The Week in Review and the Irascible Dr. Scrooge

I’m back to chronicle my progress with the Type 2 diabetes drug Mounjaro and that GLP-1 RA drug’s impact on my life.

Let’s get the UTI out of the way. I’ll tell you that after a few weeks of BS, my nasty UTI symptoms are gone. The second antibiotic, a ten-day course of Cipro, did the trick. Good riddance to Serratia marcescens — I hope I don’t see yo’ pink ass again!

This week’s post is late because I want to tell you about my consult with the gastroenterologist I call The Irascible Dr. Scrooge on Monday afternoon. More on that later, but first I will give you the usual background paragraph in case you’re a new reader. Those who know about me can skip to the next section.

If you’re new here, I’m a seventy-eight-year-old Type 2 Diabetic who has been injecting the GLP-1 RA drug Mounjaro weekly since June 2024. I remain at the minimum therapeutic dose of 5mg/0.5ml, which I have found does the job well. My HbA1c has improved from 7.6% (60 mmol/mol) to 5.5% (37 mmol/mol) (as of November 2024) while on Mounjaro, but Mounjaro is only a part of the story. Concomitant with my use of the drug, I have adopted a low-carb diet with a sufficiently high protein component to maintain muscle mass in conjunction with my commitment to exercise. I work out six days per week for at least an hour per day doing both resistance and cardio training, three days at the gym and three days at home.

Goals and More

I’ve got some goals, and I’m working toward them. I would like to see the HbA1c at 5.2% (33 mmol/mol) and my weight below 170 lbs (77 kg). Although I have lost over 60 lbs (27 kg) in the eight months since starting Mounjaro to get to my current weight of 188 lbs (85.5 kg), losing another twenty to thirty pounds (9-14 kg) might take twice that long or it might not even happen. I weigh the same as I did in my freshman year at Penn State, but I had much more muscle mass then. This leads in to my current paradigm: I want to concentrate on increasing muscle mass, if that is even possible for an old fart toward the end of his eighth decade. At least I want to preserve my remaining muscle.

We all begin to lose muscle starting around age forty, but we can lessen its effect through resistance training. My poor relative weight-lifting performance between the present and the distant past reflects that muscle loss. I wish I could lift as much as when I was twenty, but we all know that ain’t gonna happen! My compromise position is just to remain functionally strong as long as possible. My gym time and weight training at home is directed at that goal, not toward body building or setting personal records.

We Don’t Offer Advice

I am not here to give advice like you get on those smarmy YouTube channels, which are replete with dilettantes calling themselves “influencers” and shepherding their flocks of clueless sheep. It’s the blind leading the blind out there in that vast YouTube wasteland. Unlike the “influencers”, I won’t tell you what to eat or what drugs you should be taking. My purpose here is to relate my experiences, not to suggest that you should be doing the same.

I am not a doctor, but I have dealt with enough of them to know that they don’t have all the answers. Far from it! I don’t give answers here, just observations and opinions. I urge you to discuss any dietary changes, drug dosage, and exercise programs with a real, live, local doctor, not some hired hand working tele-medicine over the internet at a profit-driven compounding pharmacy.

In past issues, I have given you details about the tools I use to monitor my glucose, weight, and body composition. In succeeding issues, I will update that information to include exercise equipment. For now, though, I’m going to take you back to my medical travails.

So, What’s Up with The Irascible Dr. Scrooge

Dr. Scrooge is my gastroenterologist. Although he has performed three or four colonoscopies on me, he once baffled me by favoring me with the unprovoked declaration, “I don’t have to do colonoscopies.” I didn’t ask him what the hell he meant by that. I just figured he was telling me, “Look at me. I’m a big doctor, who owns this large GI practice, and I still get my hands dirty.” Or maybe he was trying to tell me that his practice is not a colonoscopy mill. I’ll never know unless it comes up again. In the meantime, I get a lot of mileage out of that story. But I digress.

Ironically Speaking…

Back in my Week 31 update, I told you about my low iron situation. At that time, I had scheduled an appointment for a follow-up with The Irascible Dr. Scrooge because my regular doctor hand-waved me through my concerns. Even though my low iron numbers decreased even more although I had been supplementing with Feosol 65 per his direction for two months, he declared that ferritin was the important number and pooh-poohed the crappy iron saturation. In fact, he said, he did not have a clue why those numbers would be low while ferritin was low-normal. My complete blood count showed no signs of anemia, so he was willing to let the whole matter drop.

I wanted to investigate possibilities such as chronic inflammation and subclinical gastrointestinal bleeds. The latter prompted me to schedule the appointment with The Irascible Dr. Scrooge, as I believe my gut is the root of all bodily evils. Lord knows I have enough diagnoses to kill me six ways to Sunday: IPMNs, chronic erosive gastritis, and Barrett’s Esophagus, to name a few. Therefore, I decided to subject myself to requesting an audience with the old curmudgeonly GI doc.

Could DeLorean Be Right?

In defense of my regular doctor’s assessment, I must say I’m not showing outward symptoms of iron deficiency anemia. I’m not pale, I don’t get dizzy, and I am not suffering from horrible fatigue. I push myself at the gym and still have plenty of energy. For example, last Wednesday, I worked out for an hour-and-a-half in the morning, came home, ate lunch, then went for a four-mile hike in my favorite state park. Then, I came back and did the laundry. So, perhaps Dr. DeLorean (not his real name) was right about iron not being a big problem. We’ll see.

I’m writing this on Sunday night. Tomorrow, I’ll go to the gym in the morning, then see Dr. Scrooge in the afternoon. I’ll finish the column with a recap of the consult and my weekly numbers when I return. I’m bound to have some good stories to season the otherwise boring medical TMI.

A Visit with Scrooge

After the usual preliminaries, a female employee who in an earlier time would have been called a “nurse” ushered me into an examination room to await the arrival of the Irascible Dr. Scrooge. Upon his arrival, he issued a perfunctory greeting, then declared that he would be reviewing my chart, after which a two-way conversation could proceed. Dictating the salient features to his transcriptionist sidekick, he described a plethora of gastrointestinal diagnostic results and diagnoses from the past two or three years. Once finished, he turned to me and asked, “What brings you here today?”

I described my functional iron deficiency and asked whether he had the test results, which he did. This was my first time seeing Scrooge about this problem, but he was well prepared. (I had made certain that the lab sent him copies of relevant tests). After some interaction about related symptoms and observations, he opined that a capsule endoscopy of the small bowel would be appropriate. However, first, he wanted to test for celiac disease. If that test was positive, then that would be the endpoint for treatment.

In discussing ferritin levels, which react to acute infections, I disclosed that my UTI’s onset was concurrent with the most recent iron test. He said that unless there was blood in the urine, the UTI wasn’t significantly implicated. However, when I told him about the pink pee, he asked whether Dr. DeLorean had done a follow-up urinalysis to check for residual blood in the urine. Of course, following up is not a DeLorean strong suit, so my answer was no.

Lab Tests and Beyond

Scrooge ordered a celiac panel, a fecal blood test called a Fecal Immunochemical Stool Test (FIT). (Why isn’t it a FIST?) He also ordered that follow-up urinalysis. I’ll get started on those tomorrow. When the results are in, Scrooge’s office will call me and let me know where we go from there. Of course, I’ll have the lab results in hand long before they call me, thanks to Quest Diagnostics’ excellent patient communication and reporting.

If the celiac tests are negative, we’ll do the upper, middle, and lower endoscopies. Scrooge explained to me that insurers won’t let him just do the small bowel, which is where he suspects the problem may lie, without doing the colonoscopy and the upper endoscopy. So, this is the year I thought it would pay off to do a high-deductible Medicare supplement! Oy, vey! Let the bills start rolling in! At least Medicare will be covering 80% and I’ll just be on the hook for 20% of the Medicare negotiated fee schedule.

Like it or not from a TMI sense, I’ll be keeping all my wonderful readers in the loop with respect to this latest old fart malady.

This Week’s Mounjaro Numbers

The week’s numbers show a flattening of the curve. The gratuitous weight loss people in the addiction cycle would call their teledoc and demand a higher dose of Mounjaro, Zepbound, Ozempic, or Wegovy, because their brain is now programmed to recoil at the slightest upward bounce on the scale. That ain’t me. As I mentioned above, I’m taking it very slowly at this point, and I want to hang out at my current weight of 188 lbs (85.5 kg) while addressing the muscle loss caused by rapid weight loss and aging (sarcopenia). Although subject to daily fluctuations, my weight has remained nominally the same for the past three weeks.

We’re treating Type 2 diabetes here. Weight is a secondary issue. My average morning fasting glucose was 93 mg/dL (5.17 mmol/L) down slightly from last week. Average glucose was also about the same as last week, 105 mg/dL (5.83 mmol/L). This level is equivalent to HbA1c of 5.3% (34 mmol/mol), which approaches my target of 5.2% (33 mmol/mol).

As for my diet, I am sticking with low carbs while trying to hit a basic minimum daily protein goal of at least 1.2 grams per kg of body weight, which is about 103 g/day. If I work out more strenuously, I increase the protein. Invoking BYU researcher Ben Bikman’s alliterative characterization, I prioritize protein, I control carbs, and I don’t fear fat.

Wrapping It Up

So that’s it for this week. I hope my continuing health issues don’t drive you away! Although I have a keen interest in medical science, I would rather not be the subject of these clinical manifestations and their investigations.

Lest I forget why we’re here, which is my Mounjaro progress, I have a follow-up appointment with Dr. DeLorean in about a month. I’ll have a new HbA1c result before then, so stay tuned. Will I get to 5.2% (33 mmol/mol)? Will my weight and glucose bounce back because I’m on a less than therapeutic dose of Mounjaro due to developed resistance? I’m still at the minimum dose of 5mg/0.5mL, where I’ll stay as long as my blood glucose stays under control. I look forward to reporting on these and other related stories!

Byebye UTI (TMI), Doc on Thin Ice, GLP-1 News Brief

This is my weekly report of progress on my Mounjaro therapy for Type 2 Diabetes. Last week, I reported on a nasty, antibiotic resistant urinary tract infection (UTI); this week, it is my hope that I can wrap up that sordid tale of too much information (TMI). I’ll also mention a few recent news items about GLP-1 RA drugs like Mounjaro before I conclude with my update by the numbers.

If you’re new here, I’m a seventy-eight year-old Type 2 Diabetic who has been injecting the GLP-1 RA drug Mounjaro weekly since June 2024. I remain at the minimum therapeutic dose of 5mg/0.5ml, which I have found does the job well. My HbA1c has improved from 7.6% (60 mmol/mol) to 5.5% (37 mmol/mol) while on Mounjaro, but Mounjaro is only a part of the story. Concomitant with my use of the drug, I have adopted a low-carb diet with a sufficiently high protein component to maintain muscle mass. Further toward that end, I work out six days per week — three at the gym and three at home — because the rapid weight loss I have experienced comes at the cost of lost muscle as well as fat. Decent protein intake while engaging in resistance exercises several hours per week are essential to my long term health.

In the Long Term, We Are All Dead

Long term? Who am I kidding? Certainly, not me. At seventy-eight, I am aware of my limited future. None of us live forever, and I’m much closer to the end of life’s trail than the beginning. I have many risk factors of metabolic syndrome, but I’m blessed genetically with a strong heart. So, I want to stay as healthy as I can for as long as I can and then die with my boots on. At this point, I’ve given up alcohol and crappy food and I’ve conceded part of every day to sweating. This has been a big adjustment, but the alternative would be giving up and dying a slow, agonizing death.

Yet I want to get off Mounjaro at some point. Naturally, Big Pharma hopes that those who start on their expensive formulations stay on them. However, I must reflect on reported effects of withdrawing from these GLP-1 RA drugs. Tales of rebounding blood glucose with corresponding increased cardiac risks, chronic kidney disease exacerbation, and other metabolic disorders depict a horrible downward spiral I wish to avoid. So, my exit strategy is yet to be determined.

Lest I bore you further meandering through my convoluted and conflicting thoughts on eventually discontinuing Mounjaro, I’ll reel myself in. When I land on a plan, I’ll publish it here.

Mounjaro in the News

Expanded Applications

GLP-1 drugs like semaglutide (Ozempic, Wegovy) and tirzepatide (Mounjaro, Zepbound) are being explored for benefits beyond diabetes and obesity. Emerging research indicates they might help manage inflammatory conditions like rheumatoid arthritis (RA) by reducing inflammation independent of weight loss. Early studies suggest potential improvements in joint protection and reduced disease activity in RA patients.

Medicare and Medicaid Coverage Debate

The Biden administration has proposed Medicare and Medicaid coverage for GLP-1 RAs under obesity treatment, challenging existing laws that exclude weight-loss drugs. This move could expand access to millions of patients but faces political and cost-related challenges. If approved, Medicare negotiations could reduce prices significantly, potentially increasing affordability starting in 2025.

The political challenges are obvious, especially because the Biden Administration ends at high noon today. Of course, the biggest challenge is finding the money to pay for this expanded coverage. (I write that tongue-in-cheek because the Federal bankruptcy never stopped anybody in Washington on either side of the aisle from committing nonexistent public funds to a decent vote-buying opportunity).

Cardiometabolic Benefits

New trials have highlighted the cardioprotective effects of GLP-1 drugs, including improved cardiovascular outcomes and reductions in insulin resistance, especially in populations with chronic conditions like diabetes and rheumatoid arthritis. This reinforces their role as a multi-benefit therapeutic option.

What You’ve Been Waiting For — My UTI

My ten-day course of the antibiotic ciprofloxacin ended on Thursday. By that time, I was no longer peeing fire. The only lingering symptom is some slight suprapubic pain (in the bladder area). My test strips continue to be positive for leukocytes, but negative for nitrites and protein. I’m told by Dr. ChatGPT that residual inflammation can cause leukocyte esterase to hang around for up to a couple weeks after the infection resolves. If the chronic inflammation and bladder pain persists, I could have a chronic condition called interstitial cystitis.

I’ll keep an eye on this presumably resolved infection, but as of now I’ll spare you the sordid details. For an amusing digression, I’ll segue to my annoyance with my doctor.

Stainless Steel Doc

Dr. DeLorean (not his real name) is annoying the hell out of me with his deficient communication. One-way messages relayed through office staff are not why I’m paying him $3,500 per year as a high-falutin’ concierge doctor. The benefits still outweigh the negatives, as I can get same-day appointments, call the doc after hours, have non-rushed, half-hour to forty-five-minute appointments, and enjoy a non-frenetic environment. (Face it — most doctor’s offices are like Greyhound bus stations). Rarely do I find more than one person sitting in the comfortable waiting area. However, my current problem is that communication between Dr. D and me has deteriorated. Perhaps the good doc has spread himself too thin.

Being in the throes of a resolving acute infection is not a good time to pick a fight. You would think I could have learned some self-control and anger management through all those years, but noooooooooooo…

A vociferous complaint by me to his front office staff prompted a call from the doc. His people had screwed up my antibiotic prescription, causing the pharmacy to give me an unexpected additional ten-day supply out of the blue with no instructions to me from the doc. Was I to extend the original ten days for another ten days? Or was I to keep the supply in reserve in case the infection did not abate? What the hell was I supposed to do, with only a bottle of pills dropping on me unexpectedly like bird shit. When I called the office, no one knew what happened, why it happened, or on whose authority it happened. Neither did they know what I should be doing. Thus, I expressed my increasing frustration to them, which they laid off on the doc, who, in turn, shot me an earful.

How to Be a Good Patient (or Not)

DeLorean might be happy to dump me as a patient if I’m too much of a pain in the ass, but I’m paying him to be a cut above the typical strip mall practice. From my perspective, I still get better care and more convenience than I would elsewhere, so it would be hard to replace this relationship.

Am I too demanding? I understand that a busy doctor lacks the available time to debate esoteric treatment options and conduct detailed scientific discussions about diseases and conditions. I rarely encumber the good doc with such things, but when I do, I expect a reasonable response, not a parry.

On the other hand, to be fair, I can text or call the doc on weekends if I have acute issues that cannot wait for an office visit. I respect his time, so I don’t abuse that feature. I have used it only three or four times in our seven-year history. At my age, I never know when that capability might save my ass, so it is a strong justification for the fee. Call it insurance, if you will.

Peace Offering

I sent a nice peace lily and an apology note to the front-end staff because I had subjected them to my mild verbal abuse. No need to shoot the messengers! Hoping to salvage the relationship, in our phone conversation I had promised to apologize to his staff, a promise on which I delivered the next day with the lovely potted plant.

Toward the end of our phone conversation, the doc showed willingness to engage me on the subject of my low iron, which was an area in which he had blown me off in the past. I am hoping that this is a portent of better communication going forward, and that we can resume a calmer and more productive working relationship.

OK, I’m done beating on Dr. DeLorean. Thanks for letting me get that off my chest. Do you think I am a prima donna? Well, sheeeit, maybe I am!

The Shitty State of Health Care

Wow, I didn’t start this as a rant about my doctor, but it sure moved in that direction! My bad, for blowing my stream of consciousness your way! Nevertheless, it sure would be nice if I could live out my days without the aggravation of dealing with the medical community in its current, abhorrent state in this country! The term “necessary evil” comes to mind. For starters, it would be great if my relationship with my doctor could be like my relationship with my CPA or my lawyer, characterized by mutual respect, constructive collaboration, and ultimate recognition of who pays the bills.

If we could get corrupt Big Government, their paying co-conspirators in Big Pharma, and the bought-and-paid-for Big Medical Societies completely the hell out of controlling every aspect of healthcare, we’d all be better off. If we could fix healthcare to emphasize keeping us well instead of keeping us sick (so Big Pharma can enhance its profitability by treating chronic conditions caused by Big Fooda’s ultra-processed crap and contrived “diseases” like obesity, we could be a healthy nation again. Will the Trump Administration succeed in making any inroads? They’re up against big money and entrenched systemic defects. I wish RFK, Jr. (if confirmed, an uphill fight) and his cohort much success, but I remain cynical.

Should I merely cope with the status quo? Indeed, I could go with the flow, meditate, sign up for mindfulness seminars, do cognitive behavioral training with a trained professional, or undergo a prefrontal lobotomy. Taking those drastic steps, I might ultimately change my confrontative, conflict-driven nature, but would it truly bring me peace? Aw, hell, you can’t teach an old dog new tricks, already, so who am I kidding?

Weekly Update: Mounjaro by the Numbers

Now, after all that, I’ll get to the numbers. My average blood glucose for the week was roughly 105 mg/dl (5.83 mmol/L). I had a pig-out lunch on Thursday, which distorted the numbers upward a bit. My average first thing in the morning fasting glucose was was 95 mg/dl (5.28 mmol/L), about the same as last week. Body weight was unchanged for the week, at 188.2 lbs (85.5 kg). I expected to not lose any weight, after having lost a bunch due to the UTI, which I hope was resolved during the week.

That is all for this week. I’ll be back next week with some more narcissistic babble, and perhaps, something interesting or insightful. Thanks for reading — I am happy to know that reading is not a lost art!

If at first you don’t succeed, try, try again.

Happy Monday. Having watched my Nittany Lions and Steelers go down in flames, and having observed my Pens exhibiting mediocrity, I can concentrate on my lifestyle adjustments for Type 2 diabetes.

Welcome to my weekly update. If you have been reading this column from time to time, you’ll know that I have been injecting GLP-1 RA drug Mounjaro weekly since last June as an adjunct to cleaning up my diet and diligently pursuing an exercise program. You also know that at age seventy-eight I suffer from a variety of chronic conditions and I am about thirty pounds overweight, as the weight charts go.

Today, I’ll give you the latest on my current mishegoss, a urinary tract infection (UTI). I’ll conclude with my weekly update, telling you how effectively Mounjaro is currently working to treat my Type 2 diabetes.

Who wants a UTI?

Recently, I’ve been dealing with a UTI. I’m now on my second round of antibiotics. The first, failed drug was a seven-day course of nitrofurantoin (Macrobid). With test strips still showing significant infection after the week was up, Dr. DeLorean (not his real name) ordered a culture, while also prescribing ciprofloxacin (Cipro). It turns out that Cipro was a good choice. On Friday, the lab reported results of the culture, revealing the culprit pathogen as Serratia marcescens, which is resistant to Macrobid, but susceptible to Cipro.

S. marcescens is a cool bacterium. It is a ubiquitous strain you will find in your bathroom and other damp places in your environment, including the soil. If you have ever seen a pink film or plaque on fixtures or tile grout in the bathroom, it is likely S. marcescens. This little critter has some fascinating history, as you’ll find by reading the Wikipedia article about it. Colorful history notwithstanding, you do not want this bug multiplying in your bladder, let me tellya!

Shotgun! Shoot ‘im fo’ he run, now!

Dr. DeLorean’s logic — eradicate the most likely pathogen quickly, then execute Plan B if that fails — is a “shotgun” blast approach. E. coli accounts for 90% of UTIs, and although resistance is increasing, E. coli is susceptible to Macrobid. I suppose the numbers say it was worth a shot, especially because a culture requires four or five days to watch the little pink monsters grow. Macrobid proved to be ineffective, so the next antibiotic was Cipro. I dropped off a sample at the doc’s office just before my first dose so they could do the culture I mentioned in the opening paragraph of this section.

My symptoms and my test strips are much better seven days into the course of Cipro, which is to run for a total of ten days. I’ll keep an eye on the test strips because S. marcescens is resistant to many antibiotics and it could have figured out how to evade the effect of Cipro. I have no fever, so my hope is that this is an uncomplicated infection that will go away soon, and I have largely resumed my exercise program and streamlined diet.

My Week on Mounjaro

I wanted to write more this week, but events conspired to limit my writing time. Therefore, this will be another short update before I go see the dentist for a cleaning. If it’s not one thing, it’s another, already!

My overall average glucose measurement is unreliable, because my Stelo monitor is flaky this week, typically reading 20 mg/dL higher than the finger stick method. For what it’s worth, it tells me that my seven-day average glucose was 115 mg/dL (6.39 mmol/L), which probably means I’m right around 100 mg/dL (5.56 mmol/L). A more accurate measure is average morning fasting blood glucose at 96 mg/dL (6.00 mmol/L) per my finger stick glucometer, which tracks closely with professional lab tests.

I would hope to get my morning fasting glucose down to about 85 on the average. I don’t know whether that is doable, but my efforts to maintain a low-carb diet with adequate fiber while exercising six days per week in conjunction with Mounjaro remain directed at that goal.

My body weight, unlike my belly, was flat for the week, settling in on 187.6 lbs (85.3 kg) at my Monday morning weigh-in. It was up and down during the week due to the UTI, no doubt.

I’ll try to find some more interesting content next week, as my TMI UTI is bound to be boring many of you. I am following the court case involving a compounding pharmacy association’s battle with the FDA to keep tirzepatide on the shortage list, among other topics related to GLP-1 RAs. See you next week!