I’m back with the latest installment of my Mounjaro-fueled foray into Type 2 diabetes control. At age 78, I’ve now spent over a year jabbing myself with my preferred GLP-1 receptor agonist, watching my HbA1c drop into smugly normal territory, trimming my pharmaceutical roster, and saying goodbye to seventy-five pounds of metabolic avoirdupois.

These weekly updates serve two purposes: to share my personal progress and to vent — with style — about the medical-industrial comedy that surrounds drugs like Mounjaro. For those of you starting out with GLP-1 therapy, I offer this mix of anecdote and invective as a cautionary tale. Yes, these drugs are powerful tools. No, they are not magic. Without commitment, effort, and at least a little dietary sanity, the only thing they’ll reliably shrink is your wallet.

My Appetite is Back

Let’s talk about the so-called “miracle” of appetite suppression. The YouTube pharmababblers — pumped full of sponsorships and pseudoscience — treat GLP-1s like Ozempic Fairy Dust. But I can tell you from experience: unless you plan to dose-chase into orbit, the effect fades. Mine lasted just long enough to rewire my eating habits toward low-carb territory, which suits me fine now that I’m focusing more on muscle than weight loss. I’m at the 7.5 mg dose, with no plans to go higher. Appetite suppression? Who needs it, already? Glycemic control is the goal — not accidental anorexia.

Mounjaro Ain’t Cheap!

Sticker shock alert: if your insurance doesn’t cover GLP-1s, you’re staring down $1,200 a month. Even with Medicare Part D and a drug plan, I’m shelling out $250/month for my Mounjaro fix. It’s enough to make you consider robbing a CVS — though ironically, they’d probably deny the claim. And now the insurers are finding new and exciting ways to “manage utilization,” which brings us to this week’s delightful screed.

The PBM Shuffle: EnGuide and the Great GLP-1 Shell Game

If you’re using GLP-1s to keep your beta cells from waving the white flag, congratulations — you’ve just been volunteered into a high-stakes farce run by Pharmacy Benefit Managers (PBMs). Think of it as “Squid Game,” but for your pancreas.

EnGuide: The New Dog in Express Scripts’ Kennel

As of June 15, Express Scripts has outsourced your Mounjaro refills to a startup called EnGuide Pharmacy — “powered by CHD,” which they swear stands for Certified Health Delivery and not Congestive Heart Disease, though I remain unconvinced. The rebrand promises “convenient home delivery,” which in PBM-speak means “we’re adding another layer of bureaucratic fog between you and your meds.”

Let’s call EnGuide what it is: a utilization management checkpoint, a rebate harvester in a lab coat, a denial machine with lipstick. You don’t need a pharmacy — you need a permission slip.

The Pre-Authorization Gauntlet

If your GLP-1 refills are starting to feel like Kafkaesque quests, that’s because they are. These so-called “designated pharmacies” specialize in exhausting you into compliance — or better yet, giving up. The only weight they help you lose is the crushing burden of hope.

CVS Joins the Party

Never one to miss a chance to profit, CVS Caremark has instituted its own “clinically aligned” GLP-1 centers. Think automated chatbots with lab coats and PowerPoint slides. You may be denied medication not because you’re noncompliant, but because you’ve lost “too much” weight. Yes, being too healthy is now a problem — just not for your insurer’s earnings report.

Walgreens? They’ve launched “Health Corner,” which is like telemedicine, except it’s run by people who used to work the cosmetics counter.

The Real Agenda

Please note that a subset of patients taking a GLP-1 for weight loss will need to be enrolled and engaged in a lifestyle modification program before receiving the medication. This requirement is chosen by your employer or health plan. You will be notified if you are in this program and advised what to do when you place your medication order.

—Evernorth Health Services

These PBM spinoffs aren’t here to help you — they’re here to reshape the narrative. Their goals are simple:

• Control cost (their cost, your health be damned)
• Harvest data (ever hesitate before hitting ‘Refill’? That’s logged)
• Steer behavior (click here to confirm you’re not abusing this miracle drug)

And if you want to keep using your preferred pharmacy? Sorry, that ship has been rerouted — probably to a container port in Shenzhen. You’ll need your doctor to fax a 27-page form to EnGuide’s secret lair while standing on one leg reciting the Hippocratic Oath.

Sidebar

What’s happening?

PBMs (Pharmacy Benefit Managers) like Express Scripts, CVS Caremark, and OptumRx are increasingly pushing GLP-1 prescriptions through designated specialty pharmacies — such as Evernorth EnGuide Pharmacy, a subsidiary of Cigna/Express Scripts. They claim it’s for “convenience.” It’s really about control.
What is a ‘designated pharmacy’?
It’s a locked gate disguised as a red carpet. You may still “choose” another in-network pharmacy, but that requires effort, paperwork, and frequently — your doctor’s direct involvement. For many, it’s easier to comply than to fight.
Why now?
GLP-1s like Mounjaro and Wegovy are expensive and wildly popular. PBMs want to curb usage, maximize rebates, and closely monitor patient adherence. Routing scripts through their own subsidiaries gives them tighter reins — and a bigger piece of the financial pie.
What changes for you?
You might need new prior authorizations.
You may face refill delays.
You’ll be nudged toward online portals, virtual “coaching,” and data-sharing “opt-ins.”
You’ll lose flexibility in choosing how and where your medications are dispensed.
Is this legal?
Yes. Is it patient-centered? Not even close. It’s a quiet recalibration of access, placing corporate interests over medical autonomy.
What can you do?
Keep accurate records of delays and denials.
Talk to your doctor about keeping a paper prescription on file.
Escalate unresolved access issues to your state insurance commissioner or attorney general.
Push back. The more noise patients make, the harder it becomes for these silent maneuvers to stay hidden.

Who Wins?

Not you. Not your doctor. Not even your long-suffering pancreas.

The big winners are:

• Evernorth/EnGuide, now raking in profits from “specialty care” and shadow rebates.
• Cigna, CVS, UnitedHealth, who’ve built vertical empires where denial is a service.
• Wall Street, who loves nothing more than “patient channeling” and “therapeutic rationalization” — euphemisms for “we made it so annoying they quit.”

What Can You Do?

Short of chaining yourself to the EnGuide loading dock, consider the following:

• Refill early and often.
• Get a paper script to take elsewhere.
• Alert your doctor when “transition of care” gets mentioned — it’s rarely a good thing.
• Document every delay, denial, and duck-and-cover — they may come in handy with your state board or Medicare appeal.

And above all: remember, GLP-1s may suppress your appetite — but nothing suppresses a PBM’s appetite for profit.

This Week on Mounjaro

I placed my first order with EnGuide. No glitches yet — but I’ll be watching. Probably harder than they’re watching me.

The medical carousel slowed this week: just one PT session and a Tuesday visit with Dr. DeLorean to review my recent CT scan. No tumors — hooray! But my iron levels still look anemic and hemoglobin is slightly low. He’s not worried. I am. So I’m watching this like a hawk — or, more appropriately, like a turkey guarding his giblets.

The Mounjaro Numbers

• Weight: 176.2 lbs — steady as she goes.
• Fasting Glucose: 107 mg/dL — a modest drop.
• Stelo Overall Average: 107 mg/dL — also down a notch.

Conclusion: Same Mounjaro, New Tricks, More Nonsense

This week’s lesson? The battle for better health doesn’t end at the injection site. GLP-1s might lower your glucose, but they won’t protect you from PBMs weaponizing “care coordination” against your sanity. As for me, I’ll keep taking the drug, watching the numbers, and telling the truth — because someone has to.

See you next week, unless I’ve been put on hold indefinitely by a robot named “Clara” at EnGuide.

For an annotated catalog of all my Mounjaro updates, please visit my Mounjaro Update Catalog page.

Over a year into Mounjaro treatment for Type 2 diabetes, the well of fresh topics is running a little dry. So once again, I do what I do best: talk about me. This week’s update is a tour through six back-to-back medical appointments, starring your faithful 78-year-old narrator, with occasional tangents, health system gripes, and—naturally—a slice of carrot cake.

For those new here, I’m a Type 2 diabetic who’s attained an HbA1c of 5.3% and lost 70 pounds with the help of Mounjaro (tirzepatide), some dietary discipline, and a steady commitment to strength training. I’ve cut my losartan dose in half and ditched metformin. But let’s be clear: Mounjaro isn’t fairy dust. You still have to eat like a grown-up and move your body like you mean it.

Last week, I told you about the precursors for the forthcoming blitz. Now, onto the week’s circus.

Monday Madness

I kicked off with a hernia evaluation. Turns out I’ve got bilateral inguinal hernias, likely congenital, not gym-induced. One of them is self-reducible, which is every bit as glamorous as it sounds. Surgery’s on hold pending CT scan results for some recent weight loss and general malaise. The surgeon was great, but his scheduler? Not so much—blissfully unaware of clinical notes or context. Also on Monday: knee rehab, the one appointment where I voluntarily sweat.

Tuesday: Scan Shuffle

The CT scan got the ol’ reschedule treatment thanks to a paperwork snafu about oral contrast. Apparently, getting some contrast bottles two hours early is harder than launching a SpaceX payload. So instead of the scan, I settled for a chest x-ray and a return trek through hospital hallways after leaving my sunglasses in the radiology room. Joy.

Wednesday: Laser Light Show

Time for a YAG laser zap to fix post-cataract cloudiness. In and out. No pain, no fuss. I did recommend the Fyodorov patient turntable to the doc, but he didn’t bite. (Too bad—it would improve throughput and provide carnival vibes.)

Thursday: A Breather

Only one follow-up appointment, which in this new medical lifestyle qualifies as a day off. Thursday is Lunch with Wifey day, so I indulged in a sandwich and a pile of fried breaded onion rings, which as you’ll soon see was not my only nutritional travesty of the week.

Friday: The Grand Contrast Caper

Finally got the CT scan—after a mere 40 minutes of waiting and a foot-up-the-ass inquiry at the front desk. After slugging two bottles of vintage 2025 contrast fluid, I was free to roam until scan time. I indulged in carrot cake (for science) and amused the skinny IV blonde with tales of banana dream cake—though her sense of humor remained unscanned.

CT Results: A Reluctant Relief

Good news: no malignancy. Just hernias and the usual 78-year-old relics of prior adiposity. Bad news: still feeling off, and Dr. DeLorean tends to tap out when medicine stops being linear. We’ll see what he offers at tomorrow’s follow-up—or if I’ll be referred to The Irascible Dr. Scrooge for further adventures in GI guesswork.

This week’s medical mayhem was facilitated by my trusty Tesla, which drove me to all the appointments. Full Self Driving is quite handy for these boring medical commutes, inspiring the question asked by some of my friends: If you conk out in the car, will it drive you to the hospital? We’ll see…

Supplement Scam Alert

A brief sidebar on creatine, courtesy of influencer Thomas DeLauer. He tested various creatine gummies and found—surprise!—some contained no creatine. A smartphone app created by his partner SuppCo lets you scan barcodes to see how your supplements stack up. It’s possibly biased, definitely commercial, but potentially useful. I’ve installed it and turned off the spammy notifications.

I checked out my collection of supplements, which SuppCo calls my “supplement stack.” More vogue terminology bullshit, and I bet they say “based off of” in the office at SuppCo, but I digress. The vast preponderance of my “supplement stack” were rated “poor.” Harrumph!

Here is a link to SuppCo’s deep dive into creatine supplement testing.

As I type this, my Amazon Echo Show screen is flashing ads for creatine monohydrate gummies, triggering a directed-ad paranoia attack. Oy vey, what a world of dubiously modern bullshit we live in! Anyway, watch DeLauer’s video, with a Turkey-approved jaundiced eye, of course.

This Week’s Mounjaro Numbers

• Weight: 176.2 lbs (up 2.6 lbs) — thanks, carrot cake.
• Average fasting glucose: 109 mg/dL — edging higher, time to tighten things up.
• Stelo overall average: 108 mg/dL — steady under the circumstances.

Conclusion

So ends another thrilling episode of “As the Glucose Turns.” Six appointments, one carrot cake, and zero answers to the nagging malaise. Still, I didn’t die, didn’t need surgery (yet), and didn’t assault anyone in the waiting room—though I was tempted. The CT says I’m boringly normal, which is both comforting and confounding. Next week’s adventure hinges on whether Dr. DeLorean brings inspiration or inertia to the table. Stay tuned, my fellow metabolic misfits.

For an annotated catalog of all my Mounjaro updates, please visit my Mounjaro Update Catalog page.

Your health-conscious Nittany Turkey is back atcha with another week of medical frivolity, pharmaceutical love/hate, and whatever else crosses my mind. I’ve just passed the one-year mark both taking Mounjaro and writing these updates, which center on that GLP-1 receptor agonist drugs and more specifically, tirzepatide, whose trade names are Mounjaro and Zepbound.

Via Mounjaro therapy combined with lifestyle changes in diet and exercise, this 78-year-old Type 2 diabetic has controlled his blood sugar, most recently scoring a 5.3% HbA1c, which deliciously makes my doctor jealous. “It’s lower than mine!” he exclaimed at our last encounter. Mounjaro has allowed me to eliminate metformin and halve my dose of losartan, a blood pressure control drug. Along with Mounjaro, I credit my amazingly supportive wife, my friends, you readers, and from time-to-time, my healthcare team (when I’m not bitching about them).

Nevertheless, along with the positive strides, there exists an omnipresent background reality of a near-octogenarian body that has seen better days. While I might be accused of over-sharing some personal health information, I know many of my readers either have endured similar health travails or will do so at some point. I hope that by providing TMI (too much information), I’ll help someone, somewhere. Plus, I love to write, and my expository efforts here provide a safety valve that helps me deal with the stress of living inside an unpredictable, old body.

Weight Loss: The Good, the Bad, and the Ugly

Over the year on Mounjaro, I have lost about 72 pounds of excess body weight. However, the most recent eight or ten of those pounds were unplanned and undesirable. I wanted to stop losing weight while concentrating on retaining or even building skeletal muscle. Thus, I had increased my caloric intake, especially the protein component, and I have been doing copious strength training workouts The plan was working well, with my weight hovering in the low 180-pound area until last weekend, when I suddenly dropped eight pounds, inspiring my latest visit to the fabled Dr. DeLorean (not his real name). I’ll talk about that visit, its sequels, and my busy week ahead in healthcare after our featured article.

In This Week’s Issue…

Rapid weight loss causes not only fat loss but also loss of muscle tissue. Coupled with sarcopenia, the muscle loss associated with aging, the results can be catastrophic for older adults. Heretofore, the remedy was strength training and increasing protein in the diet. This is a big problem for a couple of reasons. First of all, primary care physicians obsessing on the weight loss aspects seldom stress the crucial need to preserve muscle mass. Patients, too, become enthralled by decreasing numbers on the scale, in their euphoria not considering the possibility of collateral damage. When that realization arrives for some of them, it could be too late.

Although I have reservations about prescription drugs addressing all our body issues better than natural methods, I found the subject we’ll cover this week exceedingly interesting, especially for those of us who focus all our attention on weight loss. What if we could lose fat and gain muscle? Is that even possible. Well, saddle up and let’s take a ride through the monkey jungle to the confluence of the Trevogrumab and the Garetosmab, which define the fertile crescent of astounding pharmacological research.

This Week’s Feature: Of Monkeys, Muscles, and Multinational Mischief

If you’ve been paying attention to the rapidly mutating landscape of weight-loss medications, you might’ve noticed that the latest shiny objects aren’t injectables, but injectable combos. And now, courtesy of Regeneron Pharmaceuticals, Inc., of Tarrytown, NY—who incidentally just pulled off a genetic database coup by acquiring the remnants of 23andMe—we’ve got a new pair of biologics in the spotlight: trevogrumab and garetosmab.

These two monoclonal antibodies are being studied in tandem with semaglutide (yes, that semaglutide, the generic name for Ozempic and Wegovy) to address the elephant in the examination room: muscle loss during rapid weight loss. As I have mentioned ad nauseam, it is a huge problem especially with GLP-1 drugs, where dieters lose weight fast but unfortunately lose a decent chunk of lean muscle in the process. So, Regeneron’s idea? Inject something that blocks muscle breakdown and perhaps even builds muscle, while semaglutide peels off the fat.

Monkey See, Monkey Gain

The inspiration comes from preclinical studies on obese monkeys, where combining semaglutide with trevogrumab and garetosmab not only reduced body fat but also increased skeletal muscle mass. Yes, you read that right—those lucky macaques lost weight and gained muscle, a metabolic unicorn if there ever was one. Try pulling that off at your local Planet Fitness!

So, what exactly are these mystery drugs?

• Trevogrumab is a monoclonal antibody that blocks myostatin, a protein that acts like a brake on muscle growth. Inhibiting it gives muscle tissue the green light to grow. Think of it as the anti-sarcopenia serum we’ve all been waiting for.

• Garetosmab targets activin A, another protein that suppresses muscle growth and promotes inflammation. Blocking both pathways theoretically amplifies anabolic signaling while dialing down the catabolic stress signals that GLP-1s may unintentionally stir up.

Together, this tag team may not only protect muscle mass during semaglutide-induced weight loss—but potentially reverse the muscle decline altogether.

Big Pharma’s Duality Dance

Now, before we break out the syringes and protein powder, remember: this is Regeneron. The company that gave us pricey eye injections and COVID monoclonals—both highly effective, mind you, but also wallet-vaporizing. So it’s no surprise that this muscle-preserving magic cocktail is currently sitting in Phase 2 clinical trials, with human results likely a year or two away. If Phase 3 goes smoothly (and that’s a big “if”), expect FDA filings around 2027 or 2028.

And pricing? Take a guess. If semaglutide alone can run $1,000+/month and a single monoclonal antibody like garetosmab (once studied for fibrodysplasia ossificans progressiva) is priced in the $300,000/year neighborhood—well, you do the dystopian math. Pairing two such drugs with a GLP-1 will likely result in a monthly bill much larger than your Social Security income and your Tom Selleck-approved reverse mortgage combined.

The Muscle Mass Mirage

Still, for a subset of patients—think elderly, frail, or cancer-cachexia cases—this combo therapy could be revolutionary. For the rest of us trying to keep our biceps from dissolving into batwings while on semaglutide or tirzepatide, it may be the ultimate carrot-and-stick routine… assuming your insurance company doesn’t laugh you out of the pharmacy.

Of course, for those of us who don’t mind some hard work, there’s always a cheaper alternative: lift weights, eat your protein, and maybe toss in some creatine. No prescription required.

My Week on Mounjaro

So, as I mentioned above, I visited Dr. DeLorean on Tuesday with my tale of rapid weight loss and feelings of malaise. He did some blood draws: a CMP, CBC, and iron, as well as a urinalysis, and ordered an abdominal/pelvic CT scan and a chest X-ray, which I have scheduled for tomorrow. The blood results revealed an elevated white cell count, especially monocytes, so something is going on in there.

I still feel like crap, although I have been trying to keep up with strength training, much to the chagrin of my lovely wife. (But like she often exhorts to me, I’m not a princess). So, we await results of the imaging for more clarity on what ails me. From my point of view, my damn digestive tract is the root of all bodily evils, so I firmly believe that the answer will be found there. It might be bad or ugly, but it likely will not be good.

However, there was some good news in my lab report. The potassium spike noted on my May 17 blood work proved to be an anomalous blip. Potassium is back to normal.

Stacking It Up

I started physical therapy for my bum knee last Wednesday. I’m supposed to do that twice per week, but I scheduled only through today for a couple of reason. For one, this morning, I’m seeing a general surgeon to evaluate my inguinal hernia. My intent is to have it surgically repaired before it becomes a medical emergency. However, my schedule is a mess. The CT scan and Chest X-Ray results will bear heavily on my decision. I will not speculate on anything until I have digested them. As I mentioned above, I might or might not be able to schedule the six weeks of physical therapy I was prescribed, given the recovery time for hernia surgery, which will also impinge on my planned August road trip. So, albeit with a foreboding sense about the CT scan, I look forward to attaining more clarity as the week progresses.

I covered Monday and Tuesday, but the medical bullshit does not end there. On Wednesday morning, I will have YAG laser surgery on my left eye. Three-and-a-half years after cataract surgery, I have developed some cloudiness of the rear surface of the lens capsule, which is a common sequel. The YAG laser is a specialty tool that zaps the film and cleans up the visual field, not that all my floaters will go away or anything, but the cloudiness will be gone. For how long, no one knows.

Whew! About time I get to the numbers for the week, which are anticlimactic in comparison to the excitement of chasing around from medical facility to medical facility while waiting for results, which I’ll share with you in next week’s exciting update.

The Mounjaro Numbers, Already!

Given my unexplained weight loss, abetted by my appetite suppressing malaise, I have been eating opportunistically, not watching carbs. Thus, the glucose is a bit higher than I would like, although the weight keeps dropping.

Body weight: 173.6 lbs (78.9 kg) —  down another two pounds (0.9 kg) with no explanation
Average fasting glucose: 104 mg/dl (5.8 mmol/L) — would like it to return to the 90s
Average overall glucose (Stelo biosensor): 108 (6.0 mmol/L) — steady, all things considered.

Bonus Info: It Wasn’t the Coffee!

Remember Week 51, when I described a glucose spike I attributed to my morning coffee? Well, friends, I found the true reason for the spike, and it wasn’t the cuppa joe. Coffee does produce what can be described more accurately as a slight hump, but as it turns out, the spike was from the damn supplements I take in the morning before my coffee. Because of the Mounjaro Effect, I take a fiber supplement. I also take probiotic and magnesium supplements. I’ve been buying gummies without paying attention to the carbs. Well, friends, it turns out that all three supplements contain significant amounts of sugar and pack a combined 20g carb punch every morning. They were the culprit, not the coffee.

Conclusion: Of Science, Supps, and Sarcopenia

So there you have it—another week of GLP-1 rumination, medical spelunking, and simian steroidal envy. We began our odyssey deep in the metabolic jungle, where macaques on miracle meds defied the laws of thermodynamics and gained muscle while shedding fat. Meanwhile, back in the human world, I’m losing weight whether I want to or not, fighting off sarcopenia like it’s a rogue AI, and booking more appointments than a celebrity dermatologist during Oscar season.

This week brought a sobering reminder: weight loss without muscle preservation is a fool’s bargain, especially as we inch toward our eighth decade (with or without dignity). Whether future drugs like trevogrumab and garetosmab will be the golden ticket—or just another pricey detour on the road to “better living through chemistry”—remains to be seen. In the meantime, I’ll stick to my current stack: sweat, protein, creatine, and sarcasm.

Next week, we’ll parse scan results, ponder potential surgery, and maybe even exorcise that cloudy lens ghost with a well-placed YAG. Until then, stay skeptical, stay strong, and please—check the damn carb count on your gummies.

For an annotated catalog of all my Mounjaro updates, please visit my Mounjaro Update Catalog page.