How do you decide whether I actually need this medication?

The deciding question is whether the medication would change your outcome at this dose for this duration. If a specific number, symptom, or trajectory would move because of it, the medication earns its place. If the next step would be the same with or without it, the medication usually is not the right move.

Do you prescribe GLP-1 medications like Ozempic or Mounjaro?

Yes, when they fit. GLP-1 medications are powerful tools for metabolic disease and obesity with real cardiovascular and metabolic benefit when used alongside protein, training, and sleep. They are not a shortcut on their own. We monitor body composition, metabolic markers, and how you feel, not just the number on the scale.

Will you put me on a statin?

We put patients on a statin (or a PCSK9 inhibitor) when the risk profile actually warrants it: elevated ApoB, elevated Lp(a), strong family history, evidence of plaque on imaging, or a high calculated risk. We do not start one reflexively based on a borderline LDL alone.

What is your view on antibiotics?

Antibiotics are critical for confirmed bacterial infections and useless for viral illnesses. We pick the narrowest effective agent for the shortest appropriate duration. Asking for an antibiotic for a cold exposes you to side effects, resistance, and microbiome disruption without any benefit. See [Antibiotics and your gut](/articles/conditions/antibiotics-and-gut-health) for the detailed lens.

Do you prescribe ADHD or anxiety medication?

Yes, with structure. Properly diagnosed ADHD often benefits from stimulant medication; anxiety often responds to SSRIs, SNRIs, or short-term anxiolytics alongside therapy. Controlled substances are prescribed under the safeguards in our [controlled substances policy](/about/controlled-substances-policy): regular follow-ups, PDMP review, and no early refills.

Why might you take me off a medication I have been on for years?

You may have outgrown the reason for it, the risk profile may have shifted, or the side-effect cost may now outweigh the benefit. Deprescribing is a deliberate, careful conversation, not a snap decision. Common candidates include long-running proton pump inhibitors, certain sleep aids, anticholinergics in older adults, and stacked supplements without a defined goal.

Most refills route through Photon to your pharmacy. You can manage them in the app without a phone call. Controlled substance refills follow the rhythm set in your [controlled substances policy](/about/controlled-substances-policy): no early refills, with follow-up cadence built in. Specialty meds with prior authorization are handled by our team.

What if my insurance does not cover the medication you recommend?

We work with you on alternatives. Options include generics, equivalent drugs in the same class, manufacturer copay programs, GoodRx-style discount pricing, and direct cash-pay where it makes sense. If insurance denies a prior authorization, our team handles the appeal.

Why is "narrowest effective" the default lens?

Because every prescription has a benefit and a cost, and the cost scales with breadth. A narrow-spectrum antibiotic has less microbiome disruption than a broad-spectrum one. A targeted ADHD medication has a cleaner side-effect profile than an off-label option. The narrowest tool that solves the problem also leaves the most room for the patient's biology to do its job.

How do you think about polypharmacy and deprescribing?

We treat polypharmacy as one of the strongest predictors of preventable harm, especially over 65. The Beers Criteria and STOPP/START framework flag medications most likely to be doing more harm than good. Deprescribing the ones that have quietly outlived their usefulness is part of every annual review.

How do you weigh GLP-1 medications against lifestyle change?

We do not weigh them against each other; we use them together when the situation warrants. GLP-1 medications shift hunger physiology in ways willpower cannot. Lifestyle work (protein, training, sleep) shifts the trajectory of body composition and metabolic health. Used together, they reinforce each other. Used alone, either one is weaker than the pair.

What is the role of advanced lipids in your statin decision?

Advanced lipids (ApoB, Lp(a), oxidized LDL, hsCRP) tell us who actually has elevated cardiovascular risk and who has been miscategorized by LDL alone. A patient with normal LDL but high ApoB still has a real risk. A patient with high LDL but low ApoB has less than the standard panel suggests. We let the better data drive the decision.

When do you favor short-term over long-term medication courses?

We favor short-term whenever the evidence supports it. Antibiotic duration is shrinking across most indications. Sleep aids are best used episodically, not chronically. Acute pain medications should have a clear endpoint. The default in much of medicine is "until further notice," and that default is responsible for a lot of avoidable harm.

How do you handle controlled substances safely?

Controlled substances are prescribed under the framework in our [controlled substances policy](/about/controlled-substances-policy): the state Prescription Drug Monitoring Program (PDMP) is checked, follow-ups are required, no early refills, and Schedule II opioids are not prescribed for chronic pain. Structure is what makes these medications safe to use long term.

What is your view on supplements that double as prescriptions?

We use supplements as targeted tools for specific gaps, not as a daily stack and not as a stealth way to "prescribe without prescribing." If a supplement crosses into pharmaceutical territory (dosing, mechanism, side-effect profile), we treat it like a prescription, with the same lens. See [how we choose supplements](/articles/supplements/how-we-choose-supplements).

How do prior authorizations affect prescribing decisions?

Prior authorizations should not change the right medication; they should change the logistics around it. Our team handles the clinical documentation, peer-to-peer reviews, and appeals when needed. If a prior auth is denied, we explore alternatives, manufacturer assistance, or cash-pay, but the clinical decision stays grounded in evidence, not in what is easiest to get approved.

How does your prescribing change in older adults?

Older adults are more sensitive to many medications, have more drug interactions, and have a different risk-benefit calculus on long-term Rx. We lean more deprescribing, more conservative dosing, more frequent reviews, and more attention to anticholinergic burden, fall risk, and renal clearance. The Beers Criteria guide is part of every annual review over 65.

How do you handle a medication that worked, until it did not?

First we make sure the medication is actually the variable that changed (versus sleep, training, life stress, or another medication). If the medication has lost its effect, we look at dose, formulation, adherence, and physiological tolerance. Sometimes the right move is a dose change, sometimes a switch within the class, sometimes a planned taper off entirely.

Why does Philadelphia's primary care landscape matter for prescribing stewardship?

Philadelphia's traditional primary care system, like most of the country, runs on short visits and quick prescriptions because the incentives reward volume. Direct primary care lets us spend the time to prescribe (or not prescribe) deliberately, monitor properly, and deprescribe when warranted. Every avoidable medication is a small local win for the city's collective medication burden.

How do you decide when an injectable beats an oral medication?

We pick injectables when adherence is the bottleneck (depot injections for certain mental health treatments), when oral absorption is unreliable (some hormone therapies), or when the evidence shows clearer outcomes (GLP-1s, PCSK9 inhibitors). Injectables are not inherently better; they are tools for specific problems.

How do you decide whether I actually need this medication?

The deciding question is whether the medication would change your outcome at this dose for this duration. If a specific number, symptom, or trajectory would move because of it, the medication earns its place. If the next step would be the same with or without it, the medication usually is not the right move.

Do you prescribe GLP-1 medications like Ozempic or Mounjaro?

Yes, when they fit. GLP-1 medications are powerful tools for metabolic disease and obesity with real cardiovascular and metabolic benefit when used alongside protein, training, and sleep. They are not a shortcut on their own. We monitor body composition, metabolic markers, and how you feel, not just the number on the scale.

Will you put me on a statin?

We put patients on a statin (or a PCSK9 inhibitor) when the risk profile actually warrants it: elevated ApoB, elevated Lp(a), strong family history, evidence of plaque on imaging, or a high calculated risk. We do not start one reflexively based on a borderline LDL alone.

What is your view on antibiotics?

Antibiotics are critical for confirmed bacterial infections and useless for viral illnesses. We pick the narrowest effective agent for the shortest appropriate duration. Asking for an antibiotic for a cold exposes you to side effects, resistance, and microbiome disruption without any benefit. See [Antibiotics and your gut](/articles/conditions/antibiotics-and-gut-health) for the detailed lens.

Do you prescribe ADHD or anxiety medication?

Yes, with structure. Properly diagnosed ADHD often benefits from stimulant medication; anxiety often responds to SSRIs, SNRIs, or short-term anxiolytics alongside therapy. Controlled substances are prescribed under the safeguards in our [controlled substances policy](/about/controlled-substances-policy): regular follow-ups, PDMP review, and no early refills.

Why might you take me off a medication I have been on for years?

You may have outgrown the reason for it, the risk profile may have shifted, or the side-effect cost may now outweigh the benefit. Deprescribing is a deliberate, careful conversation, not a snap decision. Common candidates include long-running proton pump inhibitors, certain sleep aids, anticholinergics in older adults, and stacked supplements without a defined goal.

Most refills route through Photon to your pharmacy. You can manage them in the app without a phone call. Controlled substance refills follow the rhythm set in your [controlled substances policy](/about/controlled-substances-policy): no early refills, with follow-up cadence built in. Specialty meds with prior authorization are handled by our team.

What if my insurance does not cover the medication you recommend?

We work with you on alternatives. Options include generics, equivalent drugs in the same class, manufacturer copay programs, GoodRx-style discount pricing, and direct cash-pay where it makes sense. If insurance denies a prior authorization, our team handles the appeal.

Why is "narrowest effective" the default lens?

Because every prescription has a benefit and a cost, and the cost scales with breadth. A narrow-spectrum antibiotic has less microbiome disruption than a broad-spectrum one. A targeted ADHD medication has a cleaner side-effect profile than an off-label option. The narrowest tool that solves the problem also leaves the most room for the patient's biology to do its job.

How do you think about polypharmacy and deprescribing?

We treat polypharmacy as one of the strongest predictors of preventable harm, especially over 65. The Beers Criteria and STOPP/START framework flag medications most likely to be doing more harm than good. Deprescribing the ones that have quietly outlived their usefulness is part of every annual review.

How do you weigh GLP-1 medications against lifestyle change?

We do not weigh them against each other; we use them together when the situation warrants. GLP-1 medications shift hunger physiology in ways willpower cannot. Lifestyle work (protein, training, sleep) shifts the trajectory of body composition and metabolic health. Used together, they reinforce each other. Used alone, either one is weaker than the pair.

What is the role of advanced lipids in your statin decision?

Advanced lipids (ApoB, Lp(a), oxidized LDL, hsCRP) tell us who actually has elevated cardiovascular risk and who has been miscategorized by LDL alone. A patient with normal LDL but high ApoB still has a real risk. A patient with high LDL but low ApoB has less than the standard panel suggests. We let the better data drive the decision.

When do you favor short-term over long-term medication courses?

We favor short-term whenever the evidence supports it. Antibiotic duration is shrinking across most indications. Sleep aids are best used episodically, not chronically. Acute pain medications should have a clear endpoint. The default in much of medicine is "until further notice," and that default is responsible for a lot of avoidable harm.

How do you handle controlled substances safely?

Controlled substances are prescribed under the framework in our [controlled substances policy](/about/controlled-substances-policy): the state Prescription Drug Monitoring Program (PDMP) is checked, follow-ups are required, no early refills, and Schedule II opioids are not prescribed for chronic pain. Structure is what makes these medications safe to use long term.

What is your view on supplements that double as prescriptions?

We use supplements as targeted tools for specific gaps, not as a daily stack and not as a stealth way to "prescribe without prescribing." If a supplement crosses into pharmaceutical territory (dosing, mechanism, side-effect profile), we treat it like a prescription, with the same lens. See [how we choose supplements](/articles/supplements/how-we-choose-supplements).

How do prior authorizations affect prescribing decisions?

Prior authorizations should not change the right medication; they should change the logistics around it. Our team handles the clinical documentation, peer-to-peer reviews, and appeals when needed. If a prior auth is denied, we explore alternatives, manufacturer assistance, or cash-pay, but the clinical decision stays grounded in evidence, not in what is easiest to get approved.

How does your prescribing change in older adults?

Older adults are more sensitive to many medications, have more drug interactions, and have a different risk-benefit calculus on long-term Rx. We lean more deprescribing, more conservative dosing, more frequent reviews, and more attention to anticholinergic burden, fall risk, and renal clearance. The Beers Criteria guide is part of every annual review over 65.

How do you handle a medication that worked, until it did not?

First we make sure the medication is actually the variable that changed (versus sleep, training, life stress, or another medication). If the medication has lost its effect, we look at dose, formulation, adherence, and physiological tolerance. Sometimes the right move is a dose change, sometimes a switch within the class, sometimes a planned taper off entirely.

Why does Philadelphia's primary care landscape matter for prescribing stewardship?

Philadelphia's traditional primary care system, like most of the country, runs on short visits and quick prescriptions because the incentives reward volume. Direct primary care lets us spend the time to prescribe (or not prescribe) deliberately, monitor properly, and deprescribe when warranted. Every avoidable medication is a small local win for the city's collective medication burden.

How do you decide when an injectable beats an oral medication?

We pick injectables when adherence is the bottleneck (depot injections for certain mental health treatments), when oral absorption is unreliable (some hormone therapies), or when the evidence shows clearer outcomes (GLP-1s, PCSK9 inhibitors). Injectables are not inherently better; they are tools for specific problems.

TL;DR · 30-second take

Before I prescribe anything, I run one test: does this drug actually change the outcome? If yes, we pick the narrowest effective option, the lowest effective dose, and the shortest appropriate duration. If the answer is no, we leave the pad alone. The same lens runs across antibiotics, statins, GLP-1s, hormone therapy, sleep meds, and the controlled substances we do prescribe under structure. Deprescribing what no longer helps is the same conversation in reverse.

How I Decide to Prescribe: The Lens Before a Single Rx

TL;DR: Medications are powerful tools. They are not the default move. Before I write a prescription, I ask one question: does this drug actually change the outcome for this specific person? If yes, we pick the narrowest effective option, the lowest effective dose, and the shortest appropriate duration. If no, we leave the pad alone. The same lens runs across every class I prescribe, from antibiotics to statins, GLP-1s, hormone therapy, and the controlled substances we manage under clear structure. Deprescribing what no longer helps is the same conversation in reverse. The point of the prescription is the outcome, not the prescription.

The prescription pad is one of the most powerful tools in medicine and one of the most casually overused. The same drugs that change life trajectories when used right cause real harm when used wrong: side effects, drug interactions, resistance, dependency, and the quiet kind of harm where a medication keeps getting refilled long after it stopped helping. The line between those outcomes is not the medication. It is the question we are answering when we reach for it.

The question I ask before writing anything

The lens I use before every prescription is simple: would this drug, in this person, at this dose, for this duration, change the outcome? If yes, we prescribe. If no, we do not. The test sounds obvious. It is also what most prescribing fails on. A prescription for a viral cold does not change the course of the cold. A statin for a 30-year-old with normal ApoB and zero family history does not change the cardiovascular trajectory. A daily benzodiazepine for chronic anxiety usually does not solve the anxiety; it builds tolerance and quietly creates a new problem. The question forces honesty about what we are doing with each prescription. Once the answer is yes, the next three are mechanical.

The three knobs

Every prescription is a setting on three dials:

The right drug. Match the mechanism to the problem. The narrowest effective option for what is actually happening, not the most-marketed or most-prescribed one.
The right dose. The lowest dose that produces the outcome. Many side effects are dose-dependent and reversible; many benefits are achievable at lower doses than people assume.
The right duration. The shortest appropriate course. The default in too much of medicine is "until further notice." Most prescriptions deserve a planned endpoint and a check-in.

Get those three right and most of the medication harm in the system disappears.

Let's get healthier

Get Dr. Ash's health checklist.

Bi-weekly clinical insights on the markers that matter most - what to track, what to ask your doctor, and what 'normal' actually means. Trusted by 1,248+ Philadelphians.

Evidence-informed clinical signal · no marketing · no spam

Where I lean toward prescribing

A short list of the places medications usually earn their place when the clinical picture supports them:

Antibiotics for a confirmed bacterial infection where the cost of waiting is real (pyelonephritis, cellulitis, bacterial pneumonia, certain dental and skin infections). We pick the narrowest agent the culture or clinical picture allows, for the shortest duration the evidence supports. See Antibiotics and your gut for the detailed stewardship lens.
Statins or PCSK9 inhibitors for elevated ApoB and Lp(a) when imaging or risk calculators support it. The cardiovascular benefit at meaningful baseline risk is one of the most well-supported preventive interventions in medicine. We pick the right intensity for the actual ApoB target, not the average target.
GLP-1 medications for metabolic disease, obesity with metabolic risk, and selected cases where lifestyle work has not closed the gap. They are not a shortcut. They are a tool that, used alongside protein, training, and sleep, can change long trajectories. We monitor body composition, not just the number on the scale.
Hormone optimization in symptomatic patients with clearly low values and a clean safety profile: TRT for genuine hypogonadism with monitoring; menopausal hormone therapy for patients within the right window and risk profile.
Targeted mental health prescriptions alongside therapy, sleep, and lifestyle. SSRIs, SNRIs, and short-term anxiolytics in the right person, with a real plan for follow-up, can be the lever that lets everything else move.
Controlled substances under clear structure when they fit. ADHD stimulants for properly diagnosed ADHD, short-term sleep aids in specific contexts, with the safeguards described in our controlled substances policy.

Where I lean against prescribing

The places a prescription often does more harm than good:

Antibiotics for a viral illness. Colds, flu, most sore throats, most sinus pressure in the first week. Antibiotics do nothing to viruses. They expose you to side effects, push resistance, and disrupt the microbiome.
Sleep aids as a long-term plan. Benzodiazepines, "Z-drugs" like zolpidem, and even chronic over-the-counter antihistamine sleep aids have real downsides: tolerance, dependency, worsened sleep architecture, and (in older adults) falls and cognitive side effects. Short-term, situational use is one conversation. Daily, forever use is a different one.
Statins for borderline risk without baseline imaging or advanced lipids. When ApoB, Lp(a), and risk modifiers (CAC or CCTA) are stable and reassuring, the case for a lifelong statin is weaker than the default. The decision should match the actual risk, not the prescriber's reflex.
"Just-in-case" antibiotics, antifungals, or steroid bursts without a clear diagnosis. Often the symptom resolves on its own, and the prescription took credit for the resolution while adding side-effect risk.
Stacked supplements and stacked medications without a defined endpoint. Polypharmacy is one of the strongest predictors of preventable adverse events, especially over 65. Every additional active prescription deserves a "still earning its place?" review.
Controlled substances without structure. Early refills, missed follow-ups, no Prescription Drug Monitoring Program review. These are how a treatment becomes a problem.

Deprescribing: the other half of the conversation

A medication that earned its place last year may not earn it today. Bodies change, risks change, the evidence base changes. Deprescribing, the deliberate work of stopping a medication that has stopped helping, is part of the same lens.

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We review the whole medication list at least once a year and more often when something is added. The Beers Criteria and STOPP/START framework help us flag medications most likely to be doing more harm than good in older adults: anticholinergics, long-acting benzodiazepines, certain sleep aids, NSAIDs in patients with kidney or cardiovascular risk, and proton pump inhibitors that were started for a one-week problem and have been refilling for a decade. When the lens applies in reverse, the same three knobs do the work: maybe the dose can come down, the duration can end, or the drug can come off entirely with a planned check-in. Deprescribing is not failure. It is hygiene.

How the order actually reaches you

Once a prescription is the right move, the goal is to make the rest of the path feel like one step, not five.

The Rx routes through Photon to the pharmacy you pick, so you see what was sent and where, and you can manage refills without a phone call.
Prior authorizations for GLP-1s, PCSK9 inhibitors, biologics, and newer migraine medications are handled by our team. You should not have to chase your own insurer.
For controlled substances, refills follow the structure laid out in our policy. No early refills, no chasing on weekends; the rhythm is built in advance so it actually works for both sides.
For specialty injectables and titration-based meds, we set the cadence and check-ins in advance so the medication has a chance to do its job.

Guidance from the clinic

"The point of a prescription is the outcome, not the prescription. I prescribe when a medication will move a real number, a real symptom, or a real trajectory. I leave the pad alone when it will not. The harder discipline is the one most prescribing misses: knowing when to stop. Deprescribing a medication that has quietly outlived its usefulness is one of the most underrated things a doctor can do for a patient."

Actionable Steps

Before you start (or stay on) a medication.

Name the outcome. "Lower my ApoB to under 60." "Get my A1c below 5.7." "Sleep through the night without grogginess." A specific outcome lets us measure whether the drug is doing its job.
Ask what changes if you do not take it. If the answer is "not much," the medication probably is not earning its place.
Set a planned check-in. When will we look at whether this is working? Most prescriptions deserve a 4-to-12-week first check, not "see you next year."
Bring the full list every visit. Every supplement, every over-the-counter, every leftover prescription from another clinician. Hidden interactions are responsible for a lot of preventable harm.
Ask the deprescribing question once a year. "Is anything on my list still earning its place?" If the answer is unclear, that is the conversation to have.

Key Takeaways

The deciding question for any prescription is whether the drug would change the outcome for this person at this dose for this duration. If not, do not write it.
Every prescription has three knobs: right drug, right dose, right duration. Most medication harm comes from defaulting on one of them.
Strong evidence cases (statins for elevated ApoB in real risk, GLP-1s for metabolic disease, antibiotics for confirmed bacterial infection, hormone optimization in the right patient) deserve a real plan, including monitoring.
Polypharmacy is one of the strongest predictors of preventable adverse events. Deprescribing what no longer helps is hygiene, not failure.
Logistics matter. Clear routing, clean follow-up, and structured monitoring are what make medications safe to use long term.

Scientific References

Llor, C., & Bjerrum, L. (2014). Antimicrobial resistance: risk associated with antibiotic overuse and initiatives to reduce the problem. Therapeutic Advances in Drug Safety, 5(6), 229-241.
Scott, I. A., et al. (2015). Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Internal Medicine, 175(5), 827-834.
Sabatine, M. S., et al. (2017). Evolocumab and Clinical Outcomes in Patients with Cardiovascular Disease (FOURIER). New England Journal of Medicine, 376(18), 1713-1722.
Wilding, J. P. H., et al. (2021). Once-Weekly Semaglutide in Adults with Overweight or Obesity (STEP 1). New England Journal of Medicine, 384(11), 989-1002.
Grundy, S. M., et al. (2018). 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol. Journal of the American College of Cardiology, 73(24), e285-e350.
By the 2023 American Geriatrics Society Beers Criteria Update Expert Panel. (2023). American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 71(7), 2052-2081.
O'Mahony, D., et al. (2015). STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age and Ageing, 44(2), 213-218.

Fishtown Medicine | Articles

2418 E York St, Philadelphia, PA 19125(267) 360-7927 hello@fishtownmedicine.comHSA/FSA Eligible

Book Your Warm Invitation Call

Frequently Asked Questions

Common Questions

Deep-Dive Questions

Still have a question?

He answers personally. Usually within a few hours.

TL;DR · 30-second take

How I Decide to Prescribe: The Lens Before a Single Rx

The question I ask before writing anything

The three knobs

Every prescription is a setting on three dials:

The right drug. Match the mechanism to the problem. The narrowest effective option for what is actually happening, not the most-marketed or most-prescribed one.
The right dose. The lowest dose that produces the outcome. Many side effects are dose-dependent and reversible; many benefits are achievable at lower doses than people assume.
The right duration. The shortest appropriate course. The default in too much of medicine is "until further notice." Most prescriptions deserve a planned endpoint and a check-in.

Get those three right and most of the medication harm in the system disappears.

Let's get healthier

Get Dr. Ash's health checklist.

Bi-weekly clinical insights on the markers that matter most - what to track, what to ask your doctor, and what 'normal' actually means. Trusted by 1,248+ Philadelphians.

Evidence-informed clinical signal · no marketing · no spam

Where I lean toward prescribing

A short list of the places medications usually earn their place when the clinical picture supports them:

Antibiotics for a confirmed bacterial infection where the cost of waiting is real (pyelonephritis, cellulitis, bacterial pneumonia, certain dental and skin infections). We pick the narrowest agent the culture or clinical picture allows, for the shortest duration the evidence supports. See Antibiotics and your gut for the detailed stewardship lens.
Statins or PCSK9 inhibitors for elevated ApoB and Lp(a) when imaging or risk calculators support it. The cardiovascular benefit at meaningful baseline risk is one of the most well-supported preventive interventions in medicine. We pick the right intensity for the actual ApoB target, not the average target.
GLP-1 medications for metabolic disease, obesity with metabolic risk, and selected cases where lifestyle work has not closed the gap. They are not a shortcut. They are a tool that, used alongside protein, training, and sleep, can change long trajectories. We monitor body composition, not just the number on the scale.
Hormone optimization in symptomatic patients with clearly low values and a clean safety profile: TRT for genuine hypogonadism with monitoring; menopausal hormone therapy for patients within the right window and risk profile.
Targeted mental health prescriptions alongside therapy, sleep, and lifestyle. SSRIs, SNRIs, and short-term anxiolytics in the right person, with a real plan for follow-up, can be the lever that lets everything else move.
Controlled substances under clear structure when they fit. ADHD stimulants for properly diagnosed ADHD, short-term sleep aids in specific contexts, with the safeguards described in our controlled substances policy.

Where I lean against prescribing

The places a prescription often does more harm than good:

Antibiotics for a viral illness. Colds, flu, most sore throats, most sinus pressure in the first week. Antibiotics do nothing to viruses. They expose you to side effects, push resistance, and disrupt the microbiome.
Sleep aids as a long-term plan. Benzodiazepines, "Z-drugs" like zolpidem, and even chronic over-the-counter antihistamine sleep aids have real downsides: tolerance, dependency, worsened sleep architecture, and (in older adults) falls and cognitive side effects. Short-term, situational use is one conversation. Daily, forever use is a different one.
Statins for borderline risk without baseline imaging or advanced lipids. When ApoB, Lp(a), and risk modifiers (CAC or CCTA) are stable and reassuring, the case for a lifelong statin is weaker than the default. The decision should match the actual risk, not the prescriber's reflex.
"Just-in-case" antibiotics, antifungals, or steroid bursts without a clear diagnosis. Often the symptom resolves on its own, and the prescription took credit for the resolution while adding side-effect risk.
Stacked supplements and stacked medications without a defined endpoint. Polypharmacy is one of the strongest predictors of preventable adverse events, especially over 65. Every additional active prescription deserves a "still earning its place?" review.
Controlled substances without structure. Early refills, missed follow-ups, no Prescription Drug Monitoring Program review. These are how a treatment becomes a problem.

Deprescribing: the other half of the conversation

Fishtown Medicine

A 90-minute conversation with Dr. Ash. A written plan you can actually follow.

Book a Free 20-Min Call

How the order actually reaches you

Once a prescription is the right move, the goal is to make the rest of the path feel like one step, not five.

The Rx routes through Photon to the pharmacy you pick, so you see what was sent and where, and you can manage refills without a phone call.
Prior authorizations for GLP-1s, PCSK9 inhibitors, biologics, and newer migraine medications are handled by our team. You should not have to chase your own insurer.
For controlled substances, refills follow the structure laid out in our policy. No early refills, no chasing on weekends; the rhythm is built in advance so it actually works for both sides.
For specialty injectables and titration-based meds, we set the cadence and check-ins in advance so the medication has a chance to do its job.

Guidance from the clinic

Actionable Steps

Before you start (or stay on) a medication.

Name the outcome. "Lower my ApoB to under 60." "Get my A1c below 5.7." "Sleep through the night without grogginess." A specific outcome lets us measure whether the drug is doing its job.
Ask what changes if you do not take it. If the answer is "not much," the medication probably is not earning its place.
Set a planned check-in. When will we look at whether this is working? Most prescriptions deserve a 4-to-12-week first check, not "see you next year."
Bring the full list every visit. Every supplement, every over-the-counter, every leftover prescription from another clinician. Hidden interactions are responsible for a lot of preventable harm.
Ask the deprescribing question once a year. "Is anything on my list still earning its place?" If the answer is unclear, that is the conversation to have.

Key Takeaways

The deciding question for any prescription is whether the drug would change the outcome for this person at this dose for this duration. If not, do not write it.
Every prescription has three knobs: right drug, right dose, right duration. Most medication harm comes from defaulting on one of them.
Strong evidence cases (statins for elevated ApoB in real risk, GLP-1s for metabolic disease, antibiotics for confirmed bacterial infection, hormone optimization in the right patient) deserve a real plan, including monitoring.
Polypharmacy is one of the strongest predictors of preventable adverse events. Deprescribing what no longer helps is hygiene, not failure.
Logistics matter. Clear routing, clean follow-up, and structured monitoring are what make medications safe to use long term.

Scientific References

Llor, C., & Bjerrum, L. (2014). Antimicrobial resistance: risk associated with antibiotic overuse and initiatives to reduce the problem. Therapeutic Advances in Drug Safety, 5(6), 229-241.
Scott, I. A., et al. (2015). Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Internal Medicine, 175(5), 827-834.
Sabatine, M. S., et al. (2017). Evolocumab and Clinical Outcomes in Patients with Cardiovascular Disease (FOURIER). New England Journal of Medicine, 376(18), 1713-1722.
Wilding, J. P. H., et al. (2021). Once-Weekly Semaglutide in Adults with Overweight or Obesity (STEP 1). New England Journal of Medicine, 384(11), 989-1002.
Grundy, S. M., et al. (2018). 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol. Journal of the American College of Cardiology, 73(24), e285-e350.
By the 2023 American Geriatrics Society Beers Criteria Update Expert Panel. (2023). American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 71(7), 2052-2081.
O'Mahony, D., et al. (2015). STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age and Ageing, 44(2), 213-218.

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How I Decide to Prescribe

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The question I ask before writing anything

The three knobs

Get Dr. Ash's health checklist.

Where I lean toward prescribing

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Deprescribing: the other half of the conversation

How the order actually reaches you

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Actionable Steps

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Scientific References

Fishtown Medicine | Articles

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Common Questions

Deep-Dive Questions

Related Intelligence

Longevity Strategies | Fishtown Medicine

Metabolic Health

Antibiotics and Your Gut: Do You Need a Probiotic?

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