Latest news with #MatthewWatto
Medscape
4 days ago
- Health
- Medscape
Harm Reduction in Alcohol Use Disorder: Lessons From Sex Ed
This transcript has been edited for clarity. Matthew F. Watto, MD: Welcome back to The Curbsiders . I'm Dr Matthew Frank Watto, here with my great friend and America's primary care physician, Dr Paul Nelson Williams. We had an awesome episode with Dr Stephen Holt and our addiction medicine crew, where we had a higher-level focus on medications for alcohol use disorder (AUD), mainly in the outpatient setting. Paul, I think it's important to start off by saying that when we were young people coming up in this field, abstinence was pretty much the only approach in the treatment of AUD. The attitude was that if your patient was unable to reach absolute abstinence, you were a failure. We were also probably calling it "alcoholism" at the time. But now, I think we're starting to take a more realistic, patient-centered, and evidence-based approach by recognizing that abstinence is not realistic for everybody. Instead, just a reduction in alcohol use can improve outcomes, including mortality. You really have to meet the patient where they are in the process. And yes — for many patients, achieving complete abstinence would be most optimal for their overall health, but it may not be in the cards for them, and a reduction in use is worth shooting for. Anything to say about that, Paul? Paul N. Williams, MD: It's all true. I think keeping things patient-centered is always important. We also need to recognize that even if the patient's goal is abstinence, it's really hard. These medications are effective but they're far from perfect. Accept that there may be returns to use and that you may not be able to achieve complete abstinence; be okay with that outcome and support the patient throughout the process. It's critical to avoid viewing it as a treatment failure, regardless of what your patient's goals might be. Watto: We have three FDA-approved medications: Naltrexone (oral or intramuscular), disulfiram, and acamprosate. Paul, I was not familiar with targeted therapy. I thought you had to take these medications every day or once a month. Teach me something, Paul. Williams: With AUD, there are often triggers of alcohol use, and often patients can anticipate what these triggers might be. On the episode we talked about Thanksgiving dinner — where we know an uncle's going to get us angry — or the anniversary of a loved one's death or being in a social situation. There are times when someone will know and recognize that they're going to be more likely to drink alcohol. So rather than being on chronic medication, patients can take medications in advance of whatever this occasion might be to help reduce their potential for use. That can be done with naltrexone — the Sinclair Method — and it sounds like the data are especially good for nalmefene, but it's a European medication that is not approved in the United States. Dr Holt and our colleague, Carolyn Chan, also mentioned doing this with disulfiram as well. This method of taking medication in anticipation of a known trigger — maybe a day or two before — can help patients be less likely to drink alcohol during that time, and can help them avoid all the burdens and hassles that come with being on a chronic medication. It's a neat technique that is not used as commonly as it could be, at least in my experience. Watto: It sounded like Dr Holt advises patients to start the medication a couple days before the known trigger and to continue using the medication until they feel like things are settled again. But Paul, Dr Holt loves disulfiram — I was shocked! I did not know this about him, and I thought no one was using disulfiram anymore. Have you prescribed it, and did you know that it was still "in vogue"? Williams: I have prescribed it, but I don't know if it's "in vogue." It's got a bad reputation and it's not necessarily my first line, but Dr Holt has a lot of enthusiasm for it and he makes a really interesting point. He brought up the fact that the studies that looked at disulfiram were randomized, double-blinded control trials. However, if you're a participant who believes that what you're taking (placebo or not) might make you deathly ill when you drink alcohol, that potential of severe illness will inevitably change patient behavior, regardless of what treatment arm they fall into. That kind of defeats the purpose of studying the efficacy of disulfiram in comparison to placebo. But when you actually look at the results of open-label trials — where patients knew what treatment arm they were randomized into and participants receiving the placebo knew there wasn't a real threat of severe illness — there's good evidence for disulfiram's efficacy in an observed setting. Dr Holt had a lot of personal success with disulfiram, so he was a big advocate for it. Our conversation certainly made me more inclined to prescribe it than I had been prior to the episode, but it's probably still not my first choice. Watto: I thought that was a really smart point about how, typically, randomized, blinded trials are our gold standard, but in this case the placebo becomes very strong in a blinded setting when the patient is not sure whether their treatment will cause them to get horribly ill if they drink. The standard dose of disulfiram is 250 mg. If patients don't become sick after drinking at that dose, Dr Holt said he would up the dose to 500 mg. That usually isn't common, but some patients just don't have that typical response at the standard dose and must be metabolizing alcohol some other way. However, most patients need to be really careful. Patients should avoid all alcohol-containing products, including mouthwash, vanilla extract, and many types of aftershave. The contraindications for disulfiram include: Pregnancy Cognitive impairment, as patients may not remember if they took their medications or not Severe cardiovascular disease, as a reaction can cause ischemia Advanced liver disease (eg, cirrhosis with Child-Pugh class B or C) Dr Holt would still use disulfiram for patients with mild cirrhosis who are considered Child-Pugh class A but recommends following the liver closely. I looked disulfiram up on LiverTox and there is some concern about acute medication-induced hepatitis that could be really serious. So, if a patient already has a sick liver at baseline, you probably don't want to give them this medication. Williams: Beyond the fact that I feel like this medication sometimes feels a little bit moralistic or kind of punitive for people who are drinking, as though it's just a sort of built-in punishment, my larger concern with prescribing disulfiram is the potential for hepatotoxicity. However, that may have been overstated in my brain. Watto: If I had a patient without contraindications, I would at least have a conversation to see if it's the right person, because it does take drinking off the table. Even if they're having cravings, they know they'll get violently ill if they drink and they don't want to end up in an ER for IV fluids because they're vomiting. I think it works, but it requires a little bit of a tricky conversation. But I do think this episode made me reconsider disulfiram as an agent to prescribe. Williams: It goes back to your original point of shared decision-making: We need to make sure we're making informed decisions together and matching treatments with patients' goals. If a patient is interested in disulfiram after a detailed conversation, I would not try to talk them out of it. I'm more inclined to reach for it now after speaking with Dr Holt. Watto: So, Paul, what off-label medications might listeners consider for AUD treatment? Williams: There's a bazillion, and there have been lots of small studies looking at different options and combinations. If you're unable to use the FDA-approved medications, topiramate is the one medication Dr Holt would reach for. It's even highlighted in the Veterans Affairs/Department of Defense guidelines. It can be a tricky medication because it has to be titrated slowly; we're talking about increments of 25 mg. As such, you have to have a patient who can follow directions, is committed to taking a medication, and is fairly well organized, which is not always the case when someone has an underlying AUD. There's also a lot of intolerable side effects for a lot of folks; patients might experience somnolence and paresthesias, so you have to be a little bit cautious with those. However, topiramate does have evidence to support its use. We talk a good bit about gabapentin as well, Matt. It's something that we've all prescribed for a million different reasons. Dr Holt is a fan of it, specifically for alcohol withdrawal, but also there is some evidence for its use with AUD. It seems helpful, especially in combination with, say, naltrexone. I'm more inclined to reach for that. We touched briefly on baclofen, and I've known people who have been enthusiastic about it as an option. There is evidence to support its use, but it's not one we talked too much about this episode. Watto: We also talked a little bit about combination therapy. There's not really strong evidence for it. I know you mentioned that sometimes you might use naltrexone and gabapentin together, but the evidence overall for something like naltrexone and acamprosate didn't seem to pan out. Williams: It's not well supported — correct.
Medscape
06-06-2025
- Health
- Medscape
A PCP Guide to Emerging Therapies for Resistant Hypertension
This transcript has been edited for clarity. Matthew F. Watto, MD: Welcome back to The Curbsiders . I'm Dr Matthew Frank Watto, here with my great friend and America's primary care physician, Dr Paul Nelson Williams. Paul, this is a topic you know a ton about, isn't it? Paul N. Williams, MD: It's one I always have questions about; I think this is our 37th episode on high blood pressure, if I'm not mistaken. Watto: The audience can't get enough of it — turns out, neither can I. Williams: Me neither! Watto: I love talking about high blood pressure, and this was with a great guest, Dr Jordy Cohen. She's a hypertension expert and a nephrologist. Paul, to start us off, what are we doing with blood pressure cuffs these days? Those manual ones on the wall, those are the way to go, right? Williams: This is a scenario we talk about all the time, and we've beat this drum a lot in prior episodes. I think we've all experienced a patient whose initial triage blood pressure reading is elevated, and either you or the patient will ask for a recheck and you're tempted to use a blood pressure cuff that's been hanging on the wall, has not been calibrated in 17 years, has a decaying spiral cord, and looks like it would fall apart if you touched it. Turns out that's probably not the best way to do it, Matt. So, to reiterate: Automated cuffs are the preferred option. They are more accurate. In this episode with Dr Cohen, we talked about making sure we use the appropriate cuff size and when we have patients who have large arms, you may have to use a wrist measurement every so often. In these circumstances, positioning matters: feet flat, back supported, elbow resting on a table, and have two fingers on the opposite clavicle so that everything is at heart level. If you're taking the blood pressure reading using a cuff around the arm itself, again, you should make sure the patient's arm is resting on a tabletop, bedside, or even on your own arm to ensure it's at heart level. You also shouldn't talk with the patient during that process so you can give them every chance to have an accurate blood pressure reading. That's the first thing: Get an accurate reading. Then everything else follows that step, as you should only treat a diagnosis that you've appropriately made. Watto: All the goals are based on a properly taken blood pressure, so if your patient's blood pressure hasn't been appropriately measured, you might overtreat or undertreat someone. For most patients who are nonfrail, we're now shooting for a blood pressure that is below 130/80 mm Hg. The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines for patients with chronic kidney disease state that normal blood pressure should be below 120/80, which is very hard to do. If we're getting people with a systolic in the 120s, that's probably about as good as we're going to get. For treatment, Dr Cohen and I have adopted this practice of using combination pills for hypertension management — either a calcium-channel blocker with an angiotensin-converting enzyme inhibitor or an angiotensin II receptor blocker (ARB). I usually prefer a calcium-channel blocker with an ARB or the 'triple pill,' a single-pill combination of a calcium-channel blocker, an ARB, and a diuretic. That's what I go to now as my first-line agent. I'm using a lot of either low-dose or medium-dose combination therapy. I don't usually go to the highest dose unless I'm in a situation where I have to decide between starting a fourth medication or going to a higher dose. That's really been a practice change for me. Dr Cohen reiterated that point and emphasized that it's easiest for the patient and they usually experience fewer side effects when you choose a low-to-moderate dose in comparison to a high dose. Williams: It's a point that we've made in prior episodes, as well. As you start to max out the doses of these medications, you get diminishing returns in terms of their efficacy in lowering blood pressure efficacy and patients can start to experience increased side effects. It's a far better option to start with a kind of median dose as opposed to really trying to crank up the dose, because you just don't get that much more benefit with that approach. Watto: We're going to discuss some of the newer blood pressure–lowering agents. Paul, the first one I want to ask you about is not quite a blood pressure medication, but it does lower blood pressure. Which medication am I talking about here? Williams: I think you're probably referring to semaglutide, Matt. I think we all have a fair amount of comfort with these diabetes and weight loss medications. These are remarkable medications and the indications keep piling on, which is great. Semaglutide, in particular, is not approved for hypertension, but it does lower blood pressure, likely as a result of the weight loss that is achieved with the medication. So, it's not technically an antihypertensive, but it provides a great blood pressure benefit. I think there's also some 'fancy pants' medications coming down the pipeline that we should probably be aware of, right? Watto: Yes, and the first one I'll mention is endothelin receptor antagonists. As a generalist, you're probably not going to be prescribing these; they will probably be prescribed by a hypertension specialist. Compared with placebo, they have a modest effect in lowering blood pressure (~4 mm Hg), but they are officially approved, so they're out there. What's more exciting, Paul, are aldosterone synthase inhibitors. The generic names for these include baxdrostat and lorundrostat. They're not yet approved, but I believe they are in phase 2 or phase 3 trials, depending on the indications. They seem promising, as they have a much stronger effect on blood pressure (~10-15 mm Hg) compared with placebo. Dr Cohen thinks these medications are probably going to be in the primary care wheelhouse soon. Cost will probably an issue with these medications at the start, but otherwise, these are pills that are taken once a day and they don't have the antiandrogen side effects that you can get with the mineralocorticoid receptor antagonists (MRAs), like spironolactone. Dr Cohen was really excited about being able to prescribe these at some point. Williams: And the MRAs are traditionally a fourth-line medication (unless you have compelling indications), so to have something else in your armamentarium that has less side effects is super exciting. It'll be great to see these in the pipeline. Watto: Now, what would you say, Paul, if I told you there was a medication for blood pressure that is only administered once every 6 months and will shut down the renin-angiotensin-aldosterone system (RAAS)? How does that sound? Williams: As someone who's taken medical school physiology, it sounds lightly terrifying! It feels like you do need the RAAS for some things, but I think for patients that are less interested in taking medications — which turns out to be most patients — it could potentially be exciting. I think as long as we have a way to reverse the effects of this medication if needed, then I think there's potential for excitement around this medication. Watto: I'm of course talking about a small interfering RNA (siRNA) agent. The one we talked about in this episode was zilebesiran; it's an siRNA agent and is administered once every 6 months. But no one would feel comfortable giving this unless there's an antidote, because if a patient gets septic, they probably need their RAAS to help them out there. Williams: Or if you have a patient who is pregnant — lots of reasons why you might actually want that system working. Watto: Exactly. Now, some people just don't want to take medications even if they need them, Paul. What else might be offered to a patient with high blood pressure? And how excited should we be about this next therapy? Williams: I feel like you're asking the wrong guy, Matt! I think you're alluding to renal denervation therapy. I feel it had a lot of wild enthusiasm initially, then it kind of waned, and now I feel like enthusiasm is back, baby — we're back into renal denervation. It sounds like a great option and I think we're doing a little better job with it, but its effect on lowering blood pressure is about equivalent to the effect you observe with a single-agent medication. So, realistically, these patients may still need to be on medications for blood pressure control. It's only effective for about two thirds of patients who get the procedure; that's 33% of your patients who would go through this invasive procedure where we're frying a nerve and in the end, they may not actually experience any blood pressure benefit. I think there's still a population that would benefit from and be interested in this option, but I don't think it's something that we should consider as first-line therapy for the majority of folks because of that potential for treatment failure and the continued need for medications among a substantial portion of the patients who undergo this procedure. It's still exciting that there's evidence for it and it does cause significant blood pressure lowering, so it's nice to have another option. Watto: Yeah, and I think patients are going be coming in and asking about it, so having some knowledge about the pros and cons of the procedure is important.
Medscape
21-05-2025
- Health
- Medscape
Still Recommending Albuterol for Asthma? Time for an Update
This transcript has been edited for clarity. Matthew F. Watto, MD: Welcome back to The Curbsiders . I'm Dr Matthew Frank Watto, here with my great friend and America's primary care physician, Dr Paul Nelson Williams. Paul N. Williams, MD: Matt, how are you? Watto: I'm doing well. Paul, we recently discussed asthma management with Dr Cyrus Askin. He's a homegrown pulmonologist, I would say. Williams: Dr Askin is a longtime Curbsiders team member. I just had the occasion to listen to the episode. Typically, I try not to rewatch our episodes if I can help it because I hate listening to my own voice, but man, he did a good job with this topic. It's a really strong and comprehensive episode. Watto: And he has his own podcast, Critical Care Time. Now, Paul — I heard that albuterol is dead. Can you tell me about that? Because albuterol is what I give to all my patients as first line. I tell them not to mess with any other asthma medications. Williams: That's right: Albuterol is dead, at least in regards to asthma. I think we've all seen (and probably still have) a lot of patients with mild intermittent asthma who have an albuterol inhaler, that they may or may not use, that's been on their medication list for 20,000 years. We should have moved past that paradigm at this point, Matt. The 'new' guidelines— I say 'new' but they've been around for over 5 years now, at this point — Watto: Yeah, we covered this in 2019. Williams: Exactly. So that idea of using short-acting beta-agonist (SABA) monotherapy is verboten. We should not be doing that anymore. SABA monotherapy leaves the airways unprotected from inflammation and the outcomes of SABA monotherapy alone are not great. What you want is a little bit of inhaled corticosteroid (ICS) to reduce the inflammation in addition to the bronchodilation. ICS with formoterol (ICS/FORM) is the new albuterol, and we can talk about whether we're using this only as a rescue medication or as a controller or as both — all of which are okay, but you want to have the ICS there because patients just don't do as well on SABA monotherapy. They end up with worse exacerbations and more hospitalizations. Watto: Using ICS with formoterol, a long-acting beta-agonist (LABA), is prioritized because it has a quick onset of action. There is an ICS, budesonide, that is commonly paired with formoterol. The pairing of budesonide with albuterol, a SABA, has also been advertised recently and I've noticed that it's on some formularies. We asked Dr Askin about his opinion on pairing budesonide with a LABA vs a SABA, and he prefers the LABA formoterol. However, in some cases, patients may only have access to albuterol with inhaled steroids. So, I guess having some inhaled steroid is better than none. Williams: Dr Askin even gave us very hesitant permission to have an ICS plus albuterol as needed as a rescue inhaler in extreme circumstances. But again, you want that ICS in there as your base note. Watto: In my experience, the ICSs by themselves are not that cheap compared with the combination therapy, so it almost doesn't make sense to not go with the ICS/FORM option. But I know there are some patients that just can't afford the formoterol-containing formulation, so you may just be stuck there. Paul, I heard there's some nonpharmacologic measures we can take to improve asthma symptoms. Do you have any favorites? Williams: I loved a lot of points that Dr Askin made at the end of the episode when we started talking about nonpharmacologic measures. He talked specifically about how exercise is a potential trigger. He doesn't even use the term exercise-induced asthma because he feels like that gives a signal to patients that they should stop exercising, and it turns out that patients do better when they exercise — as is the case in almost every circumstance. Instead, he identifies exertion as a potential asthma trigger, as opposed to exercise-induced asthma. Then, as physicians, we just treat asthma appropriately and the patient should still be encouraged to exercise, as that will help them have better health outcomes overall. We also spent a fair amount of time talking about weight loss. Patients with obesity have poor asthma control and more frequent exacerbations. Even in his pulmonology clinic, he has conversations with patients about medications for weight loss and therapeutic lifestyle changes. And in the primary care setting, especially, we should do the thing we're supposed to be doing anyway: vaccinating against viruses. Make sure COVID, influenza, and pneumococcal vaccinations are all up to date so we can protect our patients against potential infectious triggers, as best as we're able to. I thought that was a nice reminder that we should be making sure our patients are vaccinated, especially for our patients living with asthma. It's really important to be diligent about protecting our patients in that way. Watto: In terms of asthma diagnosis, we had previous guests who weren't the biggest fans of spirometry. However, both the guidelines and Dr Askin support the use of spirometry as the gold standard for asthma diagnosis. Now, if you're in an extremely resource-limited setting and someone has a very classic presentation of asthma, treating them and then confirming diagnosis at later timepoint is probably alright to do. But if you're in a well-resourced setting, getting spirometry is the best course of action for most patients. If your patient has no symptoms at the time of spirometry, that may be normal. In those cases, Dr Askin said he might go right to spirometry with methacholine and administer escalating doses of methacholine to try to induce some obstruction that you can detect on the test. Then, you would do the bronchodilator challenge after that to see if you can reverse the airway obstruction in order to make the diagnosis of asthma. In some cases, Paul, you can even use peak expiratory flow to diagnose asthma in resource-limited settings. But that's not something I've done before. Williams: No, neither have I. Every place I've practiced, both rural and urban, has had fairly easy access to pulmonary function testing, although I have not seen it conducted as consistently as it probably should be for our patients with asthma or presumed asthma.
Medscape
08-05-2025
- Health
- Medscape
Use the Geriatric 5Ms to Manage Unintentional Weight Loss
This transcript has been edited for clarity. Matthew F. Watto, MD: Welcome back to The Curbsiders . I'm Dr Matthew Frank Watto here with my great friend and America's primary care physician, Dr Paul Nelson Williams. Paul, I feel like you probably see unintentional weight loss in primary care all the time. Paul N. Williams, MD: It does come up often and I was happy to learn about it. It can be very frustrating, so I was grateful to learn about a framework I could use to diagnose and manage unintentional weight loss. Watto: For this topic, we partnered with Penn's Division of Geriatrics — one of their faculty, Dr Eva Szymanski, was our expert and a lot of their fellows helped to write this episode. Paul, how do we define unintentional weight loss? What amount of weight loss is considered significant? Williams: It's important to define your terms, especially as the topic of unintended weight loss is typically identified and/or brought up by a family member who's concerned. It might be a little bit tricky to quantify, but the actual definition of unintentional weight loss is weight loss of greater than 5% of a patient's body weight that occurs unintentionally within a 6-12-month period. If a patient is trying to lose weight, we don't count it. If it has happened over the span of 5 years, it doesn't quite cut mustard. It has to occur in those 6-12 months, it has to be greater than 5% of body weight, and there cannot be an intentional reason as to why they're losing weight. Watto: On the episode, Dr Szymanski made the point unintentional weight loss does not automatically mean "failure to thrive". Failure to thrive is a geriatric syndrome that involves multiple other symptoms — it's more than just weight loss. So, don't write failure to thrive in the chart just because someone's lost a little bit of weight. Williams: I like that we got granular about it, because I think these terms are often used interchangeably. Failure to thrive is more of a syndromic picture, cachexia is wasting as a result of illness, and sarcopenia, specifically, is loss of muscle mass. It's good to be super specific when it comes to these conditions, because it does affect your interventions and your workup, to some extent. Watto: We put this into the 5Ms framework. It's a mnemonic and a simple way to stay organized when you're working up these geriatric syndromes, which are multicomplex, multisystem problems. Given that unintentional weight loss is usually a geriatric syndrome, let's put in the 5Ms framework. Williams: The 5Ms are: Mentation: Are there mood issues? Is there cognitive impairment? Are they depressed? Medications: Medications are our bread and butter, our favorite. We talked a lot about de-prescribing — we love it. Mobility: How active are they? Can they get around? Can they perform their activities of daily living? Matters: What matters? What do they value? What makes them happy? Multimorbidity: What else is going on with this patient? What other illnesses could be contributing to unintentional weight loss? Watto: When you go through the 5Ms with unintentional weight loss, Dr Szymanski mentioned that it can take a long time to go through all five topics in a single visit. If you only have 15 minutes to talk, going through all the medications, supplements, and substances the patient is taking may end up eating up your whole visit. Although you might not be able to hit every single M in one visit, you should try to cover all 5Ms over the course of your workup. Williams: Luckily, most of the time this weight loss is happening relatively gradually. This is typically not something that happens between two visits, so you have time to work on this longitudinally. Watto: I think a good place to start is often the screening questions. ls this person depressed and that's why they're not eating? Are they having memory issues and have trouble remembering how to fix meals or remembering if they've eaten or not? The next step would be the medication list. Paul, are there any common medications that can cause trouble here? Williams: Almost all of them — that's kind of the issue. We talked about some of the medications that are on the Beers List, and if you live long enough, eventually you accumulate medications and then you treat the side effects of those medications with other medications and then treat the side effects of the medications for your side effects… and so on and so forth. It's not unusual to have lots of anticholinergic medications that cause dry mouth, nausea, or constipation. Some of the medications that we use to treat dementia, for example, are commonly associated with gastrointestinal symptoms. Antihypertensives medications classically cause all kinds of side effects that may make eating less appealing. So really take a good, hard look at your patient's medication list and see what absolutely has to be there, because you may be able to de-prescribe and that may help their appetite a great deal. Watto: I recently had a geriatric patient who was losing weight, so we checked his medication list. He was taking metformin, even though his A1C was around 5.8. He was having a little bit of stomach upset and he was on iron supplements, even though I had not prescribed any iron supplements and I could not find a clinical indication for it. We stopped both the metformin and the iron supplementation. His A1C came up a little bit, but it wasn't concerning, and now he's eating better and his family is happy. Sometimes, it can be that easy. In terms of laboratory work, you will probably want to do a limited, minimal evaluation. You might run a comprehensive metabolic panel or check for some chronic viral illnesses, like HIV or hepatitis. Checking B12 levels can clue you in to malabsorption issues or explain some cognitive impairment. Paul, what kind of imaging do you order in circumstances like this? Williams: It's really, truly a case-by-case basis. Oftentimes, imaging has already been done for you. If your patient had a fall, they probably went through the donut of truth, and you can look at the trauma CT scan. Almost everyone has had a chest x-ray at some point! Some research recommends doing abdominal ultrasound as part of the evaluation, but that recommendation probably occurred at a time when CT scans were not quite as readily available as they are now. Depending on how aggressive the patient and/or the family want to be and depending on what's already been done, I may do cross-sectional imaging — but certainly not every time. Oftentimes, that data is already available for you. Watto: And finally, I think a lot of the time you're not going to find one specific thing that is causing the weight loss. The diagnostic workup functions mostly to make sure you're not missing anything glaringly obvious, but a lot of the time you won't find much. If you do find a cause, treat that. If you don't find a clear cause for the unintentional weight loss, liberalizing the diet is a good way to go. If the patient becomes a picky eater, keep their favorite highly palatable foods on hand. Give them more time to eat and make sure the eating environment remains pretty simple. If a patient has dementia, they can get confused if the place settings are too complicated. Williams: I really appreciated the emphasis on making eating a social experience, too. I've seen it work in the past and it really can make a difference. Watto: I have had a couple patients, Paul, where they had lost their sense of taste or sense of smell, and we realized that was the main contributing factor to unintentional weight loss. That can be another factor to look out for. This is a common condition. You're definitely going to see it in your practice, so if you stay organized, use the 5Ms, and follow some of the steps we talked about, you should be able to work towards correcting the problem and stopping the weight loss.
