: fewer events, no effect on disability or dementia (STAREE)
[Clinical trial] [Australia]
9,971 people aged 70 or older (mean 74.7; 52% women) without cardiovascular disease, diabetes, or dementia, seen in general practice in Australia, received atorvastatin 40 mg or placebo for a median of 5.9 years. Major cardiovascular events: 6.0% versus 8.3% (HR 0.70; 95% CI 0.61–0.82). The other co-primary outcome, survival free of dementia and physical disability, did not differ: 12.8% versus 13.6% (HR 0.94; 0.84–1.05; p = 0.25). Muscle, liver, and diabetes-related events were more frequent with atorvastatin; serious events 2.7% in both groups. Published in the New England Journal of Medicine; public funding.
Why it matters: this is the first solid randomized evidence for primary prevention in people over 70, with an absolute reduction of 2.3 points (about 43 people treated for almost six years to prevent one event, by our calculation). It does not improve disability-free life or prevent dementia, and the population was healthy: it should not be extrapolated to frail older adults with polypharmacy or used to hold back deprescribing at the end of life. Generic and inexpensive: applicable in the Dominican Republic.
No verifiable news this month in metabolic fatty liver disease, osteoporosis, gout, thyroid disease, anemia, palliative care, or clinical artificial intelligence: what the searches returned predated the period (for example, the survodutide fatty liver trial is from June) or its date could not be confirmed.
Cross-cutting
Guidelines: besides the bacteremia consensus (item 10), the searches returned the Surviving Sepsis 2026 guideline (March) and the IDSA guidance on resistant gram-negative infections (July); both fall outside the window.
Regions: searches in Japanese, Chinese, Russian, Arabic, Turkish, German, and French yielded no verifiable news dated within the period. What was found was older: the Saudi registration of orforglipron dates from August 2, the Japanese approval of insulin icodec with semaglutide from February, and the Russian hypertension and French type 2 diabetes guidelines from 2024.
Excluded because the date could not be verified: the ISLEND trials of once-weekly oral islatravir with lenacapavir for HIV already appear in the New England Journal of Medicine and The Lancet, but we could not confirm the publication day; they are held for the next issue.
Upcoming meetings and dates
- IDWeek: October 21 to 24, Washington, D.C.
- American Society of Nephrology Kidney Week: October 21 to 25, Denver.
- The Liver Meeting (AASLD): November 5 to 9, Denver.
- American College of Rheumatology meeting (ACR Convergence): November 6 to 11, Orlando.
- American Heart Association Scientific Sessions: November 7 to 9, Chicago.
Ready-to-paste LinkedIn post
Monthly internal medicine bulletin — October 2, 2026 14 verified items from the New England Journal of Medicine, The Lancet, Circulation, and JACC: Heart Failure, plus FDA and ANVISA decisions. Three worth your time: • STAREE: atorvastatin 40 mg in 9,971 people aged 70 or older without cardiovascular disease cut major events from 8.3% to 6.0% (HR 0.70), with no effect on dementia or disability. A healthy population: do not extrapolate to frail patients. • TRIUMPH-2: weekly retatrutide achieved −20.8% body weight at 80 weeks in type 2 diabetes with obesity (placebo −4.0%). A manufacturer trial, with no cardiovascular outcomes yet. • The FDA approved efsitora, the first once-weekly basal insulin in the United States: noninferior to daily insulins in four open-label trials, not superior. The risk lies in dosing errors. Full bulletin, with a critical reading of each study and links to primary sources: https://boletinesmedicos.com/en/medicina-interna/2026-10-02.html #InternalMedicine #HospitalMedicine #Diabetes #Obesity #Statins
Ready-to-paste X (Twitter) post
Internal medicine, October: statins after age 70 cut cardiovascular events by 30% (STAREE, n = 9,971) without changing disability; retatrutide achieves −20.8% body weight in type 2 diabetes (TRIUMPH-2). https://boletinesmedicos.com/en/medicina-interna/2026-10-02.html
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