Dawnbreaker Health – A different approach to chronic illness, unwavering, resolute care

Chronic Disease

High level options for everyday conditions outside of the specialist’s office

Mental Health

A personalized neurobiological approach to psychiatry beyond simple algorithms

Sleep Apnea

Diagnostics, RX-medication, surgery advice, and advanced CPAP alternatives

Wellness and Anti-Aging

Weight Loss, Hair Restoration, Treatment of Menopause, Low Testosterone, Sexual Health

Resolute, Modern Care

Too often, chronic conditions mean settling for dated medications and dismissive responses. Many PCPs prescribe familiar older generics greatly surpassed by better options. Conditions impacting quality of life get brushed aside but we believe you deserve better. We take an evidence-based, pharmacologically sophisticated approach using the best options available and focusing on the body as a whole. We’re comfortable prescribing newer treatments many PCPs don’t consider—for diabetes, blood pressure, migraine, constipation, allergies, kidney disease, dermatitis, asthma, reflux, cholesterol, insomnia, and sleep apnea. In mental health, we reject blanket approaches, using neurobiologically targeted medications based on specific symptoms for faster-acting, better-tolerated, personalized treatments

Common Problems: Our Approach

Type 2 Diabetes

Our approach to diabetes centers on maximizing metabolic benefits while minimizing medication burden. Our core strategy pairs a GLP-1 receptor agonist (ideally Mounjaro for its superior efficacy) with an SGLT2 inhibitor like Farxiga. This combination alone can normalize blood sugar for many patients while simultaneously promoting significant weight loss, reducing cardiovascular risk, and providing renal protection—benefits that older diabetes medications simply don’t offer. Metformin can be added as an adjunct if needed, and for resistant cases, we have additional agents available to avoid the need for daily insulin injections.

Beyond glucose control, we prioritize preventing long-term vascular complications. We often recommend statin therapy (such as rosuvastatin) based on overall cardiovascular risk—even when baseline cholesterol numbers look ‘normal.’ We consider an ACE inhibitor or ARB (such as telmisartan) when blood pressure is elevated and/or there is evidence of kidney involvement (for example, albumin in the urine) or another clear indication. Statins can cause a small rise in blood sugar in some people; we monitor A1c and adjust diabetes therapy as needed, because the reduction in heart attack risk and stroke is substantia. This comprehensive approach addresses not just your hemoglobin A1c, but your long-term health outcomes.

High Blood Pressure

Current hypertension guidelines generally start with one of the following medication classes: an ACE inhibitor or ARB, a thiazide‑type diuretic, or a calcium channel blocker. Beta blockers are typically used when there are specific indications (such as coronary disease, certain arrhythmias, or heart failure) or as an add‑on later, depending on the patient. While ACE inhibitors and ARBs generally provide the most cardiovascular protection, renal preservation, and reduction in left ventricular hypertrophy, many providers default to whichever agent they’re most familiar with—often not an ACE inhibitor or ARB, or an older one with a less favorable benefit profile. We take a more strategic approach.

Our preferred first-line agent is telmisartan, which offers superior metabolic and organ-protective advantages compared to other ARBs. Beyond blood pressure reduction, telmisartan provides insulin sensitization through PPAR-gamma activation, has the longest half-life of any ARB (ensuring true 24-hour coverage), offers robust cardiovascular and renal protection, and demonstrates anti-inflammatory effects. Through these means, it is uniquely metabolically positive, making it ideal for patients with diabetes or metabolic syndrome.

If blood pressure remains uncontrolled, we add amlodipine, a well-tolerated calcium channel blocker with proven cardiovascular benefits. If additional therapy is needed, we tailor the next add‑on to the patient. Thiazide‑type diuretics remain an effective, evidence‑based option (with electrolyte and metabolic monitoring), while a cardioselective beta blocker may be preferred in selected patients—especially when tachycardia, angina, arrhythmias, heart failure, or intolerance to a diuretic is part of the picture.” Our preferred agent is bisoprolol, a highly cardioselective (β1-selective) beta blocker with proven mortality benefits in heart failure, once-daily dosing, and a significantly lower side effect burden than older non-selective beta blockers. Bisoprolol is also less likely to adversely affect lipid or glucose metabolism.

High Cholesterol

Our preferred first-line approach to elevated cholesterol is rosuvastatin. Unlike lipophilic statins that can penetrate various tissues throughout the body, rosuvastatin is hydrophilic (water-soluble), which limits its distribution to undesired areas and may reduce certain side effects. It’s also the most potent statin per milligram, meaning we can achieve excellent LDL reduction at lower doses—which theoretically further minimizes the risk of adverse effects like muscle pain or elevated liver enzymes.

We recommend statins as our primary strategy not just for cholesterol reduction, but for their extensive cardiovascular benefits: reduction in arterial inflammation, plaque stabilization, improved endothelial function, decreased thrombotic risk, and proven mortality reduction in both primary and secondary prevention. Through these mechanisms, statins can even reduce cardiovascular risk weeks to months after starting. However, we understand that some patients prefer to avoid statins due to personal choice or intolerable side effects. Additionally, newer guidelines recommend tighter LDL control than statins alone can provide for some patients with diabetes, established cardiovascular disease, or multiple risk factors.

For these situations, we’re comfortable prescribing several newer medications that many PCPs may be unfamiliar with:

Ezetimibe (Zetia) – Selective inhibitor of cholesterol transporters in the small intestine (and hepatocytes), reducing absorption of dietary and biliary cholesterol. Generally well tolerated. Lowers LDL by 15–22% alone and or when combined with a statin.

Fenofibrate – Specifically targets very high triglycerides (>500 mg/dL), reducing pancreatitis risk and improving the overall lipid profile in patients with severe hypertriglyceridemia.

Repatha (Evolocumab) – A PCSK9 inhibitor given by monthly or biweekly injection. Dramatically lowers LDL cholesterol (typically 50-60% reduction) and has proven cardiovascular benefits. Particularly valuable for patients with familial hypercholesterolemia, statin intolerance, or those who haven’t reached goal LDL despite maximum tolerated therapy.

Bempedoic Acid (Nexletol) – An oral medication that works similarly to statins but is activated only in the liver, not in muscle tissue—making it an excellent option for patients who experienced muscle-related side effects with statins. Reduces LDL by approximately 15-25% and is also available as “Nexlizet”, a combination pill including ezetimibe.

Vascepa (Icosapent Ethyl) – A high-purity, prescription-grade omega-3 fatty acid that reduces triglycerides and has demonstrated cardiovascular event reduction in high-risk patients, particularly those with elevated triglycerides despite statin therapy.

We tailor our approach based on your specific lipid profile, cardiovascular risk factors, medication tolerance, and personal preferences—not simply prescribing what’s most familiar.

Allergies and Nasal Obstruction

Many primary care providers stop at oral antihistamines, steroid nasal sprays, and perhaps a nasal antihistamine or Singulair. For many patients, that’s simply not enough—and if you’ve gotten this far, you likely know this firsthand. We’re comfortable prescribing a comprehensive range of safe therapies that extend well beyond traditional PCP comfort zones.

Our typical escalation approach includes:

Second-generation oral antihistamines – We favor fexofenadine (Allegra) for its superior efficacy, true non-sedating profile, and lack of cardiac effects seen with some other antihistamines.

Montelukast (Singulair) – A leukotriene receptor antagonist that blocks a different inflammatory pathway than antihistamines, particularly effective for patients with both allergic rhinitis and asthma, or those with exercise-induced symptoms. Has boxed warning for mental health concerns so other alternatives are usually tried first when available.

Nasal antihistamines (azelastine, olopatadine) – Provide rapid, direct relief of nasal symptoms with onset in 15-30 minutes, and can be more effective than oral antihistamines for purely nasal symptoms.

Fluticasone (and other nasal corticosteroids) – The gold standard for reducing nasal inflammation. Most effective when used consistently rather than as-needed, with maximal benefit after 1-2 weeks of regular use.

Nasal anticholinergics (ipratropium) – Specifically targets rhinorrhea (runny nose) by blocking parasympathetic-mediated mucus secretion. Excellent add-on for patients whose primary complaint is anterior nasal drip or discharge.

Sublingual immunotherapy (SLIT) – FDA-approved tablets for specific allergens (ragweed, grass pollen, dust mite) that you dissolve under your tongue daily. This actually modifies your immune system’s response to allergens rather than just masking symptoms, and can provide lasting benefit even after discontinuation. Requires commitment to daily dosing for years but can be life-changing for appropriate patients. Protocol required due to anaphylaxis risk.

Dupixent (dupilumab) – A biologic injection targeting IL-4 and IL-13, key drivers of type 2 inflammation. Appropriate for patients with severe chronic rhinosinusitis with nasal polyps, or those with allergic rhinitis plus comorbid moderate-to-severe asthma or atopic dermatitis. Requires biweekly or monthly injections but can be truly transformative for patients who’ve tried everything else.

Xolair (omalizumab) – An anti-IgE biologic given by monthly injection. Best suited for patients with documented elevated IgE levels and allergic asthma, or those with chronic spontaneous urticaria (hives). Particularly effective when allergies are driven by multiple environmental triggers. Protocol required due to anaphylaxis risk.

For patients with predominant nasal obstruction that hasn’t responded to medical management, we’re also happy to refer for nasomaxillary expansion (also called EASE, MSE or MARPE)—a revolutionary procedure that can effectively improve resistant nasal obstruction provided it’s executed correctly. Unlike traditional septoplasty or turbinate reduction, this approach widens the nasal sidewalls themselves by expanding the upper jaw (maxilla), creating fundamentally more space for airflow. Think of it as moving from a studio apartment to a mansion rather than trying to rearrange the furniture. It addresses the root structural issue rather than modifying the anatomy within an already-constricted space. Due to alteration of skeletal structure, many patients may perceive cosmetic or chewing function benefits as well.

Migraine

Many primary care providers stop at traditional migraine treatments: triptans for acute episodes, and beta blockers, topiramate, or amitriptyline for prevention. While these can be effective, they often come with significant side effects—beta blockers cause fatigue and can worsen asthma, topiramate frequently causes excessive sedation, and amitriptyline leads to sedation and weight gain. Additionally, triptans are contraindicated in patients with cardiovascular disease and can cause rebound headaches with overuse. We offer a range of newer options that are not only more effective for many patients, but also safer with fewer systemic side effects.

Nurtec (rimegepant) – An oral CGRP receptor antagonist that can be used both for acute migraine treatment and prevention. Unlike triptans, it doesn’t cause vasoconstriction, making it safer for patients with cardiovascular risk factors. For prevention, it’s taken every other day and has been shown to significantly reduce monthly migraine days without the cognitive or metabolic side effects of traditional preventives. It can be used as needed as well.

Zavegepant – A nasal spray CGRP antagonist for acute migraine treatment. Offers rapid onset (as early as 15 minutes) and is particularly useful for patients with nausea who can’t tolerate oral medications, or those who need faster relief than oral CGRPs provide. Like all gepants, it’s safe in patients with vascular disease.

Reyvow (lasmiditan) – A 5-HT1F receptor agonist that treats acute migraines through a different mechanism than triptans. It doesn’t cause vasoconstriction, making it appropriate for patients with coronary artery disease, uncontrolled hypertension, or previous stroke. Important limitation: it can cause dizziness and drowsiness, requiring patients to avoid driving or operating machinery for at least 8 hours after taking a dose.

Injectable CGRP monoclonal antibodies (Aimovig, Ajovy, Emgality) – Monthly or quarterly self-injections for migraine prevention. These specifically target the CGRP pathway and have shown impressive efficacy (50%+ reduction in monthly migraine days for many patients) with minimal side effects since they don’t cross the blood-brain barrier (though some patients may have GI side effects). Particularly valuable for patients who’ve failed multiple traditional preventives or can’t tolerate their side effects.

We tailor acute and preventive therapy based on your migraine frequency, associated symptoms, comorbidities, and previous treatment responses—not simply what’s most familiar or easiest to prescribe.

Asthma

Many primary care providers will refer to a pulmonologist if inhaled corticosteroids, long-acting beta agonists, and Singulair prove insufficient. While referral is certainly reasonable at this stage—especially for severe, life-threatening, or difficult-to-control asthma—specialists can have wait times of months, and there are many evidence-based options we can initiate during that wait (or potentially obviate the need for referral altogether).

Dupixent (dupilumab) – A biologic injection targeting IL-4 and IL-13, two key drivers of type 2 inflammatory asthma. Administered every two weeks, it’s particularly effective for patients with eosinophilic asthma or those with comorbid atopic dermatitis or chronic rhinosinusitis with nasal polyps. Clinical trials show significant reductions in exacerbations and improvement in lung function, often allowing patients to reduce or eliminate oral corticosteroid use.

Xolair (omalizumab) – An anti-IgE monoclonal antibody given by monthly injection. Best suited for patients with moderate-to-severe allergic asthma with elevated IgE levels and documented sensitivity to perennial allergens. Reduces exacerbations by blocking the allergic cascade before it triggers airway inflammation.

Tezspire (tezepelumab) – A biologic that targets thymic stromal lymphopoietin (TSLP), an upstream inflammatory mediator. Unique among asthma biologics because it works regardless of eosinophil levels or allergic status, making it appropriate for both type 2 and non-type 2 asthma. Given by monthly injection and has shown dramatic reductions in exacerbations across diverse asthma phenotypes.

Advair/Symbicort inhaler and newer combinations – While many patients are already on combination ICS/LABA inhalers, optimizing the specific agent, delivery device, and dosing can make a significant difference. Newer formulations offer improved delivery and dosing convenience. For patient’s on only albuterol these can be an overwhelming improvement and are now considered first line.

Airsupra – A recently approved rescue inhaler that combines albuterol with an inhaled corticosteroid (budesonide) in a single device. Unlike traditional albuterol-only rescue inhalers, each use provides both immediate bronchodilation and anti-inflammatory effect, reducing the risk of exacerbations triggered by increased rescue inhaler use. Particularly valuable for patients who frequently need their rescue inhaler.

We’re comfortable initiating and managing these advanced therapies, monitoring response, and coordinating with specialists when truly necessary. Our goal is to achieve asthma control without unnecessary delays or the limitations of multiple failed trials that traditional step-wise approaches often require.

Acid Reflux and GERD

Many primary care providers rely on traditional proton pump inhibitors (omeprazole, esomeprazole) or H2 blockers (famotidine) for acid reflux management. While these can be effective, many patients experience incomplete symptom control, delayed onset of relief, or require inconvenient timing around meals. We offer more sophisticated options tailored to your specific needs.

Voquezna (vonoprazan) – A potassium-competitive acid blocker (PCAB) that represents a fundamentally different mechanism than traditional PPIs. Unlike PPIs, which require activation by acid and must be taken 30-60 minutes before meals, Voquezna provides faster onset of action (within hours rather than days), more complete and consistent acid suppression throughout the 24-hour period, and works regardless of meal timing. It’s not as affected by CYP2C19 genetic variations that cause 30% of patients to be rapid PPI metabolizers, meaning it works more reliably across all patients. Particularly valuable for nocturnal reflux, refractory GERD, or patients who’ve failed multiple PPIs.

Pantoprazole – When a traditional PPI is appropriate, we favor pantoprazole over other options in the class. It has significantly fewer drug-drug interactions than omeprazole or esomeprazole because it’s metabolized through multiple pathways and doesn’t inhibit CYP2C19 or CYP3A4 as much as other PPIs. This makes it safer for patients on multiple medications, particularly antiplatelet agents like clopidogrel, anticoagulants, or immunosuppressants.

Famotidine (H2 blockers) – While less potent than PPIs for acid suppression, H2 blockers like famotidine offer a lower side effect profile and can be effective for mild-to-moderate reflux or breakthrough symptoms. Unlike PPIs, famotidine doesn’t significantly affect nutrient absorption (calcium, magnesium, B12), has minimal impact on gut microbiome, carries less increased risk of C. difficile infection or osteoporosis with long-term use, and doesn’t cause rebound acid hypersecretion upon discontinuation. Can be taken as-needed or twice daily for maintenance. Additionally, famotidine may offer benefits for chronic hives (urticaria), allergic conditions, and systemic inflammation through H2 receptor blockade—though evidence for these non-GI indications remains mixed. A reasonable option for patients seeking milder acid suppression with fewer long-term concerns, or as adjunctive therapy to PPIs for refractory symptoms.

We also address underlying contributors to reflux—including evaluation for H. pylori when appropriate, optimizing timing and dosing of acid suppression, and discussing lifestyle modifications—rather than simply increasing PPI doses indefinitely when symptoms persist.

Insomnia and Sleep

Many primary care providers default to basic antihistamines like diphenhydramine or doxylamine, or prescribe GABAergic medications (benzodiazepines, “Z-drugs” like zolpidem/Ambien, eszopiclone/Lunesta) that can provide short-term relief but come with significant long-term concerns. We take a more nuanced, neurobiologically-informed approach to sleep medication selection.

Antiserotonergic agents with antihistamine properties – We generally favor medications that combine serotonin antagonism with H1 antihistamine effects, as these tend to provide more robust and sustainable sleep benefits. Mirtazapine and trazodone work by blocking specific serotonin receptors (5-HT2A, 5-HT2C) while also providing antihistamine effects, promoting both sleep initiation and maintenance. These medications enhance natural sleep architecture rather than forcing sedation, and patients typically don’t develop tolerance. Mirtazapine is the more potent of the two, while trazodone is weaker, but less likely to cause next day sedation or weight gain.

GABAergic medications – While benzodiazepines (temazepam, triazolam) and Z-drugs (zolpidem, eszopiclone, zaleplon) can be effective initially, they carry substantial risks: rapid tolerance development (often within weeks), rebound insomnia upon discontinuation, dependence potential, cognitive impairment, increased fall risk, and disruption of natural sleep architecture. These agents essentially force sedation rather than facilitating natural sleep processes with over-activation of the inhibitory system leading to rapid tolerance.

Pure antihistamines – Over-the-counter options like diphenhydramine (Benadryl) or doxylamine may help occasionally, but tolerance develops quickly. Most also act as “anticholinergics” which contributes to next-day grogginess, and can worsen cognitive function in older adults or contribute to anticholinergic burden. For patients who prefer antihistamines, we lead with hydroxyzine which has less anticholinergic activity (though not zero).

DORAs (Dual Orexin Receptor Antagonists) – These represent a fundamentally different and superior approach that many PCPs are unfamiliar with. Medications like Quviviq (daridorexant) and Belsomra (suvorexant) work by blocking orexin, a neurotransmitter that promotes wakefulness—essentially dampening the “wake signal” rather than forcing sleep through sedation. This allows natural sleep architecture to proceed normally, preserving REM and deep sleep stages. DORAs cause less tolerance, next-day impairment, and dependence compared to gabaergic medications, and can be used long-term safely. They work with your body’s natural sleep-wake regulation rather than overriding it, making them a more physiologic and sustainable solution. Quviviq in particular has favorable pharmacokinetics with less next-morning residual effects than older DORAs.

We select sleep medications based on your specific insomnia pattern (sleep onset vs. maintenance), comorbid conditions (depression, anxiety, pain), age, and medication history—not simply what’s most familiar or easiest to prescribe.

Atopic Dermatitis and Eczema

Many primary care providers rely exclusively on topical corticosteroids for atopic dermatitis management—starting with low-potency options and escalating to high-potency steroids when symptoms persist. While corticosteroids can be effective for acute flares, long-term use leads to skin atrophy (thinning), telangiectasias (visible blood vessels), striae (stretch marks), and tachyphylaxis (reduced effectiveness over time). Patients often end up trapped in a cycle of escalating steroid potency with diminishing returns and increasing side effects. We offer a range of steroid-sparing and targeted anti-inflammatory agents.

Tacrolimus (Protopic) – A topical calcineurin inhibitor that suppresses T-cell activation and inflammatory cytokine production without the skin-thinning effects of corticosteroids. Can be used on sensitive areas like the face and eyelids where steroids are problematic, and is safe for long-term maintenance therapy. Initial burning/stinging typically resolves after the first week of use.

Roflumilast cream (Zoryve) – A topical PDE4 inhibitor that reduces inflammatory signaling. Works through a completely different mechanism than steroids or calcineurin inhibitors, making it an excellent option for steroid-refractory cases or as a steroid-sparing maintenance agent. Well-tolerated with minimal systemic absorption, approved for both atopic dermatitis and seborrheic dermatitis.

Otezla (apremilast) – An oral PDE4 inhibitor taken twice daily. Works by reducing inflammatory signaling within immune cells. Advantages: no injection required, no need for lab monitoring (unlike older systemic agents like methotrexate), can be used in patients with contraindications to biologics. Moderate efficacy. Main side effect is GI upset (nausea, diarrhea) during the first few weeks, which usually resolves with continued use and dose titration.

Vtama (tapinarof) – A novel topical therapy that works as an aryl hydrocarbon receptor (AHR) agonist—a completely unique mechanism. Applied once daily, it’s highly effective for plaque psoriasis with a favorable safety profile. Unlike steroids, can be used long-term without thinning the skin. May cause mild folliculitis or redness initially. Represents a major advancement in topical psoriasis therapy, particularly for patients seeking steroid-free options.

Topical JAK inhibitors – Ruxolitinib (Opzelura) is a topical JAK1/JAK2 inhibitor that directly interrupts the inflammatory cascade driving atopic dermatitis. Provides rapid improvement (often within days) and can be remarkably effective for localized areas. Unlike systemic JAK inhibitors, topical application minimizes systemic exposure and side effects while maintaining efficacy. However they still have important safety cautions and are typically used for limited body surface area and duration; we review risks and monitor as appropriate.

Oral JAK inhibitors – For moderate-to-severe atopic dermatitis not adequately controlled with topical therapy, oral JAK inhibitors like upadacitinib (Rinvoq) or abrocitinib (Cibinqo) offer systemic control with rapid onset. These require monitoring but can be truly life-changing for patients with extensive disease. Because systemic JAK inhibitors affect immune signaling, they carry boxed warnings and require careful patient selection, baseline screening, and ongoing monitoring. They can be life‑changing for the right patient, but they are not appropriate for everyone.

Dupixent (dupilumab) – For patients with moderate-to-severe atopic dermatitis who need systemic therapy, this biologic injection (discussed in our allergy section) targets IL-4 and IL-13 and is highly effective with an excellent safety profile. Particularly appropriate for patients with comorbid asthma or chronic rhinosinusitis.

We design treatment plans that minimize steroid dependence, preserve skin integrity long-term, and utilize targeted anti-inflammatory agents based on disease severity and distribution—not simply prescribing increasingly potent steroids until side effects become unavoidable.

Seborrheic Dermatitis

Many primary care providers treat seborrheic dermatitis with topical corticosteroids and ketoconazole shampoo or cream. While this combination addresses both the inflammation and the Malassezia yeast overgrowth that contributes to the condition, many patients experience incomplete control, frequent relapses, or develop steroid-related side effects with chronic use—particularly on sensitive areas like the face and scalp. We offer several alternatives that provide superior control without the limitations of long-term steroid use.

Tacrolimus (Protopic) – A topical calcineurin inhibitor that effectively reduces the inflammation of seborrheic dermatitis without causing skin atrophy or other steroid-related complications. Particularly valuable for facial involvement where long-term steroid use is problematic. Can be used as maintenance therapy to prevent flares rather than only treating active disease.

Roflumilast cream (Zoryve) – A topical PDE4 inhibitor that’s FDA-approved for both atopic dermatitis and seborrheic dermatitis. Works by reducing inflammatory cytokine production through a completely different mechanism than steroids. Well-tolerated, steroid-sparing, and can be used long-term on the face and scalp without adverse effects. Many patients find it more effective than ketoconazole for controlling both inflammation and recurrence.

Cyclopirox shampoo – An antifungal with a broader mechanism of action than ketoconazole, including anti-inflammatory properties. Many patients find it significantly more effective than ketoconazole for scalp seborrheic dermatitis, with better control of flaking, itching, and redness. It also has a more favorable cosmetic profile (less drying) and may be less likely to develop resistance with chronic use.

We create treatment regimens that control symptoms while minimizing steroid exposure, utilizing targeted anti-inflammatory and antifungal agents that can be sustained long-term without losing effectiveness or causing progressive skin damage.

Anxiety (and panic and trauma)

This page is not for emergencies. If you or someone you know is in immediate danger, having thoughts of self-harm, or may harm others, call 911 or go to the nearest emergency department. In the U.S., you can call or text 988 to reach the Suicide & Crisis Lifeline (available 24/7). If you are outside the U.S., call your local emergency number or local crisis hotline. Messages sent through this website may not be seen right away. Examples of options we may consider after evaluating you; not everyone qualifies; some uses may be off‑label; risks/contraindications will be reviewed before prescribing.

Many primary care providers follow a standard algorithm: try an SSRI or two, and if symptoms persist, refer to psychiatry. While SSRIs are excellent for the right patients, this one-size-fits-all approach ignores the heterogeneity of anxiety presentations and often leaves patients undertreated or dealing with unnecessary side effects

We take a neurobiologically-informed approach, analyzing whether your anxiety is predominantly physical (racing heart, tremor, sweating, muscle tension), emotional (worry, dread, panic), or ruminative (intrusive thoughts, cognitive spinning), as well as whether it’s acute/situational or chronic/persistent. This allows us to select medications that target your specific symptom profile while minimizing side effects. We believe this “dimensional approach” to be effective for anxiety with specific triggers such as trauma, social, or performance related anxiety, as well as more generalized anxiety.

For predominantly physical/somatic anxiety or acute anxiety:

Propranolol – A beta blocker that directly blocks the physical manifestations of anxiety (rapid heartbeat, tremor, sweating) without affecting cognition or causing sedation. Ideal for performance anxiety, social situations, or acute physical panic symptoms. Can be taken as-needed or daily.

Clonidine – An alpha-2 agonist that reduces sympathetic nervous system hyperarousal. Particularly effective for patients with physical hypervigilance, startle responses, or general anxiety with prominent physical symptoms. Also helpful for rumination, comorbid ADHD or trauma-related anxiety.

Hydroxyzine – A non-addictive antihistamine with anxiolytic properties that works within 30-60 minutes. Excellent for as-needed use for acute anxiety episodes without the dependence risks of benzodiazepines. Some sedation but less cognitive impairment than benzos.

Mirtazapine and Trazodone – Described further below, these potent anti-anxiety meds may be effective on an as needed basis, but might have more side effects if not used daily

For predominantly chronic emotional/generalized anxiety:

SSRIs (Serotonin Reuptake Inhibitors) – This group is extremely potent in treating emotional anxiety and depression with more “active or emotional symptoms”. They come with a downside of delayed efficacy and more side effects, especially when first starting, versus other medications that are targeted at specific parts of the serotonin system.

This results in delayed improvement of up to 6-8 weeks and possibly short term worsening of symptoms as problematic parts of the system are triggered before they are overwhelmed and eventually down-regulate. We favor Lexapro (escitalopram) for patients with pure anxiety and Prozac for patients with mixed anxiety and depression.

Buspirone – A 5-HT1A partial agonist that reduces anxiety that gives some of the regulatory benefits of SSRIs, but is more targeted which greatly reduces side effects. Takes 2-4 weeks to reach full effect, making it ideal for chronic generalized anxiety rather than acute situations. Usually is more tolerable than SSRIs, and generally enhances rather than reduces sexual function. It does not carry the full mechanisms of SSRIs making it less effective in severe cases.

Mirtazapine – A direct acting antiserotonergic agent (blocks problematic serotonin receptors 5-HT2A, and 5-HT2C) that particularly useful when anxiety coexists with insomnia, nausea poor appetite, or depression. Works faster than SSRIs (often within days) and addresses multiple symptoms simultaneously. It is likely to cause increased appetite and can be sedating, but is less likely to have other side effects than SSRIs. Like Buspirone it generally enhances rather than reduces sexual function.

Trazodone – An medication that is somewhat of a middle ground between mirtazapine and SSRIs with both a moderate degree of serotonin re-uptake inhibition and receptor antagonism. Can be added to other antidepressants specifically for sleep when insomnia is resistant, allowing the primary antidepressant to be chosen based on daytime symptoms. We generally prefer mirtazapine alone or in combination with an SSRI/SNRI unless side effects are intolerable.

Trintellix (vortioxetine) A multimodal medication that combines serotonin reuptake inhibition with the mechanism of Buspirone (5-HT1A), and anti-nausea medications such as Zofran (5-HT3) and several others all in one pill. This unique mechanism provides antidepressant and anxiolytic effects while potentially enhancing cognitive function, reducing side effects (versus SSRIs), and resulting in faster action (though still on the order of weeks).

For predominantly ruminative/cognitive anxiety:

Wellbutrin (bupropion) – A norepinephrine-dopamine reuptake inhibitor and nicotine modulator that can reduce anxious rumination and improve energy/motivation without the sedation effect of SSRIs. Contrary to older teaching, it’s often well-tolerated in anxiety when dosed appropriately, particularly for patients with cognitive/ruminative anxiety, anxious depression or executive dysfunction. Like buspirone it can also improve sexual function.

Clonidine – Also particularly helpful for rumination in addition to the above.

SNRIs – These work similarly to SSRIs, but also inhibit re-uptake of noradrenaline, raising its concentration. These may be more effective for patients with heavy rumination or comorbid ADHD, but may worsen physical and possibly emotional symptoms of anxiety. Examples include venlafaxine and duloxetine

Depression

The DSM-5 diagnostic criteria for major depression can be conceptually divided between “active/positive” symptoms (negative rumination, guilt, agitation, insomnia) and “passive/negative” symptoms (cognitive slowing, fatigue, hypersomnia, amotivation, anhedonia). Despite this heterogeneity, many primary care providers follow a standard algorithm: try an SSRI or two, and if inadequate response, refer to psychiatry. This approach fails to account for the reality that depression presents very differently across patients, and that medication selection should be tailored to the specific symptom constellation.

We take a symptom-based approach, determining whether your depression is predominantly passive (low energy, excessive sleep, cognitive fog, lack of motivation or pleasure) or active (negative thoughts, guilt, restlessness, insomnia), as well as whether it’s acute or chronic. This allows us to select medications that target your specific symptoms rather than just taking a default approach for all patients with “depression”

CRITICAL: Ruling out underlying medical causes. For patients with predominantly passive/negative symptoms, we strongly recommend a sleep study in most cases to rule out obstructive sleep apnea (OSA). OSA is dramatically underdiagnosed and can present identically to depression—causing fatigue, cognitive impairment, low motivation, and mood disturbance. Similarly, in perimenopausal or postmenopausal women, hormonal changes can produce depressive symptoms that respond poorly to antidepressants alone but dramatically improve with hormone replacement. Treating someone with undiagnosed OSA or untreated menopause with antidepressants alone often provides minimal benefit, whereas addressing the underlying cause can be transformative. We also screen for thyroid dysfunction, vitamin D deficiency, and testosterone deficiency (in men) before committing to long-term antidepressant therapy.

For predominantly passive/negative depression (fatigue, hypersomnia, anhedonia, amotivation, cognitive slowing) – “Atypical Depression”:

Wellbutrin (bupropion) – A moderate norepinephrine-dopamine re-uptake inhibitor and nicotine modulator that increases energy, motivation, concentration, and pleasure response without the sedation, weight gain, or sexual dysfunction of SSRIs. Often our first-line choice for passive depression and anhedonia. Works within 1-2 weeks, faster than SSRIs. Can be activating in a therapeutic way for patients stuck in low-energy states.

Atomoxetine (Strattera) – A potent norepinephrine reuptake inhibitor primarily indicated for ADHD, but potentially effective for atypical depression with prominent executive dysfunction, poor concentration, and low energy. Doesn’t have abuse potential and provides sustained noradrenergic enhancement. Takes up to 6-8 weeks for full effect but can significantly improve motivation and cognitive function and some patients may notice immediate improvement.

Fetzima (levomilnacipran) – A strong SNRI with preferential norepinephrine activity, useful when energy and motivation are impaired alongside mood symptoms.

Dopamine agonists (pramipexole, ropinirole) – Primarily indicated for Parkinson’s disease and restless legs syndrome, but increasingly used off-label for treatment-resistant depression with severe anhedonia (inability to experience pleasure). Works by directly stimulating dopamine receptors rather than just preventing re-uptake. Can be remarkably effective for patients who don’t respond to traditional antidepressants, particularly when loss of interest and pleasure is the dominant symptom. Require careful titration and monitoring.

Selective/Transdermal MAOIs – While traditional MAOIs require strict dietary tyramine restrictions, newer options are much safer. Selegiline (Emsam patch) at low doses is a selective MAO-B inhibitor that is less likely to induce hypertensive crisis and provides excellent efficacy for atypical depression with often less side effects than other medications. The transdermal delivery avoids first-pass metabolism, further improving the safety profile. MAOIs are particularly effective for atypical depression that hasn’t responded to other agents and are underutilized due to outdated fears about the older, non-selective formulations.

Trintellix (vortioxetine) A multimodal medication that combines the mechanisms of SSRIs with others that can minimize side effects and fight negative symptoms of depression.

For predominantly active/positive depression (rumination, guilt, agitation, insomnia, anxiety):

SSRIs (Serotonin Reuptake Inhibitors)– This group is extremely potent in treating emotional anxiety and depression with more “active or emotional symptoms”. They come with a downside of delayed efficacy and more side effects, especially when first starting, versus other medications that are targeted at specific parts of the serotonin system.

SSRIs more broadly increase serotonin levels through re-uptake inhibition. However, rather than treating a “deficiency”, new evidence suggests they work by stabilizing the quality of serotonin signaling, and down regulating problematic parts of the serotonin system that may be over activated. Some, SSRIs, particularly Prozac may also raise levels of neuroplasticity promoting growth factors (BDNF) and mood regulating neurosteroids.

This results in delayed efficacy of up to 6-8 weeks and possibly short term worsening of symptoms as problematic parts of the system are triggered before they are overwhelmed and eventually downregulate. Examples include escitalopram, sertraline, and fluoxetine. We generally favor Prozac (fluoxetine) due to it’s unique mechanisms in treating depression in addition to re-uptake inhibition.

SNRIs – These work similarly to SSRIs, but also inhibit inhibit re-uptake of noradrenaline, raising its concentration. They may be particularly helpful for patients who also have negative/passive symptoms of depression as described, and also for treating rumination. Examples include venlafaxine and duloxetine.

Gepirone (Exxua) – A 5-HT1A receptor agonist is similar to buspirone in that is more targeted, but smaller in scope than SSRIs. This makes it somewhat weaker, but greatly reduces quality of life side effect burden and possibly speeds effectiveness. Has stronger 5-HT1A agonism than buspirone but less dopamine modulation. Requires initial EKG and baseline labs due to potential for QT prolongation, with periodic monitoring during treatment. Particularly good for patients with active/positive depressive symptoms (rumination, guilt, anxiety, agitation) who can not tolerate SSRIs or prefer other options. Still takes several weeks for full antidepressant effect.

Trintellix (vortioxetine) – As briefly introduced above. Trintellix combines serotonin reuptake inhibition with the mechanism of Gepirone (5-HT1A), and Zofran (5-HT3) and several others all in one pill. This unique mechanism provides antidepressant and anxiolytic effects while potentially enhancing cognitive function, reducing side effects (versus SSRIs), and resulting in faster action (though still on the order of weeks)

Trazodone – An antidepressant that is somewhat of a middle ground between mirtazapine and SSRIs with both a moderate degree of serotonin re-uptake inhibition and receptor antagonism. Can be added to other antidepressants specifically for sleep when insomnia is resistant, allowing the primary antidepressant to be chosen based on daytime symptoms. Has some antidepressant effects on its own at higher doses. We generally prefer mirtazapine alone or in combination with an SSRI/SNRI unless side effects are intolerable.

For mixed presentations or treatment-resistant cases:

Combination therapy – We frequently combine medications with complementary mechanisms. Common examples: Wellbutrin + SSRI (addressing both dopamine/norepinephrine and serotonin), Wellbutrin or (S)NRI+ mirtazapine (“California rocket fuel” for severe depression), or augmentation with low dose aripiprazole (Abilify) or brexpiprazole (Rexulti).

Tricyclic antidepressants (TCAs) – Older medications like nortriptyline or desipramine are often overlooked but can be highly effective, particularly for melancholic depression or when insomnia and pain are prominent features. While they have more side effects than newer agents (dry mouth, constipation, potential cardiac effects), they’re often more effective than SSRIs for certain presentations. Require baseline EKG and occasional monitoring but are safe when used appropriately. We favor secondary amines (nortriptyline, desipramine) over tertiary amines (amitriptyline, imipramine) due to better tolerability.

Auvelity (dextromethorphan-bupropion) – A novel combination pairing dextromethorphan (NMDAR antagonist and sigma-1 agonist) with bupropion (which provides dopamine/norepinephrine reuptake inhibition and stabilizes dextromethorphan levels. This creates ketamine-like glutamatergic effects promoting rapid synaptogenesis and neural plasticity, combined with dopaminergic/noradrenergic enhancement—without ketamine’s dissociative effects or need for IV administration. Shows separation from placebo by week 1 with ~60% response rates by week 6.

Particularly effective for depression with prominent anhedonia (“I feel nothing” rather than “I feel sad”), severe amotivation, psychomotor slowing, cognitive fog, or residual emotional blunting on SSRIs. For early treatment-resistant depression (after 1-2 failed trials), this represents a genuine mechanism switch rather than cycling through more SSRIs.

Contains bupropion with similar warnings. May be non-ideal for highly agitated patients who don’t tolerate activation well, but can be a great option for anhedonia-predominant depression or for patients who can’t wait 6-8 weeks for improvement. If Auvelity isn’t affordable, we can discuss prescribing it’s two ingredients separately. However this off‑label strategy, may not be identical and requires careful risk review.

Our approach is to match the medication mechanism to your specific symptom profile and neurobiological needs—not to reflexively prescribe medications that may be suboptimal or even counterproductive for your particular type of depression. We also investigate and address underlying contributors like sleep disorders, hormonal imbalances, and metabolic dysfunction, recognizing that depression is often multifactorial and requires comprehensive evaluation beyond simply prescribing antidepressants.

Chronic Kidney Disease

Chronic kidney disease (CKD), defined by decreased glomerular filtration rate (GFR) and/or albuminuria (protein in the urine), has traditionally been managed by primary care providers with blood pressure control and referral to nephrology once kidney function declines significantly. However, recent landmark trials have revolutionized CKD treatment, demonstrating that specific medication classes can dramatically slow progression and reduce cardiovascular complications—yet many PCPs remain unfamiliar with these protocols or uncomfortable initiating them.

Our core approach to CKD includes:

SGLT2 inhibitors (Farxiga/dapagliflozin) – Originally developed for diabetes, SGLT2 inhibitors have proven remarkably renoprotective across many causes of CKD, even in non-diabetic patients. By reducing intraglomerular pressure and decreasing inflammation, these medications slow decline in kidney function, reduce albuminuria, and significantly decrease the risk of kidney failure requiring dialysis. It also provides substantial cardiovascular benefits, reducing heart failure hospitalizations and cardiovascular death. This is now considered essential therapy for many CKD patients with a GFR above 20, regardless of diabetic status.

ARBs (telmisartan) – Angiotensin receptor blockers remain foundational CKD therapy by reducing intraglomerular pressure, decreasing proteinuria, and slowing fibrosis progression. As discussed in our hypertension section, we favor telmisartan for its superior metabolic profile, longest half-life (ensuring consistent 24-hour kidney protection), and additional PPAR-gamma activation that provides anti-inflammatory and insulin-sensitizing effects. The combination of an ARB with an SGLT2 inhibitor is synergistic and forms the backbone of modern CKD management.

GLP-1 receptor agonists – For patients who are eligible for GLP-1s for other indications (diabetes, weight loss, cardiovascular disease), we strongly encourage their use in CKD patients. Beyond their glucose-lowering and weight loss effects, GLP-1s have demonstrated significant renoprotective benefits, reducing albuminuria progression and slowing GFR decline. The combination of a GLP-1, SGLT2 inhibitor, and ARB is a powerful medical therapy for diabetic kidney disease.

Finerenone (Kerendia) – A selective, non-steroidal mineralocorticoid receptor antagonist (MRA) that blocks aldosterone’s harmful effects on the kidneys and heart while being much less likely to cause the dangerous hyperkalemia (elevated potassium) seen with older MRAs like spironolactone. Clinical trials have shown that finerenone, when added to standard therapy (ARB + SGLT2i), further reduces CKD progression and cardiovascular events in patients with diabetic kidney disease. This represents a major advance—for the first time, we can safely block the mineralocorticoid pathway in CKD patients who would have been at prohibitive risk with traditional agents. We offer finerenone for diabetic CKD patients with persistent albuminuria despite optimization of other therapies. It is critical to note that the risk of elevated potassium is not zero so monitoring is still important.

This comprehensive, guideline-based approach—combining SGLT2 inhibition, renin-angiotensin system blockade, GLP-1 therapy when appropriate, and selective mineralocorticoid antagonism—can slow or even halt CKD progression, often delaying or preventing the need for dialysis. We also address modifiable risk factors including blood pressure optimization, glycemic control, smoking cessation, and dietary sodium restriction. Rather than waiting until kidney function has severely declined before referring to nephrology, we implement maximum medical therapy early to preserve kidney function for as long as possible.

Obstructive Sleep Apnea

Many primary care providers, when they suspect obstructive sleep apnea (OSA), refer patients to a sleep specialist for evaluation and at most will maintain existing CPAP prescriptions with annual refills. This leaves patients navigating months-long wait times for sleep studies, struggling with poorly tolerated therapy, or simply going untreated. We take a more comprehensive and proactive approach to both diagnosis and treatment.

Diagnostics – We offer convenient, mail-order home sleep studies that allow you to complete testing in your own bed rather than spending a night in an unfamiliar sleep lab. Our testing device meets AASM Type 1A criteria with 3% recording accuracy, placing it among the highest sensitivity home sleep tests available—as close as possible to in-lab polysomnography for detecting OSA. These FDA-approved devices provide accurate diagnosis of OSA severity and can be completed within days rather than waiting months for an in-lab study. For most patients with suspected OSA (without complex comorbidities like central sleep apnea or significant cardiac/pulmonary disease), home sleep testing is reasonably effective and far more accessible.

Medical Management – Weight Loss Therapies – For many patients, OSA is directly related to excess weight, particularly around the neck and upper airway. Even modest weight loss (10-15% of body weight) can significantly improve or even resolve OSA in overweight patients. We actively incorporate medical weight loss strategies into OSA management:

GLP-1 receptor agonists (semaglutide/Wegovy, tirzepatide/Zepbound) – These medications produce substantial, sustained weight loss (15-25% of body weight on average) and have been shown in clinical studies to significantly improve OSA severity. As patients lose weight on GLP-1 therapy, AHI (apnea-hypopnea index) often drops dramatically, sometimes to the point where CPAP is no longer necessary. For overweight patients with OSA, GLP-1s address both the metabolic dysfunction and the mechanical airway obstruction simultaneously.

Combination pharmacotherapy – For patients who need more aggressive weight loss, we can combine GLP-1s with other agents like bupropion, topiramate, metformin, orlistat, or naltrexone to maximize weight reduction and OSA improvement. These can also be used without a GLP-1 in case of insurance issues individually providing 3-4% weight loss.

Metabolic optimization – Weight loss not only reduces airway obstruction but also decreases systemic inflammation, improves insulin sensitivity, and reduces cardiovascular risk—all of which compound the benefits for OSA patients who frequently have metabolic syndrome.

For appropriate patients, medical weight loss can transform OSA from a chronic condition requiring lifelong CPAP into a resolved issue, or at minimum reduce severity enough to make PAP therapy far more tolerable at lower pressures.

Advanced PAP Therapy – BiPAP with ASV (Adaptive Servo-Ventilation) – While CPAP (continuous positive airway pressure) remains the standard first-line therapy, many patients find it poorly tolerated or experience inadequate symptom resolution despite technically “adequate” treatment. We offer BiPAP with ASV, a more sophisticated form of positive airway pressure therapy that has been shown to be superior to CPAP in both tolerability and symptom management.

BiPAP ASV can be particularly valuable for patients with:

CPAP intolerance or failure
Residual daytime sleepiness despite “compliant” CPAP use
Central or complex sleep apnea patterns
Comorbid insomnia alongside OSA
Difficulty tolerating high CPAP pressures

Surgical Options – Curative Approaches – For patients seeking long-term solutions rather than nightly device dependence, we provide detailed discussions of modern surgical treatments that can actually be curative, unlike older procedures (uvulopalatopharyngoplasty/UPPP, tongue reduction) that had poor success rates and significant morbidity.

Maxillomandibular Advancement (MMA) – The gold standard surgical treatment for OSA, with success rates exceeding 85-90% in appropriately selected patients. This procedure advances both the upper jaw (maxilla) and lower jaw (mandible) forward, expanding the entire airway from the nose through the throat. Beyond curing sleep apnea, MMA often significantly improves facial aesthetics by enhancing jaw projection, improving facial balance, and creating a more youthful appearance. Unlike UPPP, which destroys tissue, MMA creates space—addressing the root anatomical problem.

Nasomaxillary Expansion (MSE/MARPE/FME/EASE) – As discussed in our allergies section, this procedure expands the upper jaw, widening the nasal passages and improving nasal breathing. For patients with OSA who also have nasal obstruction or midface deficiency, this can be combined with MMA or used as a standalone treatment. Like MMA, it may improve facial aesthetics while addressing the underlying skeletal restriction causing airway collapse. It is often used in combination with MMA as part of a two phase treatment.

We’re happy to discuss specific surgeons and orthodontists with expertise in these procedures and help you determine if you’re a surgical candidate. For many patients—particularly younger individuals tired of nightly devices, those with anatomical skeletal deficiency, or people who’ve failed conservative therapy—these surgical options represent a genuine cure rather than lifelong management.

Our approach is comprehensive: accurate and convenient diagnosis using the highest-sensitivity home testing available, medical management through weight loss when appropriate, optimization of PAP therapy (including advanced technologies that go beyond basic CPAP), and informed discussion of surgical options that can permanently resolve OSA while potentially improving facial structure and aesthetics.

Overactive Bladder and Urinary Frequency

Many primary care providers treat overactive bladder (OAB) and urinary frequency with anticholinergic medications such as oxybutynin, tolterodine, or solifenacin. While these medications can reduce urgency and frequency by blocking bladder muscle contractions, they come with a significant cost: anticholinergic side effects including dry mouth, constipation, blurred vision, and most concerningly, cognitive impairment. Studies have linked chronic anticholinergic use to increased risk of dementia, decreased memory performance, and overall cognitive decline—particularly in older adults. Many patients are entirely unaware of these risks and continue taking these medications for years, attributing their mental fog or memory problems to aging rather than their bladder medication.

Mirabegron (Myrbetriq) – Our preferred first-line agent for OAB. Mirabegron is a beta-3 adrenergic agonist that relaxes the bladder through a completely different mechanism than anticholinergics, with no anticholinergic effects whatsoever. This means no cognitive impairment, no dry mouth, no constipation. Beyond simply avoiding side effects, mirabegron may offer several metabolic benefits. In research studies it increases brown fat activity and energy expenditure. While not conclusive this may help aid in weight management and improve metabolic parameters. Clinical trials show efficacy comparable to or better than anticholinergics with dramatically superior tolerability. It does have a possible side effect of increased blood pressure which we can monitor appropriately. For patients concerned about cognitive health or who’ve experienced side effects from anticholinergics, mirabegron represents a clearly superior approach.

Trospium – We recognize that mirabegron can be expensive, particularly for patients with high-deductible insurance plans or limited coverage. For cost-conscious patients who still want to avoid cognitive side effects, trospium offers an excellent alternative. While trospium is technically an anticholinergic medication, it’s a quaternary amine that minimally crosses the blood brain barrier, meaning it affects the bladder with low chance of causing the central nervous system side effects—including cognitive impairment—seen with other anticholinergics. Patients get effective bladder symptom control while protecting brain function. Trospium is available generically and costs a fraction of mirabegron’s price, making it accessible for patients where cost is a barrier. However, it does still carry most of the other side effects of anticholinergics.

We also address contributing factors to urinary frequency: caffeine intake, fluid timing, bladder training techniques, pelvic floor physical therapy referrals when appropriate, and screening for underlying conditions like diabetes or urinary tract infections. For men with OAB symptoms, we evaluate for benign prostatic hyperplasia (BPH) and can treat both conditions simultaneously when indicated.

Our goal is bladder symptom control without sacrificing cognitive function or quality of life—something that’s entirely achievable with modern, non-anticholinergic approaches or peripherally-selective alternatives.

Weight Management and GLP-1s

Many primary care providers have begun prescribing GLP-1 receptor agonists for weight loss, recognizing their transformative efficacy demonstrated in recent trials. However, some remain unfamiliar with the latest and most effective agents, continuing to prescribe the older semaglutide (Wegovy) rather than the superior tirzepatide (Zepbound). Additionally, many PCPs lack experience navigating the complex prior authorization process required by insurance companies, leaving patients to struggle through denials and appeals on their own—or simply giving up on treatment entirely.

GLP-1 receptor agonists offer benefits far beyond weight loss: Major reduction in heart attacks and strokes, slowing of chronic kidney disease progression, and improvement of fatty liver disease, sleep apnea, inflammation, and chronic pain. Emerging research suggests potential neuroprotective benefits and reduction in addictive urges beyond food. For patients with obesity plus these conditions, GLP-1s represent disease-modifying therapy addressing multiple aspects of metabolic dysfunction—not just a weight loss medication.

Tirzepatide (Zepbound/Mounjaro) – A dual GIP/GLP-1 receptor agonist that has demonstrated superior weight loss compared to semaglutide in head-to-head trials. While semaglutide produces average weight loss of 15-17% of body weight, tirzepatide achieves 20-25% weight loss—approaching what was previously only possible with bariatric surgery. The dual mechanism (targeting both GIP and GLP-1 receptors) provides more comprehensive metabolic benefits, better appetite suppression, and often improved tolerability. For patients seeking maximum efficacy, tirzepatide should be the preferred agent when insurance coverage allows.

Semaglutide (Ozempic/Wegovy)

Semaglutide is slightly inferior in weight loss and side effect burden, but is now available from the official manufacturer pharmacy for a little a $149 a month for starting doses. In some cases these differences can be a “toss up” for individual patients. We often prescribe this to cost conscious patients for whom a GLP-1 is still the best option. Additionally, unlike Zepbound it comes in a pill for for patients who like to avoid needles.

Insurance Navigation – We have extensive experience with prior authorization requirements, appeal processes, and alternative coverage pathways for GLP-1 medications. Additional FDA approvals for sleep apnea and fatty liver may help us get these payed for if your insurance does not cover them purely for weight loss. We handle prior authorizations and appeals by documenting diagnoses and medical necessity accurately and submitting the clinical information insurers require. When coverage is limited, we can also discuss manufacturer savings programs and other cost‑reduction pathways. Getting these medications approved requires expertise that goes beyond simply writing a prescription—we handle this process so you don’t have to.

Adjunctive Medications – The “Stacking” Approach – While GLP-1s represent the most powerful single agent for weight loss, they’re expensive (often $199-500/month without insurance coverage) and not always accessible. Moreover, combining GLP-1s with other weight loss medications can enhance results beyond what any single agent achieves. We prescribe a wide array of older, generic medications that produce modest weight loss individually (3-7% each) but are stackable—meaning multiple agents can be combined for additive effects. Critically, these medications cost approximately $2-4 per month each, making medical weight loss accessible even for patients without insurance coverage or those waiting for GLP-1 approval.

Bupropion (Wellbutrin) – Produces 5-7% weight loss through dopamine and norepinephrine reuptake inhibition. Reduces appetite, increases energy expenditure, and helps with food cravings. Also addresses comorbid depression or low energy. Can be combined with naltrexone for enhanced effect (marketed as Contrave, but we can prescribe both generics separately for far less cost).

Metformin – Beyond its diabetes indication, metformin produces modest weight loss (2-3%) by improving insulin sensitivity and reducing hepatic glucose production. Particularly valuable for patients with prediabetes, PCOS, or metabolic syndrome. Side benefit: may have longevity and anti-cancer properties.

Topiramate – Produces 5-10% weight loss through multiple mechanisms including appetite suppression and altered taste perception. We use lower doses (25-100mg) than the epilepsy indication to minimize cognitive side effects while maintaining weight loss efficacy. Particularly effective when combined with other agents.

Naltrexone – An opioid antagonist that reduces reward-driven eating and food cravings by modulating the mesolimbic reward pathway. Produces 3-5% weight loss and is especially helpful for patients with binge eating or emotional eating patterns. Synergistic when combined with bupropion.

Orlistat – Works peripherally by blocking intestinal fat absorption (about 30% of dietary fat). Produces 5-7% weight loss when combined with a reduced-calorie diet. The only weight loss medication that works outside the central nervous system. Gastrointestinal side effects (loose stools, urgency) can be significant with high-fat meals but serve as behavioral reinforcement for dietary adherence.

Combination Strategies – We frequently combine 2-5 of these medications simultaneously for patients who need significant weight loss but can’t access or afford GLP-1s, or to enhance GLP-1 efficacy for patients who’ve plateaued. For example: metformin + bupropion + topiramate can produce 15-20% weight loss at a total cost of $8-10/month, rivaling much more expensive branded combination products. When combined with a GLP-1, these adjunctive agents can push total weight loss into the 25-30% range.

Our approach makes medical weight loss accessible regardless of insurance status, maximizes efficacy through rational polypharmacy, and ensures patients receive the most advanced agents (tirzepatide) when appropriate—along with the insurance navigation expertise to actually get them covered.

Pattern Hair Loss (Androgenic Alopecia)

Many primary care providers, if they treat hair loss at all, limit themselves to topical minoxidil (Rogaine) and occasionally finasteride. Many dismiss hair loss concerns entirely as “cosmetic” or refer patients to dermatology, where wait times can stretch months. We recognize that hair loss significantly impacts quality of life, self-esteem, and psychological wellbeing—and we offer evidence-based treatments that go well beyond the basic options many PCPs are comfortable prescribing.

Oral Minoxidil – While topical minoxidil has been the standard for decades, oral minoxidil at low doses (0.625-5mg daily) is substantially more convenient—no messy twice-daily scalp application, no scalp irritation, no concerns about inconsistent absorption. Emerging evidence suggests oral minoxidil may be more effective than topical formulations, likely due to more consistent systemic levels and complete scalp coverage. Originally developed as a blood pressure medication, low-dose oral minoxidil is remarkably safe with minimal side effects (occasional increased body hair, rare mild fluid retention). It works by prolonging the anagen (growth) phase of hair follicles and improving blood flow to the scalp. We’re comfortable prescribing oral minoxidil for both male and female pattern hair loss.

Dutasteride – An alternative to finasteride that blocks both Type I and Type II 5-alpha reductase enzymes (finasteride only blocks Type II), resulting in more complete DHT (dihydrotestosterone) suppression—the hormone primarily responsible for androgenic alopecia. Studies suggest dutasteride is likely more effective than finasteride for hair regrowth and maintenance, particularly for men who’ve had suboptimal response to finasteride. The side effect profile is similar to finasteride (small risk of sexual side effects and possibly depressive symptoms in some patients), but the enhanced efficacy makes it our preferred 5-alpha reductase inhibitor when appropriate. Typically dosed at 0.5mg daily.

Finasteride – We still prescribe finasteride (1mg daily for hair loss) when patients prefer it or when dutasteride isn’t appropriate. It remains highly effective for male pattern baldness, with clinical trials showing hair regrowth in about two-thirds of men and stabilization in 90%.

Spironolactone (for female pattern hair loss) – An antiandrogen that blocks androgen receptors and reduces androgen production, particularly valuable for women with androgenic alopecia. While often prescribed for acne or hirsutism, spironolactone (typically 50-200mg daily) is highly effective for female pattern hair loss when combined with oral minoxidil. It addresses the hormonal driver of hair loss in women, particularly those with evidence of hyperandrogenism (PCOS, elevated DHEA-S or testosterone). Requires monitoring of potassium levels and blood pressure but is generally well-tolerated.

Combination Approach – We frequently combine medications for synergistic effects. Common regimens include:

Men: Oral minoxidil + dutasteride (or finasteride)
Women: Oral minoxidil + spironolactone
For maximum efficacy, some patients add topical treatments on top of oral therapy

Our goal is meaningful hair regrowth and stabilization using the most effective, evidence-based agents available—not the limited toolkit that many PCPs restrict themselves to out of unfamiliarity or discomfort. We take hair loss seriously because you do, and we’re willing to prescribe the medications that actually work.

Acne

Many primary care providers treat acne with traditional therapies: topical clindamycin or benzoyl peroxide, tretinoin (Retin-A), and oral doxycycline for inflammatory acne. While these can be effective, they represent decades-old approaches that haven’t kept pace with newer, more targeted options that offer improved efficacy and tolerability. We prescribe both traditional and modern acne therapies based on your specific acne type, severity, and location.

Traditional Therapies – We utilize the full range of established treatments:

Topical clindamycin – An antibiotic that reduces acne-causing bacteria (C. acnes) and inflammation. Most effective when combined with benzoyl peroxide to prevent antibiotic resistance.

Tretinoin (Retin-A) – A topical retinoid that normalizes skin cell turnover, prevents comedone (blackhead/whitehead) formation, and reduces inflammation. Remains the gold standard topical therapy for comedonal and mild-to-moderate inflammatory acne. Requires gradual introduction to minimize irritation and peeling.

Adapalene – Similar to Tretinoin, but generally less prone to side effects such as burning, redness, or irritation, at the cost being less likely to improve Acne scars or possibly reduce visible aging.

Doxycycline – An oral tetracycline antibiotic used for moderate-to-severe inflammatory acne. Reduces bacterial counts and has intrinsic anti-inflammatory properties beyond its antibiotic effect.

Advanced Therapies – We also offer newer agents that many PCPs are unfamiliar with:

Sarecycline (Seysara) – A recently FDA-approved tetracycline antibiotic that’s been molecularly modified for greater selectivity against C. acnes (the acne-causing bacteria) while having less activity against beneficial gut bacteria. This narrow-spectrum approach means significantly less disruption to the gut microbiome compared to doxycycline—reducing the risk of GI upset, yeast infections, and long-term dysbiosis. Sarecycline also has a lower incidence of vestibular side effects (dizziness, vertigo) compared to minocycline. Once-daily dosing and can be taken with or without food. For patients who need oral antibiotic therapy, this represents a meaningfully better option than traditional tetracyclines.

Trifarotene (Aklief) – A fourth-generation topical retinoid that selectively targets retinoic acid receptor gamma (RAR-γ), which is particularly abundant in sebaceous glands. Unlike tretinoin (which hits all RAR subtypes), trifarotene’s selectivity provides potent efficacy with potentially less irritation. Most notably, trifarotene has been specifically shown to be highly effective for truncal acne—acne affecting the chest, shoulders, and back—which often responds poorly to tretinoin. If you struggle with body acne, trifarotene may be significantly more effective than traditional retinoids.

Spironolactone – An oral antiandrogen (typically 50-150mg daily) that’s highly effective for hormonal acne in women, particularly when acne follows a cyclical pattern with menstruation or is concentrated along the jawline and chin. By blocking androgen receptors and reducing androgen production, spironolactone addresses the underlying hormonal driver of acne rather than just treating surface inflammation. Often takes 3-6 months for full effect but can be transformative for women with hormonally-driven acne. Requires monitoring of potassium levels and blood pressure. Not appropriate for men due to feminizing effects, but highly valuable for women who haven’t responded adequately to topical therapies.

Clascoterone (Winlevi) – A novel topical antiandrogen cream that works by blocking androgen receptors in the skin, preventing DHT and testosterone from stimulating sebaceous gland activity and inflammation. This is the first topical acne treatment that directly targets the hormonal component of acne with minimal to no systemic effects. Because it works locally on the skin rather than systemically, it can be used by both men and women without the concerns associated with oral antiandrogens like spironolactone. Clascoterone represents a fundamentally new mechanism for acne treatment and is particularly valuable for hormonal acne patterns (jawline/chin acne in women, persistent acne despite standard therapies).

Combination Strategies – We tailor regimens based on acne characteristics:

Comedonal acne (blackheads/whiteheads): Tretinoin or trifarotene
Inflammatory facial acne: Clindamycin + tretinoin, add sarecycline if moderate-severe
Truncal/back acne: Trifarotene specifically
Hormonal acne in women: Topical clascoterone and/or oral spironolactone, often combined with topical retinoid
Persistent acne: Multiple topical agents + oral therapy (sarecycline or spironolactone depending on presentation)

For severe cystic acne, we can discuss isotretinoin (Accutane) or refer to dermatology when appropriate. Our approach utilizes the most advanced, targeted therapies available rather than limiting ourselves to the same treatments that have been used for 30+ years.

Low Libido & Sexual Dysfunction

Many primary care providers are uncomfortable addressing low libido or sexual dysfunction, often dismissing these concerns as psychological or simply a normal part of aging. Even when they do investigate, many limit their evaluation to checking testosterone levels—and if labs are normal, they offer little beyond “try talking to a therapist.” We recognize that diminished libido significantly impacts quality of life and relationships, and we offer evidence-based medical treatments for patients with low libido even when hormonal testing is normal.

FDA-Approved Treatments:

Vyleesi (bremelanotide) – An injectable melanocortin receptor agonist administered subcutaneously (like an insulin pen) 45 minutes before anticipated sexual activity. Vyleesi works by activating pathways in the brain that regulate sexual desire and arousal. Clinical trials demonstrated significant improvements in sexual desire and satisfying sexual events in premenopausal women with hypoactive sexual desire disorder (HSDD). Particularly effective for many patients, with relatively rapid onset. Can cause transient nausea or flushing in some users, but side effects typically diminish with repeated use. Used as-needed rather than daily.

Addyi (flibanserin) – A daily oral medication that modulates serotonin receptors (5-HT1A agonist, 5-HT2A antagonist) to enhance dopamine and norepinephrine while reducing serotonin in key brain regions regulating sexual desire. Requires nightly dosing and takes 4-8 weeks to reach full effect. FDA-approved for premenopausal women with HSDD. Generally recommended to avoid use with alcohol due to possible blood pressure and syncope issues.

Off-Label Alternatives – While we’re happy to prescribe the FDA-approved options above, many patients find them expensive or prefer alternatives. We’re comfortable trialing other medications that have shown efficacy for low libido:

PDE-5 Inhibitors (Viagra/Cialis) – While primarily indicated for Erectile dysfunction, these medications may offer some benefit for libido issues or general sexual dysfunction for patients of all genders

Buspirone – A 5-HT1A partial agonist (similar mechanism to Addyi) typically used for anxiety, but effective for enhancing libido through its effects on dopamine and serotonin. Significantly cheaper than Addyi (generic available) and doesn’t have alcohol restrictions. Typically dosed 5-15mg 2-3 times daily or 1-2 hours before sexual activity.

Bupropion (Wellbutrin) – By increasing dopamine and norepinephrine, bupropion often enhances libido and can be particularly effective for patients with comorbid depression or low energy. Unlike SSRIs which commonly cause sexual dysfunction, bupropion frequently improves sexual function. Can be used daily as an antidepressant or in some cases as-needed.

Trazodone – While primarily used for sleep, low doses of trazodone (25-100mg taken 1-2 hours before sexual activity) can enhance arousal and genital sensation through its effects on serotonin receptors and nitric oxide. Some patients find it particularly helpful for arousal difficulties.

Mirtazapine – An antiserotonergic antidepressant that, at low doses (7.5-15mg), can enhance libido by blocking the serotonin receptors that inhibit sexual function. Can be taken nightly if sleep is also an issue, or used as needed.

Cyproheptadine – An antihistamine with antiserotonergic properties, often used as-needed (4-12mg taken 1-2 hours before sexual activity) to counteract serotonin’s inhibitory effects on sexual function. Particularly useful for addressing SSRI-induced sexual dysfunction.

SSRI-Induced Sexual Dysfunction – These same medications can be highly effective for treating sexual side effects from SSRIs or other psychiatric medications. Many patients on SSRIs experience decreased libido, delayed orgasm, or anorgasmia—side effects their prescribing provider may not have warned them about or may dismiss as unavoidable. Rather than simply accepting sexual dysfunction as the price of treating depression or anxiety, we can add medications like bupropion, buspirone, or as-needed cyproheptadine to restore sexual function while maintaining the psychiatric benefits of the SSRI.

Our approach is individualized based on your specific symptoms (desire vs. arousal vs. orgasm difficulties), medication tolerance, cost considerations, and whether you prefer daily medication or as-needed dosing. We take sexual health seriously and believe effective medical treatments should be accessible regardless of whether labs show hormonal abnormalities.

Erectile Dysfunction

Many primary care providers are uncomfortable discussing or treating erectile dysfunction (ED), often dismissing it as an inevitable part of aging or immediately referring to urology. When they do treat it, many stick exclusively to sildenafil (Viagra) or tadalafil (Cialis)—the medications they’re most familiar with. We recognize that erectile dysfunction significantly impacts quality of life, relationships, and often serves as an early warning sign of cardiovascular disease. We offer comprehensive ED management including both traditional and newer PDE5 inhibitors tailored to your lifestyle and tolerability.

Traditional PDE5 Inhibitors:

Sildenafil (Viagra) – The original PDE5 inhibitor, taken as-needed approximately 30-60 minutes before sexual activity. Effective for 4-6 hours. Works by increasing blood flow to erectile tissue in response to sexual stimulation. Should not be taken with nitrates (can cause dangerous blood pressure drops) or more than once in 24 hours.

Tadalafil (Cialis) – Available in two formulations: as-needed (taken 30 minutes before activity, effective for up to 36 hours—the “weekend pill”) or daily low-dose (2.5-5mg daily for continuous 24-hour coverage). Many patients prefer the daily option as it provides spontaneity without planning around medication timing. Beyond convenience, daily tadalafil offers additional health benefits not seen with as-needed PDE5 inhibitor use: improved endothelial function (the lining of blood vessels), potential cardiovascular benefits through enhanced nitric oxide signaling, significant improvement in lower urinary tract symptoms/BPH (benign prostatic hyperplasia), possible metabolic benefits including improved insulin sensitivity, and anti-inflammatory effects. Some studies suggest benefits for exercise performance and recovery. For men with both ED and urinary symptoms, or those interested in potential cardiovascular/metabolic optimization, daily tadalafil may offer advantages beyond sexual function alone.

Common Side Effects – Both sildenafil and tadalafil can cause headaches, facial flushing, nasal congestion, indigestion, and visual changes (blue tinge with sildenafil). While effective, many patients experience these side effects significantly enough to limit use or seek alternatives.

Newer, More Selective PDE5 Inhibitors:

Avanafil (Stendra) – A newer-generation PDE5 inhibitor that’s significantly more selective for the PDE5 enzyme compared to older agents. This selectivity translates to fewer side effects—particularly less headache, flushing, and nasal congestion. Additionally, Stendra has the fastest onset of any PDE5 inhibitor (works in as little as 15 minutes for some patients), providing more spontaneity than sildenafil or tadalafil. Effective for 4-6 hours. For patients who’ve experienced bothersome side effects from Viagra or Cialis, Stendra often represents a significantly better-tolerated option.

Vardenafil (Levitra) – Another highly selective PDE5 inhibitor with a side effect profile generally milder than sildenafil. Works within 30-60 minutes and lasts 4-5 hours. Some patients find it more effective than sildenafil at equivalent doses due to its higher potency and selectivity. Lower rates of visual disturbances compared to sildenafil.

Our Approach – We select PDE5 inhibitors based on your preferences and needs:

For spontaneity without planning: Daily tadalafil (Cialis)
For as-needed use with fast onset: Avanafil (Stendra)
For weekend coverage: As-needed tadalafil (Cialis)
For patients with side effects from Viagra/Cialis: Stendra or Levitra
For patients interested in cardiovascular/metabolic optimization alongside ED treatment: Daily tadalafil
Cost-conscious patients: Generic sildenafil or tadalafil

We also evaluate and treat underlying contributors to ED: cardiovascular disease (ED is often an early sign), diabetes, hypogonadism (low testosterone), psychological factors, and medication side effects (particularly from antidepressants, blood pressure medications, or antipsychotics). Addressing these underlying factors alongside PDE5 inhibitor therapy often provides superior results.

For patients who don’t respond to oral PDE5 inhibitors, we can discuss alternative treatments including intraurethral or injectable therapies, or refer to urology for more advanced interventions when appropriate.

Menopause & Hormone Replacement Therapy

Many primary care providers are hesitant to prescribe hormone replacement therapy (HRT) for menopause, either due to outdated concerns from the 2002 Women’s Health Initiative study (which has since been substantially reinterpreted) or simple unfamiliarity with modern HRT protocols. As a result, women suffering from debilitating hot flashes, night sweats, brain fog, mood changes, sleep disturbances, vaginal dryness, and sexual dysfunction are often told to “just deal with it” or offered only SSRIs (which have modest efficacy at best). We recognize that menopausal symptoms profoundly impact quality of life, and we offer comprehensive, evidence-based hormone replacement using FDA-approved bioidentical hormones covered by insurance—not proprietary blends requiring expensive subscriptions from direct-to-consumer companies.

Vaginal Estrogen – For genitourinary symptoms (vaginal dryness, painful intercourse, urinary urgency/frequency), low-dose vaginal estrogen is highly effective with minimal systemic absorption. Available forms include:

Vaginal creams (estradiol cream, conjugated estrogen cream)
Vaginal tablets (Vagifem, Yuvafem)
Vaginal rings (Estring – releases continuous low-dose estrogen for 90 days)

These can be used safely even in women who choose not to pursue systemic HRT, and have minimal contraindications since absorption is primarily local.

Systemic Estrogen – For systemic menopausal symptoms (hot flashes, night sweats, mood changes, sleep disturbance, cognitive symptoms), systemic estrogen replacement is the most effective treatment available. We strongly recommend transdermal formulations (patches, gels, or sprays) over oral estrogen due to reduced risk of blood clots (venous thromboembolism). Oral estrogen undergoes first-pass metabolism through the liver, increasing clotting factors and thrombotic risk, whereas transdermal estrogen bypasses hepatic metabolism and doesn’t significantly affect clotting factors. Available transdermal options include:

Estradiol patches (changed once or twice weekly—Climara, Vivelle-Dot, Minivelle)
Estradiol gel (applied daily to skin—Estrogel, Divigel)
Estradiol spray (applied daily—Evamist)

Progesterone – For women who still have a uterus, progesterone must be added to systemic estrogen to protect the endometrial lining and prevent hyperplasia or cancer. We prescribe micronized progesterone (Prometrium—bioidentical oral progesterone) rather than synthetic progestins when possible, as it has a more favorable side effect profile, may improve sleep, and doesn’t negate estrogen’s cardiovascular benefits the way some synthetic progestins do. For women who’ve had a hysterectomy, progesterone is not needed.

Our Approach:

Genitourinary symptoms only: Vaginal estrogen alone
Systemic symptoms with intact uterus: Transdermal estradiol + micronized progesterone
Systemic symptoms, post-hysterectomy: Transdermal estradiol alone
Combination needs: Both vaginal and systemic therapy

Timing and Safety – Hormone therapy is safest and most beneficial when initiated within 10 years of menopause onset or before age 60 (the “window of opportunity”). We screen for contraindications (history of breast cancer, active liver disease, unexplained vaginal bleeding, history of blood clots) but recognize that for most women, the benefits of HRT far outweigh the risks—particularly when using transdermal estrogen and bioidentical progesterone.

We use FDA-approved, insurance-covered bioidentical hormones rather than expensive compounded formulations marketed by subscription services. This provides the same (or better) efficacy at a fraction of the cost, with the quality assurance and consistency that comes from FDA-regulated pharmaceuticals.

Menopause is a hormone deficiency state, and treating it with hormone replacement—just as we would treat hypothyroidism with thyroid hormone or diabetes with insulin—is rational, evidence-based medicine that can dramatically improve quality of life for symptomatic women.

Low Testosterone and TRT

Many primary care providers are uncomfortable managing testosterone replacement, often referring to endocrinology or urology even for straightforward cases of symptomatic hypogonadism. Others avoid the topic entirely, dismissing symptoms like fatigue, decreased libido, erectile dysfunction, mood changes, and loss of muscle mass as “just getting older.” Conversely, some “wellness clinics” prescribe testosterone liberally to men with normal levels, creating unnecessary medicalization and potential risks. We take an evidence-based, medically appropriate approach.

Our Prescribing Policy: Labs Required – We only prescribe testosterone replacement to men with documented low testosterone levels (below the normal reference range, typically <300 ng/dL on morning testing, confirmed on at least two separate occasions). We do not prescribe testosterone for “optimization” or to enhance athletic performance in men with normal levels. Testosterone is a controlled substance with real risks (cardiovascular effects, polycythemia, suppression of natural production, infertility), and we prescribe it only when medically indicated for true hypogonadism with corresponding symptoms.

We offer comprehensive testosterone replacement options that can be prescribed through our telemedicine platform and filled at your local pharmacy, allowing you to choose the delivery method that best fits your lifestyle, tolerance, and preferences:

Topical Gels – Daily application of testosterone gel to shoulders, upper arms, or abdomen. Provides steady testosterone levels throughout the day with once-daily dosing. Available brands include AndroGel, Testim, Fortesta, and Vogelxo. Advantages: convenient, non-invasive, mimics natural diurnal rhythm. Disadvantages: risk of transfer to partners/children through skin contact (requires careful handwashing and covering application site), daily adherence required, can be expensive, some insurance formularies have restrictions.

Topical Solutions – Similar to gels but liquid formulation. Axiron is applied to underarms like deodorant. Same advantages and transfer risks as gels.

Intramuscular Injections – Testosterone cypionate or enanthate injected into muscle (typically thigh or buttock) every 1-2 weeks. Self-administered at home after we provide detailed instructions and guidance. Advantages: highly effective, reliable absorption, low cost (generic available), no daily adherence required, no transfer risk. Disadvantages: requires comfort with self-injection, can cause fluctuations in testosterone levels (peak after injection, trough before next dose), some patients experience mood/energy swings with these fluctuations.

Subcutaneous Injections – Testosterone cypionate or enanthate can also be administered subcutaneously (smaller needle, into fat rather than muscle), often with more frequent dosing (twice weekly or every 3-5 days). Self-administered at home. Advantages: smaller needles are less intimidating, easier to self-administer, more stable levels with frequent dosing, reduced peak-trough fluctuations. Disadvantages: more frequent injections (though brief and easy once established in routine).

Nasal Gel – Natesto, applied inside the nostrils three times daily. Advantages: non-invasive, no transfer risk, doesn’t suppress fertility as much as other forms. Disadvantages: three-times-daily dosing is burdensome, nasal irritation possible, less commonly used.

Oral Testosterone – Testosterone undecanoate capsules (Jatenzo, Tlando) taken twice daily with food. Advantages: oral administration (no injections or topicals), no transfer risk, easy to use. Disadvantages: twice-daily dosing, must be taken with fat-containing food for absorption, expensive, requires monitoring of liver function and blood pressure (can increase blood pressure more than other formulations).

Our Recommendations – We help you select the best formulation based on your priorities:

Convenience and steady levels: Topical gels or solutions
Cost-effectiveness and reliability: Injectable testosterone cypionate/enanthate
Minimizing fluctuations: Frequent subcutaneous injections (twice weekly) or daily gels
Avoiding daily tasks: Intramuscular injections (weekly or biweekly)
No needles, no transfer risk: Oral testosterone (though more expensive)
Maintaining fertility: Nasal gel (Natesto) has less suppression of natural production

Self-Administration Support – For patients choosing injectable testosterone, we provide comprehensive instructions, demonstration videos, and ongoing support to ensure you’re comfortable with self-administration. Most patients find injections straightforward after the first few attempts, and many prefer them for the convenience of weekly or twice-weekly dosing rather than daily topical application.

Monitoring – Regardless of formulation, we monitor testosterone levels, hematocrit (to detect polycythemia), PSA (prostate specific antigen), liver function (particularly with oral formulations), lipids, and symptom improvement. We adjust dosing to achieve testosterone levels in the mid-normal range (not supraphysiologic) and reassess regularly to ensure benefits outweigh risks.

We provide medically appropriate testosterone replacement for men with documented hypogonadism—not indiscriminate prescribing for “anti-aging” or performance enhancement. Our goal is symptom resolution and restoration of normal physiologic testosterone levels in men who are truly deficient.

Birth Control

At Dawnbreaker Health, we’re happy to manage most forms of non-procedural birth control through our telemedicine platform. Many women struggle to access contraception due to difficulty scheduling in-person appointments, lack of local providers, or discomfort discussing reproductive health face-to-face. We provide comprehensive contraceptive counseling and prescriptions that can be filled at your local pharmacy, ensuring convenient, ongoing access to the birth control method that best fits your needs and lifestyle.

Combined Oral Contraceptives (COCs) – Pills containing both estrogen and progestin, taken daily. Available in multiple formulations with varying hormone types and dosing schedules (21-day, 28-day, extended cycle). We help select the formulation best suited to your needs, whether that’s minimizing periods, managing acne, treating PMDD, or optimizing side effect profile. Highly effective when taken consistently.

Progestin-Only Pills (POPs) – Pills containing only progestin, without estrogen. Important distinction between generations:

Traditional POPs (norethindrone/Camila, Nor-QD, etc.) – Require very strict timing with only a 3-hour window for taking the pill each day, making them less forgiving of missed doses. Often used for breastfeeding women or those with contraindications to estrogen.
Newer POP (drospirenone/Slynd) – Offers a 24-hour timing window just like combined pills, making it much more user-friendly while maintaining the estrogen-free profile. Excellent option for women who can’t or prefer not to take estrogen but want the convenience of a forgiving timing window.

Contraceptive Patch (Xulane) – A weekly transdermal patch applied to skin (abdomen, buttock, upper arm, or back), changed once weekly for three weeks, followed by one patch-free week. Delivers combined hormones (estrogen + progestin) through the skin. Advantages: don’t have to remember daily pills, steady hormone levels. Disadvantages: visible, may cause skin irritation, can occasionally fall off.

Vaginal Ring – Flexible ring inserted into the vagina that releases combined hormones continuously:

NuvaRing – Inserted for 3 weeks, removed for 1 week, then replaced with a new ring. Prescription provides monthly rings.
Annovera – A reusable ring used for an entire year (inserted for 3 weeks, removed for 1 week, rinsed and reinserted). Single prescription covers 13 cycles. Advantages: monthly or yearly rather than daily/weekly attention, self-inserted, not felt during use, steady hormone delivery. Some women prefer not having to remember daily pills.

Injectable Contraception (Depo-Provera) – Progestin-only injection given every 12-13 weeks (every 3 months). We can prescribe this for administration at your local pharmacy. Advantages: only need to think about contraception 4 times per year, no estrogen, often causes amenorrhea (no periods) which many find desirable. Disadvantages: can cause weight gain, may delay return to fertility after discontinuation (average 10 months), requires scheduled injections, potential bone density concerns with very long-term use.

Emergency Contraception – We prescribe both forms:

Levonorgestrel (Plan B) – Available over-the-counter but we can prescribe for insurance coverage or advance provision. Effective up to 72 hours after unprotected intercourse, though efficacy decreases over time.
Ulipristal (ella) – Prescription-only emergency contraception that’s more effective than Plan B, especially in the 72-120 hour window after intercourse. Possibly more effective in overweight women compared to levonorgestrel.

Our Approach – We help you select contraception based on multiple factors:

Frequency of attention required: Daily pills vs. weekly patch vs. monthly ring vs. quarterly injection
Estrogen tolerance: Combined vs. progestin-only methods
Cycle control preferences: Regular withdrawal bleeds vs. extended cycles vs. amenorrhea
Medical contraindications: History of blood clots, migraines with aura, cardiovascular disease, etc.
Additional benefits desired: Acne improvement, PMDD treatment, lighter/fewer periods
Cost and insurance coverage: Generic vs. brand options

We also provide guidance on starting new methods, managing side effects, switching between methods, and what to do with missed doses. Our telemedicine model makes it easy to check in if you’re experiencing issues, need to adjust formulations, or want to discuss switching methods—without the hassle of scheduling in-person appointments for straightforward contraceptive management.

We do not provide procedural contraception (IUDs, Nexplanon implants) as these require in-person insertion, but we’re happy to refer you to local providers for these highly effective long-acting options if that’s your preference.

PreP, Doxy Pep, and HSV Treatment

Many primary care providers are uncomfortable prescribing pre-exposure prophylaxis (PrEP) for HIV prevention, often referring to infectious disease specialists or HIV clinics even though PrEP management is well within primary care scope. Similarly, proactive STI prevention strategies and chronic viral suppression are often overlooked. We provide comprehensive sexual health management including HIV prevention and evidence-based STI risk reduction.

HIV Pre-Exposure Prophylaxis (PrEP):

Truvada (tenofovir disoproxil fumarate/emtricitabine) – The original PrEP medication, proven highly effective (>99%) at preventing HIV transmission when taken consistently. Advantages: extensive track record, generic available (lower cost), well-studied. Disadvantages: can cause kidney toxicity (usually mild, reversible, but requires monitoring), can cause bone density loss (usually modest), gastrointestinal side effects in some users during initial weeks.

Descovy (tenofovir alafenamide/emtricitabine) – Newer formulation of PrEP using a different form of tenofovir. From a patient perspective, Descovy offers significantly reduced kidney and bone toxicity compared to Truvada—making it safer for long-term use, particularly for patients with pre-existing kidney concerns, older adults, or those worried about bone health. It also tends to have fewer GI side effects. Disadvantages: more expensive (no generic yet), not recommended for receptive vaginal sex PrEP (though this restriction is controversial and evidence-based support is limited). For most patients, particularly those planning long-term PrEP use or with any kidney/bone concerns, Descovy is the preferred option due to its superior safety profile.

We provide PrEP prescriptions, required baseline and monitoring labs (HIV test, kidney function, STI screening), and ongoing follow-up every 3 months as recommended by guidelines.

Doxycycline Post-Exposure Prophylaxis (Doxy-PEP):

Recent breakthrough research has shown that taking doxycycline 200mg within 24-72 hours after condomless sex significantly reduces the risk of bacterial STIs—particularly chlamydia (by ~70%), syphilis (by ~70%), and to a lesser extent gonorrhea (~50% reduction, with variation by geographic resistance patterns). This is analogous to emergency contraception but for bacterial STI prevention. Doxy-PEP is particularly valuable for individuals at high risk of STI acquisition (MSM, people with multiple partners, those with recent STI history). We prescribe doxycycline with instructions for post-exposure dosing for appropriate candidates. This represents a major advance in STI prevention and is increasingly recommended by sexual health guidelines.

Valacyclovir for HSV-2 Suppression:

For individuals with recurrent genital herpes (HSV-2), daily suppressive valacyclovir (500mg daily) provides multiple benefits: reduces outbreak frequency by 70-80%, decreases viral shedding, significantly reduces transmission risk to partners (~50% reduction), and improves quality of life. For HSV-2 positive individuals in serodiscordant relationships (where partner is HSV-2 negative), daily suppressive therapy is an important prevention strategy to protect partners. We prescribe valacyclovir for both suppressive therapy and episodic treatment of outbreaks.

Comprehensive Sexual Health Approach:

We combine these prevention strategies as appropriate:

High-risk individuals: PrEP (Descovy or Truvada) + Doxy-PEP + regular STI screening
HSV-2 positive individuals: Daily valacyclovir suppression, especially in serodiscordant relationships
Partners of people living with HIV: PrEP for HIV-negative partner

Our goal is to provide judgment-free, comprehensive sexual health care that empowers you to protect yourself and your partners through evidence-based prevention strategies—not just treating infections after they occur.

Psoriasis

Many primary care providers limit psoriasis treatment to topical corticosteroids—prescribing increasingly potent steroids as milder ones fail, or simply referring to dermatology when steroids prove insufficient. This leaves patients trapped in a cycle of temporary improvement followed by rebound flares, dealing with skin atrophy from chronic steroid use, or waiting months for dermatology appointments. For patients with an existing psoriasis diagnosis seeking treatment beyond topical steroids, we offer a comprehensive range of advanced systemic and topical therapies.

Oral Systemic Therapies:

Otezla (apremilast) – An oral PDE4 inhibitor taken twice daily. Works by reducing inflammatory signaling within immune cells. Advantages: no injection required, no need for lab monitoring (unlike older systemic agents like methotrexate), can be used in patients with contraindications to biologics. Moderate efficacy—improves plaques and reduces itch in many patients, though typically less dramatic than biologics. Main side effect is GI upset (nausea, diarrhea) during the first few weeks, which usually resolves with continued use and dose titration.

Sotyktu (deucravacitinib) – A newer oral TYK2 inhibitor (a specific JAK family member) taken once daily. Represents a significant advance over Otezla with superior efficacy approaching that of biologics while maintaining the convenience of an oral medication. Clinical trials showed clearance rates comparable to some injectable biologics. Better tolerated than Otezla with fewer GI side effects. Requires some monitoring but less intensive than traditional oral immunosuppressants. For patients who want high efficacy without injections, Sotyktu is often the best option.

Advanced Topical Therapies:

Roflumilast cream (Zoryve) – A topical PDE4 inhibitor that we’ve mentioned for other inflammatory skin conditions. Highly effective for plaque psoriasis, including inverse psoriasis and facial involvement where potent steroids are problematic. Provides steroid-sparing therapy that can be used long-term without causing skin atrophy. Often used as adjunctive therapy alongside systemic treatments or as monotherapy for limited disease.

Biologic Injectable Therapy:

Skyrizi (risankizumab) – An IL-23 inhibitor given by subcutaneous injection every 12 weeks after loading doses. One of the most effective psoriasis treatments available, with the majority of patients achieving 90-100% clearance. The 12-week dosing interval makes it the most convenient biologic available—far less burdensome than biologics requiring weekly, biweekly, or monthly injections. Generally well-tolerated with minimal side effects. Requires screening for tuberculosis and hepatitis before initiation. For patients with moderate-to-severe psoriasis who want maximum efficacy and convenience, Skyrizi often represents the optimal choice.

Our Approach:

We tailor therapy based on disease severity, distribution, patient preferences, and previous treatment responses:

Mild-to-moderate localized disease: Advanced topicals (Vtama, Zoryve)
Moderate disease, prefer oral: Sotyktu or Otezla
Moderate-to-severe or widespread disease: Skyrizi
Combination approach: Biologic or oral systemic + advanced topicals for resistant areas

We handle prior authorizations, insurance navigation, and enrollment in manufacturer savings programs to maximize access to these newer medications. We also provide ongoing monitoring and dose adjustments as needed.

For patients with psoriatic arthritis in addition to skin disease, these same medications often treat both conditions simultaneously, and we coordinate care accordingly.

Our goal is to achieve substantial clearance or complete remission using modern, targeted therapies—not simply managing psoriasis with an endless cycle of topical steroids that provide temporary relief while causing long-term skin damage.

Chronic Constipation and IBS-C

Many patients with chronic constipation, including those with irritable bowel syndrome with constipation (IBS-C), have not been offered treatments beyond over-the-counter laxatives like Miralax (polyethylene glycol) and Metamucil (fiber supplements). While these can help mild cases, they often provide inadequate relief for patients with more severe or treatment-resistant constipation. We prescribe several powerful prescription therapies that can be transformative for patients who’ve struggled for years with inadequate bowel function.

Motegrity (prucalopride) – A selective 5-HT4 receptor agonist that enhances colonic motility by stimulating the enteric nervous system, promoting coordinated propulsive contractions throughout the colon. Unlike older prokinetics (like cisapride, which was withdrawn due to cardiac risks), prucalopride is highly selective and safe for long-term use. Taken once daily, it’s particularly effective for chronic constipation, with clinical trials showing that the majority of patients achieve significant improvement in bowel frequency and symptom relief.

Interestingly, prucalopride may also have mental health benefits—patients often report improved mood and well-being beyond what would be expected from constipation relief alone. This mirrors research on usmarapride (a related 5-HT4 agonist) being investigated specifically for depression, as 5-HT4 receptors play a role in mood regulation and neuroplasticity. For patients with both constipation and comorbid depression or anxiety, prucalopride may offer dual benefits.

Secretagogues – A class of medications that work by increasing intestinal fluid secretion, softening stool and stimulating bowel movements through increased luminal fluid volume and pressure. Rather than simply drawing water into the colon like osmotic laxatives, secretagogues actively stimulate chloride and fluid secretion by intestinal cells. Available agents include:

Linaclotide (Linzess) – A guanylate cyclase-C agonist that increases intestinal fluid secretion and also has analgesic effects on visceral pain pathways, making it particularly valuable for IBS-C patients with abdominal pain. Taken once daily on an empty stomach.
Plecanatide (Trulance) – Another guanylate cyclase-C agonist, similar mechanism to linaclotide. Some patients find it better tolerated or more effective than linaclotide. Also taken once daily on an empty stomach.
Lubiprostone (Amitiza) – Works by activating chloride channels to increase intestinal fluid secretion. Taken twice daily with food. Effective for chronic constipation and IBS-C. Some patients experience nausea, which can be minimized by taking with food and water.

These secretagogues are highly effective for both increasing bowel frequency and reducing straining, bloating, and abdominal discomfort associated with constipation.

Opioid-Induced Constipation (OIC) – PAMORAs:

For patients whose constipation is caused or worsened by opioid pain medications, we prescribe peripherally acting mu-opioid receptor antagonists (PAMORAs)—essentially gut-selective forms of naloxone (Narcan) that block opioid effects on the GI tract without crossing the blood-brain barrier or reversing pain relief. These medications are extremely targeted, reversing opioid-induced slowing of gut motility while preserving the analgesic benefits of opioids. Available agents include:

Methylnaltrexone (Relistor) – Subcutaneous injection (usually once daily or every other day) or oral tablets. Often induces bowel movement within hours.
Naloxegol (Movantik) – Oral, once-daily. Generally well-tolerated with rapid onset.
Naldemedine (Symproic) – Oral, once-daily. Newer agent with favorable efficacy and tolerability profile.

For patients on chronic opioid therapy who struggle with severe constipation despite laxatives, PAMORAs can be life-changing—restoring normal bowel function without compromising pain control.

Tenapanor (Ibsrela) – A very new option that works through a novel mechanism: inhibiting the sodium/hydrogen exchanger 3 (NHE3) in the intestine. By blocking sodium absorption in the gut, tenapanor reduces water absorption (keeping stool soft) and decreases visceral hypersensitivity (reducing abdominal pain). Approved specifically for IBS-C, it addresses both constipation and the abdominal pain component. Taken twice daily. Represents an innovative approach distinct from other available therapies, and can be particularly useful for patients who haven’t responded adequately to secretagogues or prokinetics.

Our Approach:

We select therapy based on constipation etiology and symptom profile:

Chronic idiopathic constipation: Motegrity (prucalopride) often first-line for its efficacy and once-daily dosing
IBS-C with significant abdominal pain: Secretagogues (linaclotide, plecanatide) or tenapanor for their pain-modulating effects
Opioid-induced constipation: PAMORAs (methylnaltrexone, naloxegol, naldemedine)
Treatment-resistant cases: Combination therapy or trial of multiple agents sequentially

We also address contributing factors: fiber intake, hydration, exercise, identifying medications that worsen constipation, and screening for underlying conditions (hypothyroidism, pelvic floor dysfunction).

Our goal is to achieve regular, comfortable bowel movements using targeted prescription therapies that address the underlying pathophysiology—not simply telling patients to “drink more water” and take Miralax indefinitely when clearly inadequate.

COPD (Chronic Obstructive Pulmonary Disease)

Many primary care providers manage COPD with standard inhaler combinations—typically prescribing separate inhalers containing an inhaled corticosteroid (ICS), a long-acting muscarinic antagonist/anticholinergic (LAMA), and a long-acting beta agonist (LABA). This multi-inhaler approach can be confusing, lead to poor adherence, increase costs, and make it difficult to ensure patients are using proper inhaler technique across multiple devices. Moreover, many COPD patients have never been offered roflumilast, a highly effective oral therapy that can significantly improve symptoms and reduce exacerbations—particularly for patients with chronic bronchitis phenotype.

Triple Therapy Single Inhaler:

Rather than juggling multiple inhalers, we prescribe single-device triple therapy inhalers that contain all three medication classes (ICS + LAMA + LABA) in one convenient device. Available options include:

Trelegy Ellipta – Once-daily dry powder inhaler containing fluticasone (ICS), umeclidinium (LAMA), and vilanterol (LABA)
Breztri Aerosphere – Twice-daily metered dose inhaler containing budesonide (ICS), glycopyrrolate (LAMA), and formoterol (LABA)

Advantages: Simplified regimen (one device instead of 2-3), improved adherence, ensures balanced delivery of all three medication classes, often better insurance coverage than multiple separate inhalers, single copay. For patients with moderate-to-severe COPD requiring triple therapy, single-device options represent a major improvement in convenience and reliability.

Roflumilast – An Underutilized Add-On Therapy:

Oral roflumilast (Daliresp) – A PDE4 inhibitor taken once daily (500mcg) that reduces airway inflammation through a completely different mechanism than inhaled therapies. Particularly effective for COPD patients with chronic bronchitis phenotype (chronic cough and sputum production) and frequent exacerbations. Clinical trials show roflumilast significantly reduces exacerbation frequency and improves lung function when added to standard inhaler therapy.

Many COPD patients have never been offered roflumilast despite meeting criteria for it, often because PCPs are unfamiliar with it or concerned about side effects. While GI side effects (diarrhea, nausea, weight loss) occur in some patients during the first few weeks, they typically resolve with continued use, and the benefits—particularly in reducing hospitalizations—can be substantial.

Our Approach:

Moderate-to-severe COPD requiring maintenance therapy: Single-device triple therapy inhaler (Trelegy or Breztri)
Chronic bronchitis with frequent exacerbations: Add oral roflumilast to maintenance therapy
Simplified regimen: Consolidate multiple inhalers into single-device options whenever possible

We also ensure patients have rescue inhalers (albuterol), provide smoking cessation support, recommend pulmonary rehabilitation when appropriate, ensure up-to-date vaccinations (pneumonia, flu, COVID, RSV), and monitor for exacerbations requiring treatment escalation.

Our goal is to maximize symptom control, reduce exacerbations and hospitalizations, and simplify medication regimens using the most effective and convenient therapies available—including underutilized options like roflumilast that many COPD patients have never been offered despite meeting clinical criteria.

Smoking Cessation

Many primary care providers offer minimal support for smoking cessation beyond advising patients to quit and perhaps suggesting nicotine replacement therapy (patches, gum, lozenges). While nicotine replacement can be helpful, prescription medications significantly increase quit rates—yet are often not offered or discussed. We provide comprehensive smoking cessation support including the two most effective prescription medications available.

Varenicline (Chantix) – A partial agonist at nicotinic acetylcholine receptors that works through a dual mechanism: it provides enough stimulation to reduce cravings and withdrawal symptoms, while simultaneously blocking nicotine from cigarettes from fully activating these receptors (reducing the rewarding effects of smoking). Clinical trials show varenicline is the most effective single medication for smoking cessation, approximately doubling quit rates compared to placebo. Typically started 1-2 weeks before the target quit date and continued for 12-24 weeks.

Varenicline was temporarily removed from the market due to contamination issues but has returned with improved manufacturing. Previous concerns about psychiatric side effects (depression, suicidal ideation) have been largely debunked—more recent studies show these risks were overstated, and varenicline is safe for most patients including those with psychiatric conditions. Common side effects include nausea (usually mild and temporary) and vivid dreams.

Bupropion (Wellbutrin, Zyban) – A norepinephrine-dopamine reuptake inhibitor and nicotine receptor modulator that reduces nicotine cravings and withdrawal symptoms while also addressing the mood and concentration difficulties that often accompany smoking cessation. Approximately 1.5-2x more effective than placebo for smoking cessation. Started 1-2 weeks before quit date and continued for 7-12 weeks or longer.

Particularly valuable for patients with comorbid depression or who are concerned about post-cessation weight gain (bupropion often prevents or minimizes weight gain associated with quitting). Also useful for patients who’ve experienced side effects from varenicline or prefer not to take it. Contraindicated in patients with seizure disorders or eating disorders due to lowered seizure threshold.

Combination Therapy – For highly dependent smokers or those who’ve failed single-medication approaches, we can combine bupropion with nicotine replacement therapy, or use varenicline with nicotine replacement. These combinations can further increase quit rates beyond single-medication approaches.

Fatty Liver (NAFLD/NASH/MASLD)

Many primary care providers, when diagnosing fatty liver disease (also called NAFLD, NASH, or more recently MASLD—metabolic dysfunction-associated steatotic liver disease), tell patients there’s nothing to be done except monitor liver enzymes, lose weight through diet and exercise, and cut back on alcohol. While lifestyle modification remains foundational, this approach ignores recent major advances in medical treatment that can actually reverse liver damage and prevent progression to cirrhosis.

GLP-1 Receptor Agonists – FDA-Approved Treatment:

GLP-1 medications have shown remarkable efficacy for fatty liver disease, reducing liver fat content, improving inflammation, and reversing fibrosis (scarring) in clinical trials. Semaglutide (Wegovy) is now FDA-approved specifically for the treatment of MASH making it a legitimate medical therapy beyond just weight loss.

This FDA approval is strategically valuable for patients whose insurance denies coverage for GLP-1s when prescribed “just for weight loss” but may cover them for an approved metabolic indication like NASH/MASLD. If you have fatty liver disease documented on imaging or biopsy, semaglutide prescribed for this FDA-approved indication may be covered even if your insurance doesn’t cover weight loss medications though coverage varies by plan. The weight loss that occurs is both therapeutic for the liver and beneficial for overall metabolic health—addressing the root cause of metabolic dysfunction driving the liver disease.

Tirzepatide (Zepbound) has also shown impressive results in fatty liver trials, though it’s not yet FDA-approved specifically for this indication. However, its superior weight loss efficacy compared to semaglutide makes it an excellent option when accessible.

Rezdiffra (resmetirom) – Targeted Liver Therapy:

Rezdiffra is a thyroid hormone receptor-beta (THR-β) selective agonist—the first medication specifically developed and FDA-approved for treating NASH with moderate-to-advanced liver fibrosis (scarring). It works by activating thyroid hormone receptors selectively in the liver, enhancing fat metabolism and reducing liver fat accumulation without affecting thyroid function systemically.

Rezdiffra is approved for patients with biopsy-confirmed NASH and stage 2-3 fibrosis (moderate-to-advanced scarring). Clinical trials demonstrated significant reductions in liver fat, resolution of NASH, and importantly, improvement in liver fibrosis—actually reversing scarring rather than just preventing progression. As a beneficial side effect, Rezdiffra also significantly lowers LDL cholesterol (typically 10-15% reduction), providing cardiovascular benefits alongside liver improvement.

Our approach: We can refer you for FibroScan (a non-invasive ultrasound-based test that measures liver stiffness/fibrosis and fat content) to determine your fibrosis stage and quantify liver fat. Based on FibroScan results, liver biopsy findings (if available), and clinical presentation, we can prescribe Rezdiffra if indicated. This allows for objective, non-invasive monitoring of treatment response over time.

Comprehensive Management Strategy:

Early/mild fatty liver: GLP-1 therapy (semaglutide or tirzepatide) for weight loss and metabolic improvement
Moderate-to-advanced fibrosis (F2-F3): Rezdiffra if FibroScan or biopsy confirms eligibility
Combination approach: GLP-1 + Rezdiffra for patients with significant fibrosis who also need substantial weight loss
Metabolic optimization: Address diabetes with GLP-1/SGLT2i, optimize cholesterol (statins don’t worsen fatty liver despite outdated concerns), manage hypertension with telmisartan

We also refer for FibroScan monitoring to track treatment response, assess for progression, and guide therapy adjustments. For patients with advanced cirrhosis (F4), we refer to hepatology for specialized management.

Toenail Fungus (Onychomycosis)

Many primary care providers either don’t treat onychomycosis at all (dismissing it as cosmetic) or limit treatment to traditional oral antifungals. More problematically, patients with liver disease, those on multiple medications with potential drug interactions, or those with other contraindications are often told they’re “not candidates for treatment” and must simply live with unsightly, thickened, discolored nails. We offer both traditional oral therapies and advanced topical treatments that make effective treatment accessible even for patients who can’t take systemic medications.

Traditional Oral Treatments:

Terbinafine (Lamisil) – The most effective oral treatment for toenail fungus, taken daily for 12 weeks (toenails) or 6 weeks (fingernails). Cure rates of 60-70% for toenail onychomycosis. Requires baseline liver function testing and monitoring due to rare but potential hepatotoxicity. Most effective option when oral therapy is appropriate.

Itraconazole (Sporanox) – Alternative oral antifungal, can be dosed continuously or as pulse therapy (one week per month). Less commonly used than terbinafine due to more drug interactions and cardiac concerns (can prolong QT interval, contraindicated with certain heart conditions). Also requires liver monitoring.

Fluconazole – Less commonly used for onychomycosis but can be prescribed off-label. Generally less effective than terbinafine or itraconazole but has fewer drug interactions in some cases.

The Problem with Oral-Only Approaches: Many patients can’t take oral antifungals due to:

Pre-existing liver disease or abnormal liver enzymes
Drug interactions (oral antifungals interact with statins, blood thinners, immunosuppressants, many cardiac medications)
Concerns about side effects or monitoring requirements
Previous adverse reactions to oral antifungals

These patients are frequently told “nothing can be done” or that treatment isn’t worth the risk. This is no longer true.

Advanced Topical Treatments:

Newer-generation topical antifungals have dramatically improved efficacy compared to older options like ciclopirox (Penlac), which had cure rates under 10%. Modern topical treatments can achieve cure rates of 15-20% as monotherapy and significantly higher when combined with mechanical debridement or used in patients with less severe disease. Critically, topical treatments have no systemic absorption, no liver toxicity, no drug interactions, and no monitoring requirements—making them ideal for patients who can’t tolerate oral therapy.

Efinaconazole (Jublia) – A topical solution applied daily to affected nails for 48 weeks. Superior nail penetration compared to older topicals due to its unique formulation. Clinical trials showed approximately 15-18% complete cure rates (clear nail + negative fungal culture) and much higher rates of significant clinical improvement. No systemic side effects, well-tolerated. Represents the most effective topical monotherapy available.

Tavaborole (Kerydin) – A topical solution with a novel mechanism (inhibits fungal protein synthesis through boron-based chemistry). Applied daily for 48 weeks. Similar efficacy to efinaconazole with complete cure rates around 6-9% and mycological cure (negative culture) rates around 30-35%. Excellent safety profile with minimal adverse effects.

Combination Approaches for Enhanced Efficacy:

For patients who can tolerate oral therapy, combining terbinafine with topical treatment can increase cure rates significantly (approaching 80%+). For those who can’t take oral medications, combining topical antifungals with:

Mechanical debridement (filing/trimming affected nail)
Urea-based preparations to soften and remove diseased nail material
Laser therapy (if accessible)

…can substantially improve outcomes beyond topical medication alone.

Our Approach:

No contraindications to oral therapy + moderate-severe disease: Terbinafine (most effective)
Liver disease, drug interactions, or patient preference against oral meds: Efinaconazole or tavaborole topical therapy
Mild disease or prophylaxis after oral therapy: Topical antifungals
Maximum efficacy in appropriate candidates: Combination oral + topical therapy

We also provide guidance on nail care, footwear modifications, and prevention strategies to reduce recurrence risk.

The key message: If you’ve been told you’re not a candidate for onychomycosis treatment due to liver concerns, medication interactions, or other health issues, you now have effective topical options. You don’t have to live with fungal nails simply because oral medications aren’t safe for you. Modern topical therapies provide a viable, safe alternative that can significantly improve nail appearance and eliminate infection without any systemic risks.

Hyperhidrosis (Excessive Sweating)

Many primary care providers are unfamiliar with medical management of hyperhidrosis beyond recommending clinical-strength antiperspirants. Patients struggling with excessive, embarrassing sweating that interferes with work, social situations, and quality of life are often told “that’s just how you sweat” or immediately referred to dermatology for Botox injections or other procedures. We offer comprehensive medical management of hyperhidrosis using both traditional systemic therapies and newer topical treatments.

Traditional Systemic Treatments:

Beta blockers (propranolol, atenolol) – While primarily used for blood pressure and anxiety, beta blockers can reduce sweating triggered by stress, anxiety, or sympathetic nervous system activation. Particularly effective for situational sweating (performance anxiety, social situations) or sweating associated with physical symptoms of anxiety. Works by blocking the sympathetic response that triggers sweat gland activation. Can be taken daily or as-needed before anxiety-provoking situations. Less effective for primary hyperhidrosis not related to anxiety/stress.

Glycopyrrolate (Robinul) – An oral anticholinergic medication that blocks acetylcholine receptors throughout the body, including sweat glands, reducing sweat production systemically. Taken once or twice daily, it can significantly reduce sweating across all body areas. Particularly valuable for generalized hyperhidrosis or cranial/facial sweating that’s difficult to treat with topicals.

Disadvantages: systemic anticholinergic side effects including dry mouth (very common), dry eyes, constipation, urinary retention, and potential cognitive effects with long-term use (particularly concerning in older adults). Due to these side effects, many patients can’t tolerate effective doses, or prefer to avoid systemic anticholinergics entirely.

Advanced Topical Treatment:

Sofpironium bromide (Sofdra) – A novel topical anticholinergic specifically developed for primary axillary hyperhidrosis (excessive underarm sweating). Applied once daily to underarms, Sofdra provides targeted sweat reduction with reduced systemic anticholinergic effects. Unlike glycopyrrolate which affects the entire body, Sofdra is a quaternary ammonium compound that doesn’t has limited absorption through intact skin, keeping its anticholinergic action mainly localized to the application site.

Clinical trials demonstrated significant reduction in sweat production and meaningful improvement in quality of life measures. Advantages: less dry mouth, less cognitive effects, less systemic side effects—just targeted sweat reduction where applied. Well-tolerated with minimal adverse effects (occasional mild skin irritation at application site). Represents a major advancement for patients who need more than aluminum-based antiperspirants but want to avoid systemic medications or invasive procedures.

Our Approach:

Stress/anxiety-related sweating: Beta blockers (propranolol), particularly for situational use
Primary axillary hyperhidrosis (underarm sweating): Sofdra topical as first-line prescription therapy
Generalized hyperhidrosis or facial/cranial sweating: Oral glycopyrrolate (if patient tolerates anticholinergic effects)
Refractory cases: Combination therapy or referral for Botox injections, iontophoresis, or other procedural interventions

We also provide guidance on lifestyle modifications, fabric choices, and adjunctive measures like clinical-strength antiperspirants (aluminum chloride preparations) that can be used alongside prescription medications.

Hyperhidrosis significantly impacts confidence, career opportunities, and social engagement. Effective medical treatments are available, and you don’t have to accept excessive sweating as something you just have to live with. Whether through systemic medications for widespread sweating or targeted topical therapy for localized hyperhidrosis, we can help you achieve meaningful symptom control.

Chronic Diarrhea and IBS-D

Many primary care providers treat IBS-D with basic dietary advice (avoid triggers, try low-FODMAP diet), over-the-counter loperamide (Imodium), and perhaps a trial of fiber supplements or probiotics. When these prove inadequate, patients are often left without further options or referred to gastroenterology with long wait times. For patients with confirmed IBS-D after appropriate workup to rule out other causes of chronic diarrhea, we offer both traditional therapies and a highly effective newer medication that many PCPs are unfamiliar with.

Appropriate Evaluation First:

Before diagnosing IBS-D and initiating treatment, we ensure appropriate rule-outs for other causes of chronic diarrhea including:

Celiac disease (tissue transglutaminase antibodies)
Inflammatory bowel disease (fecal calprotectin, colonoscopy if indicated)
Microscopic colitis (particularly in older adults)
Bile acid malabsorption
Infections (particularly in those with recent antibiotic use or travel)
Thyroid dysfunction
Medication-induced diarrhea

Once these are excluded and IBS-D is confirmed, we move to targeted treatment.

Traditional Treatments:

Loperamide (Imodium) – Over-the-counter opioid receptor agonist that slows intestinal motility. Effective for as-needed symptom control but doesn’t address abdominal pain or underlying pathophysiology. Can cause rebound constipation with overuse.

Cholestyramine – Bile acid sequestrant that can help if there’s a component of bile acid malabsorption contributing to diarrhea. Taken before meals. Can cause bloating and constipation.

Tricyclic antidepressants (amitriptyline, nortriptyline) – At low doses, can slow gut motility and reduce visceral pain sensitivity. Takes several weeks to work. Anticholinergic side effects limit tolerability for some patients.

Rifaximin (Xifaxan) – Non-absorbed antibiotic used for IBS-D, particularly when there’s suspected small intestinal bacterial overgrowth (SIBO). Typically given as a 2-week course, can provide lasting benefit for months. Expensive and not always covered by insurance.

Advanced Treatment:

Viberzi (eluxadoline) – A first-in-class medication that works as a mixed opioid receptor modulator (mu and kappa opioid receptor agonist, delta opioid receptor antagonist). This unique combination provides the gut-slowing benefits of opioid activity while minimizing constipation and avoiding the abuse potential of traditional opioids. Taken twice daily with food.

Eluxadoline works by:

Reducing excessive intestinal motility and cramping
Decreasing intestinal secretions
Reducing visceral pain sensitivity
Maintaining more normal gut function rather than simply causing constipation

Many patients find Viberzi remarkably effective where other treatments have failed—experiencing significant reduction in diarrhea frequency, urgency, and abdominal pain with improved quality of life. Unlike loperamide which just slows everything down, Viberzi addresses multiple aspects of IBS-D pathophysiology simultaneously. For patients who’ve struggled for years with unpredictable bowel urgency that limits their ability to work, travel, or engage socially, Viberzi can be life-changing.

Important Contraindications: Viberzi is contraindicated in patients:

Without a gallbladder (significantly increased risk of pancreatitis and sphincter of Oddi spasm)
With history of pancreatitis, biliary duct obstruction, or sphincter of Oddi dysfunction
With history of alcohol abuse or addiction
With severe liver impairment or severe constipation

We carefully screen for these contraindications before prescribing. For appropriate candidates without these risk factors, Viberzi has an excellent safety profile.

IBS-D can be profoundly disabling, causing patients to plan their entire lives around bathroom access and limiting career, travel, and social opportunities. With appropriate diagnosis and targeted treatment—particularly newer agents like Viberzi that many PCPs don’t prescribe—significant symptom control is achievable for most patients.

We’re willing to hear you out.

We believe in collaborative medicine. If you’ve researched treatment options, we want to hear about them. We’ll thoughtfully consider patient-suggested medications and work with you to find solutions that align with both evidence and your preferences, as long as they don’t involve controlled substances or expose our practice to undue risk.

Discounted Medications

Many Telehealth Clinics entice patients by offering low prices on the initial visit only then to force patients into using their in house or partnered pharmacy. These pharmacies can charge up to ten times a reasonable price even on older generic medications. Furthermore many traditional pharmacies still charge high prices on generic medications. Medications conditions seen as “aesthetic” such as obesity, hair loss, and sexual health can be particularly overpriced

At Dawnbreaker Health we do not charge for prescriptions and work with Costplus drugs to get you prices up to 90% lower on common generic medications. Like in person clinics. We can still call in prescriptions to the pharmacy of your choice too and help you get set up with discount programs such as GoodRX or medication specific discounts.

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Wellness & Longevity

At Dawnbreaker health, we treat conditions that profoundly affect wellbeing but are frequently dismissed: menopause, weight management, low testosterone, sexual health concerns, and hair loss. We approach these the same way we approach any chronic condition: with careful evaluation, evidence-based options, and clear follow-through. We offer modern treatments that may not be routinely offered in a typical primary care visit. We also keep costs straightforward. Unlike many competitors, we don’t make you to buy meds from us. We prescribe to your normal pharmacy or to cashed based alternatives for as low as $2-3 a month.

Pattern hair loss: oral minoxidil, plus finasteride, dutasteride, or spironolactone when appropriate (some options off-label)
Weight management: (if indicated) GLP-1 medications, “stackable” conventional options, and optimization of your current regimen
Hormone therapy: bioidentical estrogen and progesterone therapy for menopause symptoms, and testosterone therapy if indicated
Sexual health: Vyleesi, Addyi, buspirone, Levitra, Stendra, Viagra, Cialis, and others based on your goals and medical history
No Subscriptions, Hidden Fees, or Pharmacy Restrictions

What do you treat

Same day, after hours and weekend appointments available

Core Focus

At Dawnbreaker Health, our focus is providing excellent quality care for established conditions such as diabetes and chronic kidney disease, as well as symptom-focused concerns like acne and anxiety. We also offer preventative care, and limited urgent care for specific, well-defined acute issues that are appropriate for telemedicine.

We do not evaluate or treat musculoskeletal or orthopedic problems. We generally do not prescribe controlled substances, except for select sleep medications and testosterone when medically indicated and permitted by law.

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Urgent Care

Acute exacerbations: mild to moderate flare-ups of chronic conditions we treat (or would otherwise treat)
Upper respiratory symptoms: stable cough and/or sinus symptoms lasting more than 5 days
Urinary issues: UTI symptoms, yeast infections, and bacterial vaginosis
Sexual health: emergency contraception; symptoms suggestive of STIs; same-day evaluation for Viagra/Cialis prescriptions (when appropriate)
Confirmed infections: strep throat, COVID-19, or influenza with a positive test result
Not for: new or unexplained acute symptoms: including injuries chest pain, abdominal symptoms/pain, other unexplained pain, or fever

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Preventative Care

Vaccines: recommendations, counseling, and prescriptions (when appropriate)
Colon cancer screening: at-home Cologuard or colonoscopy referral
Screening labs: complete blood count (CBC), metabolic panel (liver & kidney), cholesterol/lipids, thyroid, A1C, PSA, vitamin D, STI screening, and other labs as indicated
Women’s health: referrals for DEXA bone density scans and mammograms; osteoporosis evaluation and management
Smoking history: screening for lung cancer (CT scan) and abdominal aortic aneurysm (ultrasound), when indicated
Cardiac risk: coronary artery calcium CT
Travel counseling: malaria prophylaxis and vaccine recommendations

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Appointments

At Dawnbreaker Health, we don’t take a one-size-fits-all approach. We offer scheduling options designed to fit your needs—most of our appointment slots are after hours and on weekends. We also accept “walk-ins” for urgent needs (within our scope) when availability allows. Visits can be as short as 20 minutes or as long as 60 minutes, with a steep discount for new patients who book directly on our site so you can see if we’re a good fit. (Use code “NewPatient” when paying) You can also call 503-664-7007 to schedule.

Visit fee: $29.99 (20 minutes) or $59.99 (60 minutes)
New patient discount: $4.99 (20-minute new patient visit)
Preventive health visit: $29.99
Insurance: We only accept PPO plans (out-of-network). However, we aim to keep cash prices reasonable (see above).
Insurance should still cover labs, imaging, and medications.
Hours: Saturday/Sunday/Wednesday 12–5PM other days 6–10PM

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Contact information

503-664-7007 (Phone & text)
689-204-0511 (fax)
contact@dawnbreakerhealth.com
All of Oregon (Telemed)

Do not send personal health information over text or email. Do not use these contacts for emergencies or urgent physical or mental health concerns. We may take up to 48 hours to respond. If you are in immediate danger or considering self-harm, call 911 or go to the nearest emergency department

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