Greetings and welcome to the continuing chronicles of this geriatric wunderkind’s travails treating his Type 2 diabetes with Mounjaro. Here, laced with my firsthand experiences, I give you the sweet lowdown on diabetes drugs, their weight loss cousins, and the healthcare industry. My opinions are — well, you know what they say about opinions.

For the uninitiated, Mounjaro is one of a class of incretin drugs called GLP-1 receptor agonists that started out as diabetes treatment but later became the darlings of the weight loss industry. Once studies and anecdotal experiences established the weight loss possibilities of GLP-1 RAs, drug manufacturers quickly obtained approval to ply their wares to the weight loss community. Mounjaro (generic: tirzepatide) was relabeled as Zepbound, Ozempic (semaglutide) became Wegovy, and Victoza (liraglutide) became Saxenda.

GLP-1 RAs have benefited many people, but in their euphoria, proponents, particularly in the weight loss industry, tend to downplay their risks. The prospect of easy, painless, automatic weight loss is too big a carrot not to take down in one big gulp. Unfortunately, unless accompanied by stringent dietary and strength training, that weight loss will be partially lean tissue — muscle. And, let’s face it— if people have failed at dieting and exercise programs in the past, they are seeking weight loss without the necessary demanding work.

That leads into this week’s two stories. One is about yet another expensive complimentary drug to stem the muscle loss associated with GLP-1 RA weight loss, a potentially costly boon for those looking for miracles. The other is a sell-out to Big Pharma by doctors who prefer drugs over lifestyle modifications as front-line treatment for obesity. Behold, a two-way winning week for Big Pharma!

The Two-Edged Syringe: Saving Muscle, Selling Out

Your weekly purveyor of metabolic mayhem returns with a double shot of GLP-1-related developments—one that might actually help people keep muscle while losing weight, and another that suggests the American College of Cardiology has finally been fully absorbed by the Big Pharma Borg.

Let’s start with the encouraging news. A recent phase 2 study suggests that semaglutide, when paired with the biologic bimagrumab, can preserve lean muscle mass during weight loss. That’s right: you get the fat loss benefits of a GLP-1 agonist without your thighs disappearing faster than a 401(k) in a bear market. In the trial, the combination led to a 15.6% reduction in body fat but actually increased lean mass by 1.5%. Compare that to semaglutide alone, which dropped fat by 8.6% but took 4.9% of muscle with it—like tossing out the baby with the bathwater, if the baby were your quadriceps.

Now, before we pop the champagne and start pricing out new belt sizes, there’s a big pharma-sized catch: cost. Bimagrumab is a monoclonal antibody, which means it doesn’t come cheap. Think “second mortgage” tier, not “skip Starbucks” tier. It’s also still experimental, so you won’t be getting this dynamic duo at your local CVS any time soon—unless your insurance plan has recently adopted a policy of underwriting miracles.

Snatching Victory from the Jaws of Defeat (with drugs)

While one hand gives (maybe), the other hand takes. Or in this case, shovels. This week, the American College of Cardiology issued new guidance that would allow physicians to initiate pharmacologic therapy for obesity without requiring patients to fail lifestyle interventions first. On the surface, this seems compassionate—why wait for people to suffer the futile shame spiral of diet failure when we have effective medications?

Yet scratch that surface and you hit gold—gold coins, that is. The ACC’s endorsement reads less like clinical guidance and more like a press release jointly issued by Eli Lilly and Novo Nordisk. By removing the need for a lifestyle “try-and-fail” period, they effectively convert every overweight adult into a potential subscriber to a lifelong, extremely expensive prescription plan. It’s a win for stockholders, not necessarily for patients—or for society, which now must reconcile the idea of drug-first treatment for a condition that remains deeply behavioral and environmental.

Let’s Fudge a Diagnosis

But the guidance doesn’t stop at endorsing first-line pharmacotherapy. It also tiptoes up to a truly uncomfortable ethical line. The document suggests that when insurance balks at covering GLP-1s for “just obesity,” clinicians might consider whether a diagnosis of prediabetes or type 2 diabetes could be used to meet coverage requirements. In plain English: if the BMI won’t get your patient the drug, go fishing for a glucose-related diagnosis code that will.

This kind of chart-padding may be common in modern medicine, but let’s not pretend it’s benign. It risks turning real diseases like Type 2 diabetes into mere leverage for insurance billing—a perversion of clinical diagnosis into a transactional code game. It also muddies the waters for those of us who have diabetes, who already navigate enough bureaucratic skepticism about whether we “really need” these drugs.

If Big Pharma’s marketing department had slipped this into a slide deck at a sales meeting, we’d all roll our eyes. That it comes from the American College of Cardiology in a formal position document should provoke outrage.

The Bottom Line

So what’s the net effect? You can preserve muscle now—maybe—if you can afford a biotech-grade add-on. And if you’re a doc, you no longer must waste time advising diet and exercise before hitting the GLP-1 easy button. It’s all very convenient. For everyone except the patient paying $1,200 a month for the privilege of being slightly less obese, with slightly less muscle.

I’ve spent 56 weeks harping on the dangers of muscle loss during GLP-1-mediated weight loss. This bimagrumab news is a legitimate scientific advance. But the rush to put everyone on injectables—without even a speed bump labeled “behavioral change”—feels like a cynical shortcut. It’s hard to view it as anything but a declaration of defeat on the lifestyle front. Or maybe just a good quarter for Novo.

My Week on Mounjaro

I continued physical therapy for my “good” knee. Monday’s session was a “come to Jesus” conference with the therapist, where I reviewed the treatment plan, noting several aspects she was failing to provide. So, naturally, my second visit that week was a torture session. Be careful what you ask for!

The only other medical encounter during the week was an always pleasant visit to my podiatrist. She runs a small, family practice, a legacy of her dad, who is a respected, semi-retired podiatrist in this area. Many of the other podiatric practices have been swallowed up in the great private equity healthcare consolidation, which drives a wedge between patients and physicians, so it is refreshing to find a friendly practice where patients are treated like family.

But I digress. Let’s move on to the numbers for the week.

• Weight: 173.6 lbs — down 2.6 lbs.
• Fasting Glucose: 106 mg/dL — about the same.
• Stelo Overall Average: 105 mg/dL — down slightly.

See You Next Week

That’s all for this week from your favorite Type 2 cyborg. Muscle matters. Ethics matter. And if the ACC needs help rewriting their next press release, I hear Novo’s hiring.

See you next week—syringe in hand, dumbbells at the ready, and moral compass (mostly) intact.

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

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.