Newer Pharmacologic Treatments in Adults With Type 2 Diabetes: A Clinical Guideline From the American College of Physicians.

DESCRIPTION: The American College of Physicians (ACP) developed this clinical guideline to update recommendations on newer pharmacologic treatments of type 2 diabetes. This clinical guideline is based on the best available evidence for effectiveness, comparative benefits and harms, consideration of patients' values and preferences, and costs. METHODS: This clinical guideline is based on a systematic review of the effectiveness and harms of newer pharmacologic treatments of type 2 diabetes, including glucagon-like peptide-1 (GLP-1) agonists, a GLP-1 agonist and glucose-dependent insulinotropic polypeptide agonist, sodium-glucose cotransporter-2 (SGLT-2) inhibitors, dipeptidyl peptidase-4 (DPP-4) inhibitors, and long-acting insulins, used either as monotherapy or in combination with other medications. The Clinical Guidelines Committee prioritized the following outcomes, which were evaluated using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach: all-cause mortality, major adverse cardiovascular events, myocardial infarction, stroke, hospitalization for congestive heart failure, progression of chronic kidney disease, serious adverse events, and severe hypoglycemia. Weight loss, as measured by percentage of participants who achieved at least 10% total body weight loss, was a prioritized outcome, but data were insufficient for network meta-analysis and were not rated with GRADE. AUDIENCE AND PATIENT POPULATION: The audience for this clinical guideline is physicians and other clinicians. The population is nonpregnant adults with type 2 diabetes. RECOMMENDATION 1: ACP recommends adding a sodium-glucose cotransporter-2 (SGLT-2) inhibitor or glucagon-like peptide-1 (GLP-1) agonist to metformin and lifestyle modifications in adults with type 2 diabetes and inadequate glycemic control (strong recommendation; high-certainty evidence). • Use an SGLT-2 inhibitor to reduce the risk for all-cause mortality, major adverse cardiovascular events, progression of chronic kidney disease, and hospitalization due to congestive heart failure. • Use a GLP-1 agonist to reduce the risk for all-cause mortality, major adverse cardiovascular events, and stroke. RECOMMENDATION 2: ACP recommends against adding a dipeptidyl peptidase-4 (DPP-4) inhibitor to metformin and lifestyle modifications in adults with type 2 diabetes and inadequate glycemic control to reduce morbidity and all-cause mortality (strong recommendation; high-certainty evidence).

Screening for colorectal cancer in asymptomatic average-risk adults: a guidance statement from the American College of Physicians (version 2)

The purpose of this updated guidance statement is to guide clinicians on screening for colorectal cancer (CRC) in asymptomatic average-risk adults. The intended audience is all clinicians. The population is asymptomatic adults at average risk for CRC. This updated guidance statement was developed using recently published and critically appraised clinical guidelines from national guideline developers since the publication of the American College of Physicians' 2019 guidance statement, "Screening for Colorectal Cancer in Asymptomatic Average-Risk Adults." The authors searched for national guidelines from the United States and other countries published in English using PubMed and the Guidelines International Network library from 1 January 2018 to 24 April 2023. The authors also searched for updates of guidelines included in the first version of our guidance statement. The Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument was used to assess the quality of eligible guidelines. Two guidelines were selected for adoption and adaptation by raters on the basis of the highest average overall AGREE II quality scores. The evidence reviews and modeling studies for these 2 guidelines were also used to synthesize the evidence of diagnostic test accuracy, effectiveness, and harms of CRC screening interventions and to develop our guidance statements.

Summary for patients: pharmacologic treatment of primary osteoporosis or low bone mass to prevent fractures in adults

Osteoporosis is a disease, common in older age, that makes your bones weaker and can lead to a fracture. People with previous fractures and those who have other risk factors for fractures, including family history of fractures, vitamin D deficiency or low calcium intake, smoking, excessive alcohol intake, rheumatoid arthritis, and long-term use of some medications (including blood thinners or steroid hormones), have a higher risk for future fractures. Osteoporosis can be treated with medicines that reduce the risk for a fracture. Treatment options may vary depending on the risk for fractures, other chronic diseases, possible harms, interactions with other drugs, and cost. Patients should discuss treatment options with their physician.

Malignant glioma of the cerebrum presenting with a lumbar radiculopathy believed due to cerebrospinal fluid (CSF) spread

The case of a male aged 21 years is being presented. He first sought medical attention for pain in the left thigh found on the basis of neurological assessment to be the result of an L3 radiculopathy. Two lumbar computed tomography (CT) scans were negative. He went on to develop headaches which progressively worsened ultimately resulting in his admission to hospital when a CT scan and a subsequently magnetic resonance imaging scan showed the presence of deep right parietal and posterior thalamic tumour, which on stereotactic biopsy was consistent with an astrocytoma grade IV by the Daumas-Duport system. Subsequent repeat investigations and CSF analysis obtained at ventricular peritoneal shunting confirmed the presence of malignant cells of a glial nature in the spinal fluid. It is therefore believed that there was spread to the lumbar subarachnoid space particularly involving the L3 nerve root, resulting in his radiculopathy. A brief review of the literature concerning CSF spread of malignant gliomas will be presented.(AU)