September’s Medicine Today leans hard into three clinic-heavy themes: the 2026 ASCIA anaphylaxis refresh (including needle-free adrenaline), residual inflammatory cardiovascular risk, and a practical MAFLD framework. Regular series pieces add menopause cognition and bleeding, paediatric ADHD pearls, travel genomics and an acne differential.
Updated ASCIA anaphylaxis guidance for primary care
Anaphylaxis remains a clinical diagnosis and can present without rash — hypotension, bronchospasm or upper-airway obstruction alone still count when allergy is plausible. Adrenaline first, every time: antihistamines and steroids do not treat airway or cardiovascular compromise and must not delay the first dose. IM adrenaline goes into the outer mid-thigh; IV boluses are not first-line outside specialist settings.
Device choice has expanded. Fixed-dose IM options (EpiPen, Anapen, Jext and equivalents) sit alongside PBS-listed intranasal neffy (1 mg for ≥4 years and 15–30 kg; 2 mg from 30 kg). ASCIA weight bands differ from some Product Information — notably 150 microg from 7.5 kg — so use current ASCIA charts and device-specific Action Plans. Avoid unplanned brand substitution without retraining technique.
Positioning kills as often as delay: keep patients flat (or sitting with legs outstretched if dyspnoeic); never walk them to the treatment bay or toilet. Observe at least four hours after the last adrenaline dose; overnight if severe, refractory, comorbid or remote. Discharge needs a device (or filled authority), technique teaching, an ASCIA plan and allergy follow-up — with GP renewal visits doubling as technique and asthma-optimisation checks.
In clinic
- Treat suspected anaphylaxis with adrenaline immediately — skin signs are optional.
- Prescribe and teach the specific device; tick “no brand substitution” when mixing brands is unsafe.
- Lie flat; stretcher/wheelchair transfer even after recovery; four-hour minimum observation.
Residual CV risk: measure inflammation, consider colchicine
Even with “perfect” LDL and BP, many secondary-prevention patients keep having events. hs-CRP is the practical marker (request the high-sensitivity assay; often private-billed ~$20–60). Interpret <1 / 1–3 / >3 mg/L, and treat ≥2 mg/L on a statin as residual inflammatory risk after excluding acute infection. Australian primary-prevention guidelines do not yet push routine hs-CRP; the clearest use is established ASCVD.
Low-dose colchicine 0.5 mg daily has COLCOT/LoDoCo2 backing (≈23–31% MACE reduction) and ESC/AHA class support for stable coronary disease, but cardiovascular use is off-label in Australia (TGA indication remains gout). Prefer clinically stable patients (often ≥6 months post-event); CLEAR SYNERGY was neutral when started immediately around PCI. Check eGFR/FBC/LFTs, avoid eGFR <30, be cautious <60, and watch CYP3A4/P-gp inhibitors. Statins, SGLT2is, GLP-1RAs and icosapent ethyl already nudge inflammation — colchicine is for what remains.
In clinic
- In stable ASCVD with residual risk, order hs-CRP and discuss low-dose colchicine if ≥2 mg/L after lifestyle/lipid optimisation.
- Counsel GI side effects, drug interactions and that this is evidence-backed off-label CV prevention.
MAFLD: diagnose steatosis, triage fibrosis, treat the dysmetabolome
MAFLD is common and systemic — CVD and extrahepatic cancer outrank liver death for most patients. Screen high-risk groups (diabetes, metabolic syndrome, central adiposity including lean phenotypes via waist metrics). Ultrasound confirms steatosis; always weigh alcohol, meds and viral hepatitis. First fibrosis screen: FIB-4 (<1.3 low risk under 65; <2 if older), then elastography/ELF/ADAPT if indeterminate/high, with specialist referral for advanced disease.
Weight loss remains first-line: ~5% steatosis, 7–10% MASH improvement, >10% fibrosis regression signals. Mediterranean pattern, aerobic activity (benefits even without large weight loss) plus resistance training. Semaglutide 2.4 mg is TGA-approved for MASH with F2–F3 fibrosis but not PBS-listed for that indication; treat lipids/BP/glycaemia aggressively and keep statins when CV risk warrants them.
In clinic
- Do not rely on BMI alone — use waist/height cues to catch lean MAFLD.
- FIB-4 every ~3 years if low risk; escalate noninvasive fibrosis testing when indeterminate.
- Frame therapy as cardiometabolic care, not “liver-only” treatment.
Highlighted regular series
Menopause brain fog. Common, usually transient subjective symptoms with little objective decline — validate, exclude progressive pathology, and push sleep, exercise, vascular risk reduction and practical memory aids. MHT helps vasomotor drivers; evidence for direct cognitive benefit is limited. Watch for unmasking of prior ADHD versus true young-onset dementia red flags.
Unscheduled bleeding on MHT. Common and often benign, but not the same as PMB off hormones. Interpret against regimen (sequential vs continuous), time since FMP and endometrial-protection adequacy. Low-risk early spotting can be observed briefly; TVUS thresholds differ (~≤7 mm sequential, ~≤4 mm continuous combined). Optimise adherence/progestogen before stopping effective MHT; escalate for persistent/heavy bleeding, thick or focal endometrium, or high cancer-risk features.
Paediatric ADHD pearls. Functional impairment across settings is required; comorbidity is the rule. Use multi-informant history and free scales (Vanderbilt/SDQ/SNAP-IV). Start parent training, school adjustments and lifestyle work while waiting — waits are long. Stimulants remain first-line from school age when impairment is clear; monitor growth, BP/HR, sleep and mood, and verify current state S8 rules.
Genetics and travel health. Confirm normal G6PD before tafenoquine/primaquine; consider thrombophilia context for VTE-risk travellers; for traveller’s diarrhoea use both OCP microscopy and faecal multiplex PCR. Pharmacogenomics still has limited routine travel use.
Facial papulopustular quiz. Comedones define acne vulgaris; their absence pushes periorificial dermatitis, rosacea or folliculitis. Mild disease stays topical; moderate–severe needs systemic options with topicals as adjuncts.
Clinician notes for personal CPD — not patient advice.
Article takeaways
Updated anaphylaxis guidelines: a summary for primary care
ASCIA 2026: adrenaline first (including neffy), lie flat, device-specific plans, and structured discharge/follow-up.
Open article →Targeting inflammation to reduce residual cardiovascular risk – where do we stand in 2026?
Use hs-CRP in stable ASCVD; low-dose colchicine 0.5 mg daily is evidence-backed off-label secondary prevention when inflammatory risk persists.
Open article →The steatotic liver diseases: a modern clinical perspective
Diagnose MAFLD, FIB-4 then second-line fibrosis tests, prioritise weight loss and whole-person cardiometabolic care.
Open article →Brain fog and menopause: practical management in primary care
Usually transient subjective fog — validate, exclude red flags, and treat sleep/vascular/lifestyle drivers; MHT is not a proven cognition drug.
Open article →Unscheduled bleeding on menopausal hormone therapy: when to investigate, adjust or reassure
Interpret bleeding by MHT regimen; optimise progestogen/adherence; use regimen-specific ET thresholds and escalate persistent or high-risk bleeding.
Open article →ADHD in children – practical clinical pearls for GPs
Multi-setting impairment, comorbidity screening, school/parent supports while waiting, and careful stimulant shared care with growth/BP monitoring.
Open article →Genetics, genomics and travel health
G6PD before 8-aminoquinolines, VTE history informs prophylaxis, and pair stool microscopy with multiplex PCR in returning diarrhoea.
Open article →A young woman with a facial papulopustular eruption
No comedones? Think beyond acne — periorificial dermatitis, rosacea, folliculitis — and match topical vs oral intensity to severity.
Open article →