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Internal Medicine Bulletin — November 2, 2026

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Colleagues: this issue covers October 3 to November 2, 2026. It was a month of large pragmatic trials with neutral results (early vasopressin in septic shock, aspirin in chronic kidney disease), a new guideline from the American College of Physicians and a great deal of regulatory activity around GLP-1 receptor agonists, with decisions in Europe, Brazil and Chile that directly affect access in our region. This issue includes 11 items verified against their source; one of them covers two countries outside North America and Western Europe (Brazil and Chile).

Cardiometabolic

1. CONNECT: continuous glucose monitoring lowers HbA1c in type 2 diabetes not treated with insulin

[Clinical trial] [United States]
A 26-week randomized trial at 22 primary care sites in the United States with 283 adults with type 2 diabetes not treated with insulin (mean baseline HbA1c 8.8%), comparing the Dexcom G7 sensor with usual care; the article was published in NEJM and Dexcom publicized it in an October 14 release. With the sensor, HbA1c fell by an average of 1.6 points, 0.9 points more than with usual care, and time in range 70–180 mg/dL was 21 percentage points higher with CGM than with routine care, about five additional hours per day; according to the company, 97% were still using the sensor at 26 weeks.
Why it matters: it is a randomized trial favoring the sensor in patients not on insulin, but it was funded by Dexcom, lasted only six months and measured glycemic control, not clinical events; in the Dominican Republic the cost of the device remains the real barrier, so the finding helps select motivated patients with high HbA1c rather than support a universal recommendation.

Sources

2. ATTACK: aspirin for primary prevention in chronic kidney disease does not reach significance

[Clinical trial] [Meeting] [United Kingdom]
A pragmatic, randomized, open-label trial in UK primary care, presented at the American Society of Nephrology Kidney Week (Denver, abstract FR-OR100): 4,633 adults with chronic kidney disease stages G1 to G4 and no prior cardiovascular disease, randomized to aspirin 75 mg daily (2,317) or no aspirin (2,316), with a mean follow-up of 3.1 years. Major cardiovascular events: 2.4% with aspirin versus 3.3% without (subdistribution HR 0.73; 95% CI 0.52–1.03), not significant. Major bleeding: 29 versus 19 events (subdistribution HR 1.54; 95% CI 0.86–2.74). Funded by the National Institute for Health Research and the British Heart Foundation.
Why it matters: the trial recruited less than one fifth of the 25,210 planned participants and was therefore underpowered; it does not allow a claim of benefit or a change in practice, and the recommendation remains not to start aspirin for primary prevention solely because a patient has chronic kidney disease. Journal publication pending.

Sources

3. ZUPREME-2: petrelintide, an amylin analog, in type 2 diabetes with obesity

[Industry] [United States]
Zealand Pharma (Denmark) announced on October 7 topline results of a phase 2b randomized, double-blind, placebo-controlled trial conducted in the United States in 220 adults with overweight or obesity and type 2 diabetes treated with metformin with or without an SGLT2 inhibitor (mean BMI 36.3; mean HbA1c 8.0%). At 28 weeks, weight loss was 7.4% to 9.2% across the three once-weekly petrelintide arms versus 2.0% with placebo; HbA1c fell by 0.61 to 0.88 points relative to placebo. Discontinuations due to gastrointestinal adverse events: 1.9% versus 1.7%.
Why it matters: this is a manufacturer press release, without per-arm doses or peer-reviewed publication; the interest lies in the good gastrointestinal tolerability of the amylin pathway, but it is not yet a drug for the clinic.

Sources

4. EMA: positive opinion for oral orforglipron in type 2 diabetes and obesity

[EMA regulatory] [European Union]
At its October 12–15 meeting, the Committee for Medicinal Products for Human Use recommended authorization of Foundayo (orforglipron, Eli Lilly), a once-daily oral non-peptide GLP-1 receptor agonist, for weight management and type 2 diabetes in adults. At the same meeting, extensions of indication were recommended for Kyinsu (insulin icodec with semaglutide) and Tryngolza (olezarsen).
Why it matters: the positive opinion precedes the European Commission decision and adds an oral option to a class dominated by injectables; for our region, what will matter is price and whether national registrations (including DIGEMAPS) rely on this assessment.

Sources

5. Brazil and Chile open the door to semaglutide and liraglutide from other manufacturers

[ANVISA regulatory] [ISP regulatory] [Brazil and Chile]
ANVISA published on October 29 in the Diário Oficial da União (Resolution RE 4.244, dated October 28) the registration of five new pens: three liraglutides manufactured by Biocon and registered by Farma Vision (Aribet for diabetes, Lyrza and Wylovol for obesity) and two semaglutides manufactured by OneSource Specialty (Embeltah, from Dr. Reddy's, and Sevema, from Aché, both for diabetes), bringing the number of GLP-1 pens approved in 2026 to 20, according to ANVISA itself. In Chile, the Public Health Institute (ISP) approved Picmagluti (Dr. Reddy's), the first chemically synthesized semaglutide authorized in the country, a decision reported on October 20; it is indicated only for adults with inadequately controlled type 2 diabetes and not for obesity.
Why it matters: these decisions broaden supplier competition after semaglutide patents expired. Marketing authorization does not guarantee immediate availability or a lower final price; Brazil also regulates maximum medicine prices through CMED. In Chile, according to Diario Estrategia coverage on October 22, there was still no official price or pharmacy launch date. For the Dominican Republic, where parallel imports and the informal market are a problem, it is worth following what DIGEMAPS does with these same products. (sources in Portuguese and Spanish)

Sources

Hospital and critical care medicine for the internist

6. VASSPR: starting vasopressin earlier does not reduce septic shock mortality

[Clinical trial] [United States]
A pragmatic, open-label strategy trial with cluster randomization and monthly crossover at 13 Intermountain Health hospitals (Utah and Idaho), published in JAMA on October 14: 3,959 adults with septic shock. Hospitals alternated between recommending fixed-dose vasopressin (0.03 U/min) when norepinephrine or equivalent reached 0.1 µg/kg/min (lower threshold) or 0.4 µg/kg/min (higher threshold). 28-day mortality: 31.8% (628/1,975) with the lower threshold versus 33.0% (655/1,984) with the higher threshold, with no significant difference; persistent or new cardiogenic shock occurred in 7.4% versus 6.3%.
Why it matters: it is a large trial on the timing of adding vasopressin and does not support the trend toward starting it early; the pragmatic design reflects real practice, with imperfect adherence to the recommendation, but everything took place within a single health system, which limits generalizability. For hospitals with restricted access to vasopressin, reserving it for high norepinephrine doses is a defensible position. Funded by the Intermountain Foundation and the National Center for Advancing Translational Sciences.

Sources

7. Phenobarbital versus diazepam for hospitalized alcohol withdrawal syndrome

[Publication] [United States]
A comparative effectiveness study using observational data, published in JAMA Internal Medicine on October 12, with 24,643 patients hospitalized for alcohol withdrawal at 754 US hospitals. Starting phenobarbital on the day of admission, compared with diazepam, was not associated with differences in hospital length of stay or use of invasive mechanical ventilation.
Why it matters: it is not a randomized trial and, as the coverage itself notes, the findings do not establish that both treatments are equally safe or effective; the practical message is that phenobarbital is a reasonable alternative in services with protocols and monitoring, but it does not justify changing a benzodiazepine protocol that works.

Sources

Infections and emerging diseases in adults

8. IDWeek 2026: antimicrobial resistance was associated with 3.5 trillion dollars in losses in 2021

[Meeting] [Global]
According to EMJ coverage of an analysis presented at IDWeek (Washington, October 21–24; abstract 162) using the Global Burden of Disease 2021 MICROBE tool, with data from 21 regions, 12 syndromes and 22 pathogens, economic welfare losses (not health care spending) associated with resistance were estimated at 3.5 trillion dollars (2.25% of global GDP) and directly attributable losses of 835 billion dollars (0.54%). Bloodstream infections account for 42.5% of attributable losses and lower respiratory infections for 31.3%; Klebsiella pneumoniae tops the list with 130 billion dollars and gram-negative organisms account for more than 60% of attributable losses.
Why it matters: this is economic modeling, not clinical data, and it depends on assumptions about the value of lost welfare; its usefulness is to argue before administrators that antimicrobial stewardship programs and gram-negative control in hospitals are an investment and not an expense, a relevant message for the Caribbean, where resistance surveillance remains fragmented.

Sources

9. ReSPECT: weekly rezafungin noninferior to standard prophylaxis in allogeneic transplantation

[Clinical trial] [Industry] [Meeting] [International multicenter]
A global phase 3, 2:1 randomized, double-blind trial presented as a late-breaking oral presentation at IDWeek on October 22: 602 adults undergoing allogeneic hematopoietic cell transplantation received once-weekly intravenous rezafungin (402) or standard daily prophylaxis with an oral azole (fluconazole or posaconazole) plus trimethoprim-sulfamethoxazole after engraftment (200). Fungal-free survival at day 90: 60.7% versus 59.0% (difference 1.6%; 95% CI −6.2 to 9.3; p = 0.0002 for noninferiority). The composite required survival, no proven or probable invasive fungal disease, and no more than ten cumulative days of non-study systemic antifungal therapy.
Why it matters: for the internist who shares the care of these patients, a single weekly intravenous dose simplifies prophylaxis and avoids azole interactions, but the data come from the manufacturer (Mundipharma), the indication is not yet approved and the FDA, which granted priority review, has a decision date in the first quarter of 2027; price and availability in our region are unknown.

Sources

Chronic diseases and aging

10. ACP: hormone therapy as first-line treatment for menopausal vasomotor symptoms

[Guideline] [United States]
The American College of Physicians published in Annals of Internal Medicine (release dated October 5) its guideline on pharmacologic treatment of vasomotor symptoms: it recommends as first line estrogen plus progestogen in women with a uterus and estrogen alone in women without a uterus; as second line, in case of contraindication or intolerance, desvenlafaxine or venlafaxine; and as third line escitalopram or paroxetine, gabapentin, or the neurokinin receptor antagonists elinzanetant and fezolinetant.
Why it matters: it returns hormone therapy to the first step for hot flashes and night sweats and places the internist at the center of the decision, with the caveat that the guideline ranks options by benefit-harm balance rather than by direct comparative evidence; in our region neurokinin antagonists are unavailable or unaffordable, so the practical hierarchy ends with antidepressants and gabapentin.

Sources

11. IgA nephropathy: povetacicept and ravulizumab reduce proteinuria (RAINIER and I CAN)

[Clinical trial] [Meeting] [United States and international]
Two phase 3 trials published in NEJM on October 23 and presented at Kidney Week. The interim efficacy analyses of RAINIER and I CAN included 199 and 352 participants, respectively. In RAINIER, povetacicept reduced the 24-hour urine protein-to-creatinine ratio by 52.0% versus 4.3% with placebo at week 36 (adjusted difference −49.8 percentage points; p < 0.001); in I CAN, ravulizumab, a long-acting C5 inhibitor, achieved a 43.4% reduction versus placebo at week 34 (99% CI 30.1–54.2). According to HCPLive coverage, final results of TELIGAN, with telitacicept (318 patients, 104 weeks), were presented at the same meeting: eGFR slope of −0.6 versus −5.7 mL/min/1.73 m² per year. These are separate trials with different populations and endpoints, and they do not establish the superiority of one drug over another.
Why it matters: proteinuria is a surrogate endpoint accepted by regulators but not a hard outcome, and in RAINIER and I CAN the eGFR results are still pending; for the internist, the message is that IgA nephropathy now has specific treatments and that biopsy and early referral once again have therapeutic consequences, although access in the Caribbean will be late and costly.

Sources

Upcoming meetings and dates

  • November 12–15: 38th World Congress of Internal Medicine (WCIM), Taipei.
  • November 25–28: XLIX National Congress of Internal Medicine of the Mexican College of Internal Medicine, Mérida, Yucatán.
  • November 27–28: 1st ACP Latin American Chapters Symposium, virtual.

Sources

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