Hypertension

Updated U.S. and international hypertension guidelines reflect new studies and analyses that support changes in hypertension management. The 2025 U.S. guideline for prevention, detection, evaluation, and management of high blood pressure (BP) recommends lower BP targets, greater use of out-of-office BP for diagnosis and medication titration, and a different approach to severe hypertension presenting without acute or evolving cardiovascular disease symptoms or signs. New treatments for resistant hypertension are recommended. Trial evidence supports benefit from tighter BP control to prevent mild cognitive impairment and dementia, further emphasizing the importance of lower BP goals.

In patients receiving benzodiazepines long-term, a web-based education and tapering tool improved cessation vs. usual care

Clinical Impact Ratings Mental Health: 6 out of 7 GIM/FP/GP: 6 out of 7

Pharmacologic Treatments for Females With Menopausal Vasomotor Symptoms: A Clinical Guideline From the American College of Physicians

Description: The American College of Physicians (ACP) developed this clinical guideline on pharmacologic treatments for internal medicine physicians and other clinicians caring in outpatient settings for females with menopausal vasomotor symptoms. Methods: The ACP Clinical Guidelines Committee developed this guideline based on systematic reviews on effectiveness, comparative effectiveness, harms, public and patient values and preferences, and economic evidence of pharmacologic treatments for females with menopausal vasomotor symptoms using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach. Recommendation: In females who are seeking treatment of vasomotor symptoms: First-line treatments ACP recommends that clinicians initiate one of the following (strong recommendation): estrogen in combination with progestogen in females with a uterus (high-certainty evidence) or estrogen monotherapy in females without a uterus (high-certainty evidence). Second-line treatments ACP suggests that clinicians use one of the following in females who have contraindications to or do not tolerate first-line treatment (conditional recommendation): serotonin–norepinephrine reuptake inhibitors, either desvenlafaxine or venlafaxine (moderate-certainty evidence). Third-line treatments ACP suggests that clinicians use one of the following in females who have contraindications to or do not tolerate first-line or second-line treatment (conditional recommendation): selective serotonin reuptake inhibitors, either escitalopram or paroxetine (low-certainty evidence); the gabapentinoid gabapentin (low-certainty evidence); or neurokinin receptor antagonists, either elinzanetant or fezolinetant (moderate-certainty evidence). When selecting a treatment of vasomotor symptoms, clinicians should use an informed decision-making approach and discuss benefits, harms, contraindications, comorbid conditions, values and preferences, financial burden, and access to and availability of treatments.

Experts discuss developments in dementia

Dementia: Clinical Challenges

In patients with painful diabetic neuropathy, pregabalin does not differ from duloxetine for pain

Clinical Impact Ratings GIM/FP/GP: 5 out of 7 Endocrinology: 5 out of 7

Public Policy Approaches to Addressing Adult Obesity: A Position Paper From the American College of Physicians

Forty percent of U.S. adults have obesity, a complex condition determined by genetics, behavior, environment, and other modifiable and nonmodifiable factors. Obesity is associated with certain comorbid conditions, including type 2 diabetes, high cholesterol, heart disease, and some cancer types, and may increase the severity of communicable illnesses, such as influenza. Treatments of obesity include behavioral modification, pharmacotherapy, and surgical procedures, but high cost and coverage restrictions are a substantial barrier for many patients. In this position paper, the American College of Physicians (ACP) offers recommendations on how policymakers can increase the affordability and accessibility of obesity treatment for adults and address modifiable factors that contribute to obesity, like diet and physical activity. ACP also includes recommendations on reducing stigma associated with obesity, improving understanding of obesity among physicians, increasing access to healthy food, and curbing the proliferation of unhealthy, highly processed fare. Population health strategies for addressing obesity are also discussed.

Correction: Hyponatremia

Surgery Versus Watchful Waiting for First Metatarsophalangeal Joint Osteoarthritis: A Randomized Controlled Trial: Annals of Internal Medicine: Vol 179, No 9

Background: Hallux rigidus, or osteoarthritis of the first metatarsophalangeal joint (MTPJ), causes pain and functional limitation. No randomized trials have compared surgery with the natural course of the disease. Objective: To compare first MTPJ arthrodesis—a widely used surgical intervention—with watchful waiting in reducing walking-related pain in symptomatic hallux rigidus at 12 months after randomization. Design: Single-center, parallel-group, randomized, controlled, superiority trial with 12-month follow-up. (ClinicalTrials.gov: NCT04590313) Setting: Orthopedic department of a tertiary care hospital in Finland. Participants: Adults aged 40 years or older with radiographically confirmed (Coughlin–Shurnas grade I to III) hallux rigidus with symptoms over a year and a walking pain score of 4 or higher on a numerical rating scale (NRS) of 0 to 10 were eligible. Exclusion criteria included type 1 diabetes mellitus, rheumatoid arthritis, and hallux valgus angle greater than 15°. Intervention: Participants were randomly assigned in a 1:1 ratio to surgery with first MTPJ arthrodesis using lag-screw and dorsal plating or to watchful waiting. Measurements: The primary outcome was walking-related pain (NRS of 0 to 10) at 12 months. The prespecified minimal clinically important difference was 1.7 points. Results: Between November 2021 and June 2024, 90 patients were randomly assigned (45 per group). The mean age was 58.1 years, and 89 participants completed the 12-month follow-up. At 12 months, the observed mean walking-related pain was 1.3 in the arthrodesis group and 5.7 in the watchful waiting group (adjusted mean difference, −5.0 points [95% CI, −6.1 to −3.9 points]), exceeding the prespecified minimal clinically important difference and favoring arthrodesis. Limitation: Single-center design. Conclusion: Among adults aged 40 years or older with painful hallux rigidus, first MTPJ arthrodesis provides a superior and clinically significant reduction in walking-related pain at 12 months compared with watchful waiting. Primary Funding Source: Suomen Lääketieteen Säätiö Foundation, Finland.

Giant Cell Arteritis

Giant cell arteritis is a relapsing large-vessel vasculitis affecting the aorta and its branches. It is the most common vasculitis in persons 50 years of age and older. Vision loss occurs in 18% of patients and is preventable with prompt recognition, evaluation, and treatment. Large-artery complications include stenosis, aortic aneurysms, or dissections. Glucocorticoid therapy is effective, but nearly 50% of patients experience relapse. Tocilizumab and upadacitinib are efficacious glucocorticoid-sparing therapies. Patients require long-term monitoring for aortic aneurysms, a late disease complication, even after therapy is discontinued.