Welcome back to Peptide Purgatory, where the blood sugar’s stable, the sarcasm’s spiking, and the federal government still thinks it’s a physician. This week, I trade the ephemeral Halloween parody of the ghost of Dr. DeLorean (trick or treat?) for a down-to-earth, flesh-and-blood doctor who actually listens—Dr. Macallan, who manages to practice real medicine without the support of a 20-person front desk, a mid-century modern castle, and a stable of vintage automotive machinery funded by concierge fees. Along the way, we’ll talk Farxiga, Mounjaro, and the ever-expanding Broadway division of Big Pharma, where even your kidneys get a dance number.
So grab your favorite low-glycemic snack, silence your CGM alarms, and enjoy this week’s episode of Peptide Purgatory: The Musical That Shouldn’t Be.
Macallan Delivers
For years, my previous doc — Dr. DeLorean — brushed off legitimate issues with all the enthusiasm of a DMV clerk on Friday afternoon. Voltaren for this, “don’t worry about it” for that. Nothing got a real work-up unless it was gift-wrapped in a disaster bow.
Enter Dr. Macallan — who spent a full hour in clinic, going line by line through my hit list. When he saw that I brought a three-page list of follow-up items, he said he’d go through my questions first before he got to his notes. After my myriad questions, he said we covered most of the follow-up items, but he had a couple of additional ones. Imagine that: a physician who listens, thinks, and even follows through.
Mounjaro: Stay the Course
He previously floated lowering me from 7.5 mg to 5 mg weekly to protect against “too much weight loss.” Cute idea, except my weight has been flat at 176 ±3 since June while my glucose has been a little higher than I’d like it. Skeleton chic is not in my near future. We’re sticking with 7.5.
CKD Protection: Farxiga Joins the Party
After warming up to the data, I agreed to start Farxiga 10 mg. The hurdles? Prior authorization with Express Scripts — patron saints of hoop-jumping. Invokana isn’t even on my formulary, so Farxiga it is. The plan: stop it 14 days before hernia surgery, then restart when life returns to normal. Until then: crotch hygiene drills. (See the sidebar on SGLT-2 inhibitors’ potentially serious side-effects).
Supplement Purge
I reviewed my list of Instagram-influencer approved supplements with Macallan. Just kidding about where I got my prior supplement recommendations, but I never found much clarity on the subject with DeLorean. So, I was happy to get some supplement advice from my new doc.
One important thing is that people like me with chronic kidney disease do not absorb oral iron supplements very well. That is why I am now doing IV iron supplementation and am dropping the Feosol Complete.
- In: Vitamin D3 boosted to 5000 IU.
- Out: B12, Feosol Complete, magnesium glycinate.
- Survivors: multivitamin, fish oil, CoQ10, creatine. Saw palmetto is optional — Macallan calls it worthless, but I reserve the right to indulge in placebos. I mentioned cranberry supplements, which he said he would favor, so I bought some to enhance the urinary tract placebo effect.
Iron, With Caution
Hemoglobin slid to 12.9: true iron deficiency confirmed. The fix: IV Venofer 200 mg ×3, with labs guiding any escalation (I’ve completed two IV infusions thus far; the third will happen on Friday). He wisely wants to avoid “overcorrection” into the land of carpenter’s-nail poop. Iron labs at 6 weeks, kidney labs every 3 months.
Protein Truce
CKD wants lower protein, sarcopenia demands higher. We struck a compromise: 120 g/day. Enough to feed the muscles without punishing the kidneys.
Hernia Surgery (Dec 9)
Plan is robotic surgical Jenga with mesh. Med hold orders: stop Mounjaro and Farxiga 14 days prior, bridge with Metformin XR (up to 500 BID).
Labs & Imaging
- Cystatin-C: Put kidney fears back in perspective. True function sits around stage 2, not 3a. Creatinine was falsely elevated due to Creatine supplementation and high-intensity workouts.
- PTH/Phosphorus/Calcium/Vitamin D: All normal. Wrist calcifications aren’t hormonal mischief. Vitamin D landed beautifully at 72.
- Surprise Add-On: Morrissey flagged an incidental lung nodule from an old CT — something DeLorean never mentioned. Follow-up CT is on deck for early 2026.
Next Steps
Hernia surgery scheduled for December 9. We regroup January 7, 2026, with ongoing tweaks as labs roll in. Meanwhile, I left my Tesla key fob in Macallan’s office. He had to call me — luckily the phone doubles as a key, so I had driven off none the wiser. Score one for modern tech saving me from myself.
Editorial Comment by the Turkey
Editorial Comment: Why I like this practice.
It’s early, but I am impressed and optimistic. Aside from his engagement level and thoughful medical assessments, Dr. Macallan has created practice model that appeals to this old fart. He and his wife, who I’ll call Dr. Calabrese, are the primary (and only) physicians who handle all the clinical tasks, including drawing blood. Dr. Macallan’s dad is the office manager. They do not take insurance (hence, the “direct primary care” moniker), so there is no need for dozens of office people running around, all asses and elbows.
The atmosphere is calm and relaxed. The waiting room is not bursting at the seams with patients dressed in midnight Walmart attire coughing loudly while nattering obnoxiously on cell phones. This ambience provides the benefits of a concierge practice without the ostentation, presumed prestige, and hefty fee. Unlike DeLorean, Dr. Macallan will not be building castles in the sky and hiring half a dozen desk ornaments who all can draw blood anytime soon. As he is not trying to attract only rich, healthy clients, at one-third of Dr. DeLorean’s fee, he is a value equation personified.
Our intelligent interaction between visits is worth its weight in gold. Unlike the DeLorean patient portal, a relic of 18th Century Internet technology he used to deflect patients, Dr. Macallan has provided patients with a useful tool, a communication system called “Spruce”, which is a private text messaging system. He responds personally, within a few hours. Both he and I can attach photos, PDFs, etc., to text messages seamlessly. Instead of being an impediment, Spruce enhances patient communication — and the responses come directly from Dr. Macallan, not from a desk ornament relaying, “He says… [whatever]”.
Big Pharma’s Broadway Auditions
You’ve seen the commercials: overweight, middle-aged Americans skipping down sidewalks, belting out songs about their blood sugar, and high-fiving complete strangers like they just got cast in Hamilton. This is what passes for pharmaceutical marketing in 2025.
Take Jardiance. Clinically, it’s a fine SGLT-2 inhibitor—works as well as Farxiga at slowing kidney decline and cutting heart failure hospitalizations. But what’s it best known for? Not the EMPA-KIDNEY trial. Not the reduction in all-cause mortality. Nope. It’s the damn song and dance routine. The pill has its own chorus line.
It’s a brand-new pill with a story to tell:
I pee out my donuts and I feel so well.
So while my crotch rots off, it’s easy to see
that I’m still lowering my A1c!
Meanwhile, Farxiga, the drug my doc picked, went a different route. No Broadway numbers. No “pill with a story to tell” jingle. Just boring old data from DAPA-CKD that showed it slows kidney disease in diabetics and non-diabetics alike. Which one do you think I’d rather swallow? (Hint: the one that isn’t trying to get me to tap-dance my way into end-stage renal disease.)
And the kicker: drug reps still have the gall to take their jingles seriously. My doc once cracked a joke at a conference about the singing Jardiance people. The rep just stared, deadpan—like someone had insulted the honor of their Broadway cast. If you can’t laugh at your own commercials, maybe don’t hire the moonlighting cast of an obscure, Little Rock, Arkansas production of Hairspray in pink cardigans skipping to choreography in the first place.
So here’s my rule of thumb:
- If your drug has a catchy tune, it’s not the data they want you to remember.
- If your drug doesn’t need a jingle, it might actually work.
Big Pharma wants patients to hum their way to the pharmacy. I’ll stick with boring Farxiga, thanks—no singing, no dancing, just working kidneys.
The Dark Side of Farxiga (and Friends)
SGLT-2 inhibitors — Farxiga, Jardiance, and the infamous Invokana — deliver on kidney protection and heart-failure reduction, but the halo comes with horns.
Euglycemic DKA (euDKA)
Ketoacidosis can strike even when glucose looks “normal.” Illness, fasting, or low-carb dieting can flip the body into fat-burning overdrive, flooding it with ketones.
Watch for: nausea, vomiting, fatigue, fruity breath, or rapid breathing.
Action: check ketones, stop the medication, and call your doctor before your blood turns artisanal.
Urinary & Genital Infections
SGLT-2s make you pee sugar — a microbe buffet. Expect burning, itching, or yeast overgrowth.
Stay ahead: hydrate, keep things clean, and treat early with antifungals or antibiotics.
Fournier’s Gangrene
Rare but horrific: a necrotizing infection of the perineum. Early swelling, pain, or odor means one thing — get to the ER immediately.
Invokana’s Amputation Rap
Canagliflozin broke ground — and nearly broke ankles. Early trials showed a higher risk of lower-limb amputation, especially in patients with neuropathy or vascular disease. The FDA later softened the warning, but the stigma stuck.
- Hold SGLT-2s if fasting, sick, or before major surgery.
- Hydrate — low volume magnifies every side effect.
- Check ketones when ill or eating poorly.
- Don’t tough out urinary or genital infections.
Used intelligently, these drugs are allies. Used carelessly, they’ll make you the next Peptide Purgatory parable.
Let’s wrap up this issue of Peptide Purgatory with a Bullshit Corner jab at federal government overreach. (So, what else is new?)
Bullshit Corner: Tylenol
Bullshit Corner: Tylenol as Political Theater — Trump & RFK Jr. Play Doctor
Acetaminophen (Tylenol to you and me) has become the latest sacrificial goat at the altar of American political theater. On September 22, the FDA issued a nationwide “alert” hinting that Tylenol use during pregnancy might increase the risk of autism or ADHD. They admitted there’s no causal link but still set in motion a label change.
That very same day, President Trump took the stage to advise pregnant women to “tough it out” rather than take Tylenol. Yes, the leader of the free world telling women to sweat through a 102° fever rather than reach for the one over-the-counter drug considered safe in pregnancy.
Trump’s medical credentials? A spray-tan habit, a passing fling with hydroxychloroquine, and that unforgettable White House riff about injecting disinfectant to “clean” the lungs — better known as the drink bleach and pray doctrine of pandemic medicine.
His HHS secretary, RFK Jr., has long made a career out of sowing vaccine paranoia and filing lawsuits. For years, he and his plaintiff-bar pals have circled Kenvue (Tylenol’s corporate parent) with autism suits, hoping to hit the jackpot. With the FDA’s shaky “warning” and Trump’s bully-pulpit bluster, they’ve now got courtroom exhibits wrapped in a red, white, and blue bow.
The Science Says Otherwise
A massive Swedish registry study following 2.5 million kids found no causal connection once you account for genetics and confounding factors. WHO and major OB-GYN bodies agree: there’s no strong evidence that Tylenol in pregnancy causes autism. What is risky is untreated high fever during pregnancy. (See this interview in JAMA for more information).
But Trump never lets science get in the way of a histrionic performance. Whether it’s bleach, sunlight, or Tylenol, his press conferences remain a mash-up of snake-oil salesman and reality-TV host: confidently wrong, dangerously loud, and always entertaining for the cameras.
Wall Street Meets Quack Street
The market reacted faster than a febrile mother at Walgreens. As soon as Trump declared Tylenol guilty, Kenvue’s stock plunged nearly 7 % to its lowest point in over a year. The next day it bounced about 6 %, like a patient briefly revived by the paddles. But zoom out: shares are still down ~14 % since early September. Investors, like obstetricians, can smell the bullshit — but not before panic-selling on the presidential quack prescription.
The Charlatan Tag-Team
So what we have here is classic quackery masquerading as policy:
- Trump the obstetrician: “Just tough it out, ladies.”
- RFK Jr. the epidemiologist: turning shaky associations into lawsuits.
- The FDA the enabler: spinning statistical noise into new warning labels.
It’s not governance; it’s malpractice with a microphone.
The Real Risk
The real victims? Pregnant women caught in the crossfire, physicians wasting time debunking junk science, and a public once again told to trust politicians playing doctor. Fever in pregnancy is dangerous. Acetaminophen remains the safest option. The hysteria, not the pill, is the true toxin.
Bullshit Factor: Terminal. When Trump turns press conferences into medical rounds and RFK Jr. brings the trial lawyers along, you don’t get public health — you get political malpractice and a stock chart in ventricular fibrillation.
Closing zinger: This whole episode is enough to give you a headache — but for God’s sake, don’t reach for the Tylenol unless you’re ready to be sued, scolded, or subpoenaed.
Mounjaro Update
I’ve been remiss in telling you what’s going on with my Type 2 diabetes, as treated with Mounjaro. It was getting boring, so I branched out into a more generalized approach to my health updates. Yet, pharmacotherapy is about to become interesting again, as you might have gleaned while reading about my newly prescribed Farxiga treatment.
While the primary intent of the SGLT-2 inhibitor addition is to slow progression of diabetes related chronic kidney disease, it, along with Mounjaro (7.5 mg) and Metformin XR (500 mg), will create a trifecta of diabetes meds. If you are shaking your head thinking about the perils of polypharmacy, I share your trepidation, but I’m willing to try this. My weight and blood sugar stats thus become interesting for a change, so here’s the baseline as of this week:
- Body Weight: 174.2 lbs (79.2 kg)
- Fasting Avg. Glucose: 112 mg/dL (6.2 mmol/L)
- Average Glucose (Stelo sensor): 109 mg/dL (6.1 mmol/L)
- Current HbA1c (17 September): 5.5% (37 mmol/mol)
Conclusion
And there you have it—another week in the glamorous life of an aging pancreas and its overdrugged handler. Dr. Macallan continues to impress by doing the radical thing: listening, thinking, and not charging a $3,500 annual “concierge” surcharge for the privilege. Meanwhile, Big Pharma keeps auditioning for America’s Got Prescriptions, the White House keeps dabbling in tele-medicine without a license, and I keep poking holes in myself for science.
I’m officially done with Dr. DeLorean as of October 1, so my harping on that soured relationship will now hereby cease and desist. No further need to beat that dead damn horse while boring the crap out of my readers with my grousing!
Next up in Peptide Purgatory: my final iron infusion, my first week on Farxiga, ramping up for hernia surgery, and whatever fresh FDA acronym drops between now and then. Until that time, keep your ketones low, your crotch dry, and your bullshit detector calibrated—because in this field, it’s the only instrument that still works properly.
For an annotated catalog of all my Peptide Purgatory and Mounjaro updates, visit my Mounjaro Update Catalog page.
