DEAR DR. ROACH: Why is it that certain medications warn against possible infections in the perineum? I saw an ad for Jardiance that warned against this. Just now, I viewed a Farxiga ad, and there was the same warning spelled out in the bottom left-hand corner of the screen. This seems very specific. What is it about the perineum that makes it so susceptible, as opposed to other areas on the body? — S.S.

ANSWER: Empagliflozin (Jardiance) and dapagliflozin (Farxiga) are both medicines for diabetes in the SGLT2 inhibitor class. These work by causing the kidneys to release sugar from the blood into the urine. Known side effects are urine and yeast infections.

Fournier’s gangrene is a very rare, soft-tissue infection of the perineum. The “perineum” is broadly considered the area around the genitals in both men and women. In men, the “perineal body” is located between the scrotum and rectum, and in women, it’s between the opening of the vagina and rectum.

Diabetes is a major risk factor for Fournier’s gangrene, but people taking SGLT2 inhibitors seem to get Fournier’s gangrene more than people who take other medications for diabetes. The risk can’t be quantified with accuracy; just over 3 per 100,000 men between the ages of 50-79 will get this condition. Fifty-five cases associated with SGLT2 inhibitors were identified by the Food and Drug Administration in a six-year time period. They were prescribed to 1.7 million people during this time period, so the risk is quite small.

The FDA was concerned enough about a possible increase in this rare but very serious condition that they issue the strongest possible warning. Every ad you see or read in the United States will include a warning about this condition.

Although I don’t recommend stopping these medicines due to concerns about this rare infection, people on these drugs should be aware of warning signs, such as fever, swelling, tenderness, or redness in and around the perineum. You should seek prompt medical attention if they occur.

DEAR DR. ROACH: Do Parkinson’s patients go through a form of sundowning, where their behavior changes during the early evening? — S.F.

ANSWER: “Sundowning” refers to the worsening of confusion at nightfall in people with cognitive disorders such as Alzheimer’s disease. However, longstanding Parkinson’s disease can also lead to cognitive problems (dementia). For people who have had Parkinson’s for more than 20 years, the prevalence of dementia is above 80%. Sundowning can be very mild or quite severe, and it can be very distressing to both the patient and their caregivers.

Cognitive impairment in Parkinson’s disease is usually treated the same way it is with Alzheimer’s, with a medication of modest effectiveness, like donepezil (Aricept). Sundowning is more about confusion, or even an impaired sense of what is real or not (“psychosis”). It is usually treated with specific medications, such as quetiapine or pimavanserin. The dosing of these can be timed so that the person experiences very little sundowning. Experienced physicians know that sometimes very little of the medication is enough to help prevent the problem.

DEAR DR. ROACH: I would like your opinion and advice. I am a very healthy 77-year-old man, and I walk about two miles each morning. Generally, I enjoy one wheat beer every afternoon, and my primary care physician has told me to feel free to continue with it. I’ve read that moderate drinking can be good for one’s health, but I’ve heard that it can be bad as well.

Recently, I saw on a news program that even more moderate consumption than this can have ill effects. As long as my health remains good, I’d be happy to live to be 100 or more. So, please tell me what you advise. I can definitely do without the daily beer. — R.G.

ANSWER: It was standard advice 20 years ago that a daily glass of wine was good for you. It is certainly true that people who drink moderately enjoy a slightly longer lifespan than those who don’t drink anything at all, but in my opinion, that’s despite, not because of, the daily drink.

People who drink moderately tend to do many other healthy behaviors: exercising, eating right, seeing their primary care doctors regularly, etc. Although researchers have tried to analyze this statistically, the only way to really be sure would be to hold a trial where one group received alcohol and another group didn’t, and neither knew if the drinks were actually alcoholic. Since this is impossible (nonalcoholic wine or beer is still easy to tell apart from those containing alcohol), we are left with other kinds of studies.

One recent study from the United Kingdom showed that people who reported alcohol consumption in the moderate range (for example, half of a standard drink for women or one drink for men daily) still had an increase in the risk of dementia compared to nondrinkers. Other studies have reached different conclusions.

Still, the current consensus would be that there is no consistent healthy benefit to moderate drinking, and there is a clear hazard at levels of drinking above one drink a day for women or two for men.

The health costs of moderate drinking, like a glass of beer a day, are small. But if it is something you really enjoy, you can continue to have it, while recognizing that it might slightly lessen your chances of making it to 100.

DEAR DR. ROACH: I have a minor case of essential tremors. It doesn’t bother me, except when I raise my hand to my mouth. I appreciate any information you can give on the subject. — T.S.

ANSWER: Essential tremors are very common and often run in families. It may begin at any time, but I most commonly diagnose it in people over 50. I most often see it in the hands and arms, but it can involve the head, voice, face or trunk. When it is clinically typical and runs in families, a generalist can usually make the diagnosis, but a definitive diagnosis may require an expert, such as a movement disorder neurologist.

Often, those affected by essential tremors notice that it gets better temporarily with alcohol, but alcohol is not an effective long-term treatment and can bring on other complications. Essential tremors tend to worsen slowly with time.

Treatment for mild essential tremors is usually medical, with propranolol or primidone. For people like you, who may have trouble eating, I’ve had some luck with adaptive devices, such as a spoon/fork with active-cancellation-of-tremor technology.

Severe cases need to be seen by an expert, and I have had a handful of patients treated with focused ultrasounds, deep brain stimulations, or surgery.

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