Monthly internal medicine bulletin — September 29, 2026

Period covered: August 30 to September 29, 2026. A month dominated by the European cardiology (Munich) and respiratory (Barcelona) congresses, two FDA approvals of direct interest to the internist, and a large negative trial in lipoprotein(a). In chronic disease and metabolic hepatology the month was thin on verifiable primary evidence; we say so rather than pad. Sixteen verified items, five of them originating outside North America and Western Europe.

Cardiometabolic

1. STAREE: atorvastatin for primary prevention from age 70 reduces events, not disability

[Clinical trial] [Australia]
Double-blind trial of 9,971 adults aged 70 or older without cardiovascular disease, diabetes or dementia (mean age 74.7; 52% women), randomized to atorvastatin 40 mg or placebo with a median follow-up of 5.9 years. The major cardiovascular outcome (cardiovascular death, myocardial infarction, stroke or revascularization) occurred in 6.0% versus 8.3% (HR 0.70; 95% CI 0.61–0.82). The co-primary disability-free survival outcome did not change (12.8% vs 13.6%; HR 0.94; 95% CI 0.84–1.05). Presented at the ESC Congress and published in NEJM on August 29; publicly funded.
Why it matters: it is the first dedicated statin trial in healthy older adults and confirms cardiovascular benefit, but at the cost of more muscle, liver and diabetes-related adverse events and with no gain in disability or mortality; in a healthy Australian volunteer population, the decision remains individual and shared, which applies equally to a Dominican clinic.
https://www.escardio.org/news/press/press-releases/cholesterol-lowering-medication-reduces-major-cardiovascular-events-by-30-per-cent-in-older-people-without-known-cardiovascular-disease/

2. CRHCP: non-physician-led intensive blood pressure control reduces dementia at seven years

[Clinical trial] [Congress] [China]
Cluster-randomized trial in rural China with 33,995 adults aged 40 or older with untreated hypertension (mean age 63; 61% women). A stepped protocol led by non-physician community health workers, targeting below 130/80 mmHg for four years, was compared with usual care and followed for three more years. All-cause dementia at seven years was 8.85% versus 10.55% (RR 0.85; 95% CI 0.78–0.91; p < 0.001), with a systolic reduction of 17.6 versus 2.4 mmHg. Presented as a Hot Line at ESC 2026 on August 30; funded by the Chinese government.
Why it matters: it is the largest experimental evidence that treating hypertension prevents dementia, and the task-shifting model is directly transferable to Latin American primary care; the design is open-label, the rural Chinese setting limits generalization, and the peer-reviewed publication is not yet available.
https://www.escardio.org/news/press/press-releases/long-term-intensive-blood-pressure-control-reduces-dementia-risk/

3. Lp(a)HORIZON: pelacarsen does not reduce cardiovascular events despite lowering lipoprotein(a)

[Industry] [Clinical trial] [Global, Novartis]
On September 4 Novartis reported topline results of its phase III trial in 8,323 patients with established cardiovascular disease and elevated lipoprotein(a) (analyzed at ≥70 mg/dL and ≥90 mg/dL), double-blind versus placebo. The primary composite of cardiovascular death, myocardial infarction, stroke and urgent revascularization did not reach significance; the hazard ratio and safety data have not been released. Mean baseline LDL was about 66 mg/dL.
Why it matters: this is the first outcomes trial of a lipoprotein(a)-targeted therapy and its failure calls the therapeutic causal hypothesis into question until OCEAN(a) and ACCLAIM report; enthusiasm for mass Lp(a) screening should be tempered while no treatment with proven benefit exists, and the only source so far is a sponsor press release without figures.
https://www.novartis.com/news/media-releases/novartis-announces-lpahorizon-phase-iii-topline-results-pelacarsen-patients-elevated-lpa-and-established-cardiovascular-disease-cvd

4. FDA approves Onswik (insulin efsitora alfa), the first once-weekly basal insulin in the United States

[Regulatory FDA] [United States, Lilly]
Approved on September 24 for adults with type 2 diabetes, in U-500 and U-1000 pens for once-weekly injection. It rests on the QWINT program: four open-label noninferiority trials in more than 3,400 patients (QWINT-1 n = 795 and QWINT-4 n = 730 versus glargine; QWINT-2 n = 928 and QWINT-3 n = 986 versus degludec), all with A1C reduction noninferior to daily insulin. It is the fourth global approval after EMA, COFEPRIS and PMDA. Not indicated in type 1 diabetes because of a higher risk of severe hypoglycemia.
Why it matters: going from 365 to 52 injections a year may improve adherence in patients who refuse insulin, but the trials were open-label and sponsored, the press release gives no hypoglycemia rates, and fixed titration in 100-unit steps demands careful education; the COFEPRIS approval anticipates its arrival in the region, though price will decide real use in the Dominican Republic.
https://investor.lilly.com/news-releases/news-release-details/us-food-and-drug-administration-fda-approves-lillys-onswiktm

5. FDA extends finerenone to chronic kidney disease associated with type 1 diabetes

[Regulatory FDA] [United States, Bayer]
On September 17 the FDA approved finerenone to reduce albuminuria in adults with chronic kidney disease and type 1 diabetes, the first new option in more than thirty years for this group. It is based on FINE-ONE (NEJM, March 2026): 242 patients in nine countries, double-blind versus placebo on top of standard therapy; 25% relative reduction in urine albumin-to-creatinine ratio at six months, with 68.1% of patients achieving at least a 30% drop versus 46.6% on placebo.
Why it matters: the approval rests on a surrogate endpoint (albuminuria), not hard kidney outcomes, in a small sponsored trial; it is reasonable in selected patients with potassium monitoring, but it does not replace renin-angiotensin system inhibitors.
https://www.bayer.com/media/en-us/us-fda-approves-finerenone-for-new-indication-in-patients-with-chronic-kidney-disease-associated-with-type-1-diabetes/

6. Orforglipron and retatrutide ahead of EASD: press-release data, not journal data

[Industry] [Congress] [United States, Lilly]
On September 15 Lilly announced the results it is presenting at the EASD congress in Milan (September 30 and October 1). In ACHIEVE-4, oral orforglipron versus insulin glargine in type 2 diabetes with obesity and increased cardiovascular risk showed noninferiority for major adverse cardiovascular events (MACE-4 HR 0.84; 95% CI 0.59–1.20). In TRIUMPH-2, retatrutide in obesity with type 2 diabetes achieved up to 22.5 kg of weight loss (20.8%) and a 1.6-point A1C reduction at 80 weeks. A phase 2 of eloralintide plus tirzepatide reached 17% versus 10% with tirzepatide alone at 16 weeks.
Why it matters: the MACE hazard ratio's interval crosses 1 and the comparator was glargine, not an active GLP-1 agonist; sample sizes and margins were not disclosed, so until the full presentation and publication these data are sponsor promotion whose scientific basis remains to be evaluated.
https://investor.lilly.com/news-releases/news-release-details/lilly-present-new-data-foundayo-retatrutide-and-eloratzp-easd

Hospital and critical care medicine for the internist

7. PRAGUE-26: catheter-directed thrombolysis in intermediate-high-risk pulmonary embolism

[Clinical trial] [Czech Republic]
Open-label trial at eleven centers with 558 patients with intermediate-high-risk pulmonary embolism (right ventricular dysfunction plus elevated biomarkers), published in NEJM on August 31. Anticoagulation plus catheter-directed alteplase (20 mg total over about nine hours) versus anticoagulation alone reduced the composite of death, recurrent embolism or cardiorespiratory decompensation at seven days from 6.8% to 0.7% (RR 0.10; 95% CI 0.02–0.44). Clinically relevant bleeding was similar (4.6% vs 5.0%), with two intracranial hemorrhages in the thrombolysis arm and none in controls. Publicly funded.
Why it matters: together with HI-PEITHO it consolidates low-dose thrombolysis in the intermediate-high-risk group, but the composite was dominated by physiologic deterioration rather than mortality, the design was open-label, and in practice this is low-dose alteplase; in hospitals without catheter capability, the real debate is low-dose systemic thrombolysis versus anticoagulation alone.
https://doi.org/10.1056/NEJMoa2608012

8. Tozorakimab reduces COPD exacerbations in two replicate phase III trials

[Clinical trial] [Congress] [International, AstraZeneca]
Presented at the ERS Congress in Barcelona on September 9 with simultaneous publication in NEJM. Two 52-week double-blind trials (OBERON and TITANIA, more than 2,000 patients combined according to coverage) in COPD with at least two moderate or one severe exacerbation in the prior year, about 90% on triple inhaled therapy. Tozorakimab, an anti-interleukin-33 antibody, 300 mg subcutaneously every four weeks reduced moderate or severe exacerbations by 29% and 34% in former smokers, with a larger effect at higher eosinophil counts (23% below 150 cells/µL; 43% at 300 or more). Serious adverse events were similar between arms.
Why it matters: it would be the second biologic in COPD after dupilumab and, unlike it, would show an effect even with low eosinophils; but these are sponsored data with discrepancies across reports on patient numbers, the main result is presented in former smokers, and cost keeps it far from most patients in the region while basic inhalers still lack universal coverage.
https://www.epocrates.com/online/article/ers-congress-2026-investigational-biologic-cuts-copd-flare-ups-by-one-third

9. Community-onset sepsis: presenting symptoms predict antibiotic delay

[Publication] [United States]
Cohort from the Michigan Hospital Medicine Safety registry with 29,647 adults with community-onset bacterial sepsis in 67 hospitals, published in JAMA Network Open in September. Timely antibiotics were given to 74%. Prehospital fever increased the likelihood of timely antibiotics (adjusted OR 1.34 with hypotension; 1.26 without), while gastrointestinal symptoms reduced it (OR 0.84 and 0.80). Timely antibiotics were associated with lower 30-day mortality (18.9% vs 21.0%).
Why it matters: it reinforces that sepsis presenting with vomiting, diarrhea or abdominal pain without fever is the one most often delayed, a correctable recognition bias for triage protocols; it is observational, single-state and subject to residual confounding, so the mortality association does not prove causation.
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2854506

Infections and emerging diseases in adults

10. SOLARIO: seven days of systemic antibiotics suffice after orthopedic infection surgery with local antibiotics

[Clinical trial] [Europe: United Kingdom, Austria, Germany, Portugal, Spain]
Multicenter noninferiority trial published in NEJM in September with 500 adults operated on for confirmed orthopedic infection, all with local antibiotic implanted, randomized to systemic antibiotics for seven days or less versus four weeks or more. Treatment failure at twelve months was 11.1% versus 14.1% (difference −3.0 points; noninferiority margin 10 points, met). Adverse events fell from 45.2% to 17.2%.
Why it matters: another step in the shorter-antibiotics agenda that matters to every consulting internist, with a large reduction in harm; the indispensable condition is the local antibiotic in the device, without which the result cannot be extrapolated, and we could not confirm the confidence intervals in the primary source.
https://www.nejm.org/doi/full/10.1056/NEJMoa2506756

11. CDC: 31 serious reactions and 12 deaths after ceftriaxone injection in 18 states

[Publication] [United States]
Clinical Infectious Diseases published on September 3 a multistate CDC investigation of serious adverse events between September 2024 and August 2025: 31 cases in 27 facilities, 12 deaths (39%), 19 requiring cardiopulmonary resuscitation, 74% with an anaphylaxis-like picture, 68% with prior ceftriaxone exposure, 77% with cardiac comorbidity, 61% on beta-blockers and a median age of 67. No adulteration, endotoxin or purity problems were found, and national trends 2016–2024 were stable.
Why it matters: it is a case series without a denominator and without a common source, so it does not change the indication of an essential antibiotic, but it is a reminder that ceftriaxone anaphylaxis in older cardiac patients on beta-blockers can be fulminant, and that regional pharmacovigilance systems would rarely capture such a signal.
https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciag521/8780510

12. High-dose influenza vaccine in older adults with chronic lung disease

[Congress] [Denmark and Galicia, Spain]
Pooled analysis of the pragmatic DANFLU-2 and GALFLU trials (466,320 adults aged 65 or older in total; subgroup of 31,976 with asthma, COPD, bronchiectasis or interstitial lung disease), presented at the ERS Congress on September 8. The high-dose vaccine, with four times the antigen, reduced hospitalizations for influenza or pneumonia by 8.8% versus standard dose, with fewer cardiorespiratory and all-cause admissions.
Why it matters: it supports prioritizing high-dose vaccine in chronic respiratory patients, but it is a subgroup of trials with a different primary objective, without confidence intervals or peer review, and the original trials had Sanofi support; in the Dominican Republic the practical limitation is availability of the high-dose formulation in the public campaign.
https://www.ersnet.org/news-and-features/news/high-dose-flu-vaccine-beneficial-for-older-people-with-lung-disease/

13. Dominican Republic: dengue within the endemic channel and leptospirosis nearly doubled

[Epidemiology] [Dominican Republic]
The National Epidemiologic Bulletin for week 36 (data through September 12) recorded 16 confirmed dengue cases that week and 338 cumulative cases in 2026 with one death, versus 220 in the same period of 2025 (50% more), within the expected levels of the endemic channel. Leptospirosis totals 275 cases and 19 deaths versus 135 cases in 2025 (98% more), with Puerto Plata accounting for 27%. Malaria fell 82% (137 vs 760). Non-neonatal tetanus, pertussis and meningococcal disease show slight increases.
Why it matters: for the ward internist the relevant figure is leptospirosis, which in the rainy season competes with dengue and hepatitis in the febrile patient with jaundice or kidney injury; the figures come from press coverage of the official bulletin, without serotypes or full provincial distribution.
https://listindiario.com/la-republica/sector-salud/20260926/pais-registra-50-mas-casos-dengue-ano_923706.html
https://www.msp.gob.do/web/?p=4697

14. The Global Fund prepares the scale-up of twice-yearly lenacapavir as pre-exposure prophylaxis

[Access] [Global, low- and middle-income countries]
On September 24 the Global Fund announced a target of reaching 3 million people with twice-yearly injectable lenacapavir by the end of 2028, with initial generic supply in late 2026 and expansion in 2027 under Gilead's voluntary licenses, in partnership with the Gates Foundation, Unitaid, CIFF and the U.S. Department of State.
Why it matters: this is the real route by which two-injections-a-year PrEP will reach middle-income countries, but the release does not mention prices, manufacturers or Latin America and the Caribbean, where the concentrated Dominican and Haitian epidemics would need to be in the first allocation wave.
https://www.theglobalfund.org/en/news/2026/2026-09-24-global-fund-prepares-major-expansion-lenacapavir-generic-supply-approaches/

Chronic disease and aging

15. REFINe: a large language model improves diagnosis of complex nephrology cases in a randomized trial

[Clinical trial] [France, multinational]
Kidney International Reports publishes in its September issue a trial with 97 clinicians (75% nephrologists, nine countries, 93% in France) and 556 evaluations of complex vignettes. With a GPT-5 suggestion available, top-3 diagnostic accuracy rose from 37.2% to 57.5% (adjusted OR 2.8; 95% CI 1.5–5.2). Clinicians corrected 47.8% of their errors when the model was right, and only 1 of 69 correct answers worsened after a wrong suggestion. No specific funding or declared conflicts.
Why it matters: it is one of the few randomized trials in the specialty showing a net positive effect with little automation bias, but these are vignettes rather than real patients, with voluntary participation and a single commercial model; the model alone scored 77%, which raises the uncomfortable question of how much the clinician adds.
https://www.sciencedirect.com/science/article/pii/S2468024926029050

16. ACP: update alert to its living guideline on pharmacologic treatment of osteoporosis

[Guideline] [United States]
The American College of Physicians circulated in September the second update alert to its living guideline on pharmacologic treatment of primary osteoporosis and low bone mass in adults, published in Annals of Internal Medicine. We could not access the full text; the current version 1 recommendations keep bisphosphonates as first line in postmenopausal women and men, denosumab as second option, and anabolic agents reserved for very high risk.
Why it matters: the living-guideline format requires periodic checks for changes; the alert should be reviewed before the next revision of hospital protocols, without assuming the core message has changed.
https://www.acpjournals.org/doi/10.7326/ANNALS-26-02740

Note of the month in chronic disease and metabolic hepatology: we found no new phase III trials in MASLD/MASH, anemia, gout or thyroid disease published in the window; the survodutide phase III (SYNCHRONIZE-MASLD, Nature Medicine) is from June and the pemvidutide phase III PERFORMA has only just started enrolling. Searches in Japanese, Chinese, Korean, Russian, Arabic, Turkish, German and Portuguese yielded no verifiable primary studies dated within the period; the Italian (FADOI, SIMI) and Japanese (JSIM) societies published only educational and congress material.

Upcoming meetings and dates

EASD 2026, Milan, September 28 to October 2 (ACHIEVE-4 and TRIUMPH-2 presentations on September 30 and October 1). 47th Chilean Congress of Internal Medicine, Concepción, September 30 to October 2. 127th SIMI National Congress, Rimini, October 2 to 4. South-Brazilian Congress of Internal Medicine (SBCM), Florianópolis, October 9 to 11. ESICM LIVES 2026, Lisbon, October 10 to 14. IDWeek 2026, Washington, D.C., October 21 to 24. IV International Congress of Internal Medicine (SMIBA, with SOLAMI symposia), Buenos Aires, October 24 to 28. AHA Scientific Sessions, Chicago, November 6 to 9. Later: 47th SEMI National Congress, Murcia, November 25 to 27. We found no verifiable date for the 2026 congress of the Dominican Society of Internal Medicine.

Monthly internal medicine bulletin — September 29, 2026
Sixteen verified items from the past month: NEJM, JAMA Network Open, Clinical Infectious Diseases, Kidney International Reports, the ESC and ERS congresses, FDA approvals and the Dominican epidemiologic bulletin.
Three worth your time:
• STAREE (NEJM): atorvastatin 40 mg in 9,971 adults aged 70+ without cardiovascular disease cut major events from 8.3% to 6.0%, with no change in disability-free survival and more adverse events.
• CRHCP (ESC 2026): non-physician-led intensive blood pressure control in 33,995 rural Chinese adults lowered 7-year dementia from 10.55% to 8.85%; open-label, not yet peer reviewed.
• PRAGUE-26 (NEJM): low-dose catheter-directed thrombolysis in 558 patients with intermediate-high-risk PE reduced the 7-day composite from 6.8% to 0.7%; the endpoint was driven by physiologic deterioration, not death.
Full bulletin, with a critical reading of each study and links to primary sources:
https://boletinesmedicos.com/en/medicina-interna/2026-09-29.html
#InternalMedicine #HospitalMedicine #Hypertension #PulmonaryEmbolism #Diabetes

Internal medicine bulletin (Sep 2026): STAREE, statins from age 70 cut CV events 30% without gaining disability-free survival; CRHCP, treating hypertension lowers dementia 15% at 7 years. 16 items, critically read: https://boletinesmedicos.com/en/medicina-interna/2026-09-29.html