The magic word Mounjaro in the title will piss off the Facebook spam algorithm again, but I do it to determine whether the Facebook humanoids have as yet favorably considered my objection to their penchant for removing these posts. Owing to their lack of communication, the only way to test the water is to post one containing the offensive word and picture. Someday, a sentient being at Facebook might read one, which will reveal that this is not attempted keyword spamming, as they accuse.

I encourage anyone who would typically access links to my articles on Facebook to subscribe here directly so you’ll never miss one of my rants.

This Week in Mounjaroville

With the negative opening behind us, we can move forward with another completely innocuous, non-spam report. I have been posting these mostly weekly updates while I proceed with the Mounjaro therapy. This is Week Twenty-One.

Today’s update will begin with some background information for those who are new to this column, and who are curious about who I am, what I am doing, and why I am writing this. Although I sometimes use this space to expound on various issues with the GLP-1 and weight loss industries, this week I will give you a break from the editorialization to touch on various areas of my health, which I hope to improve by coping with type two diabetes.

A Little Background for New Readers

At my doctor’s suggestion, I have been taking Mounjaro for type two diabetes since June 3. During that time, I have seen positive benefits in decreasing HbA1c and daily blood glucose readings, two important measures of severity of diabetes. Along the way, I’ve lost about forty-five pounds of blubber. Weight loss was not and is not the primary object of my Mounjaro therapy, but I’ll take it. Of course, it is not all attributable to Mounjaro. I also adjusted my diet and increased my exercise commitment after initiating the drug.

As I noted in a prior column, my improvements in diet and exercise have given me collateral benefits, such as reduction in chronic pain due to inflammation. My wife Jenny, a biochemist, glutenophobe, and avid follower of health topics, believes that giving up bread is the biggest contributor to easing my joint pain. If that is the case, I will happily avoid bread, as the health reward far outweighs the taste of a chopped liver on rye sandwich.

I do not know how long I will be injecting this drug beyond the next twelve weeks, which is the supply I have on hand. After I achieve my goals, I want to find a way to ease off Mounjaro. Although I am taking a low dose, five milligrams, I am wary of potential long-term adverse effects. My preference is to take as few drugs as I can — I don’t even bother with over-the-counter pain relievers unless pain exceeds my high tolerance. Any way you look at it, I am injecting a foreign substance into my body, which I must take seriously. As a crusty old fart, I am particularly concerned with undisclosed side-effects that have evaded disclosure by the limited research studies to date.

Sarcopenia and Me

One particular concern obliquely connected with Mounjaro is potential loss of muscle mass due to too rapid weight loss. We lose muscle as we age in any case, due to a process called sarcopenia. Some estimates say we lose up to 10% of our muscle mass per decade after age 50. But crash diets and rapid weight loss for any reason causes added muscle loss beyond what aging does to us. With this in mind, I increased my resistance training and upped my daily protein intake, which I check closely. Unfortunately, my back issues have recently caused a temporary halt to resistance training, which I’ll cover next.

How’s My Back Doing?

I’ll follow up on last week’s post, in which I kvetched about my lumbar spine. Yes, I know, this has nothing to do with Mounjaro, but it’s all part of the same old, decrepit body. My ability to exercise is a key factor in my approach to living with type two diabetes, and my back situation could say much about my ability to engage in both cardio and resistance exercise.

Last week, I shared my MRI report. With my collaboration, my doctor decided to put me on a conservative course, first with physical therapy. So, I arranged an evaluation at a local PT operation I have used before, and found the same therapist still there. Old farts like me appreciate familiar things. Julie is an energetic, no-nonsense task master, who looked at my MRI report and delivered the summary assessment, “If you came to me and said your lower back is completely messed up, I would have to agree.” She said she could assuage some of the nerve root compression, but not the spondylolisthesis, the stenosis, the disc degeneration, or the facet arthrosis.

The Plan

So, here’s the plan. I will undergo physical therapy twice a week for six weeks while doing targeted strengthening and stretching exercises daily. During this time, Julie the PT (physical torturer) told me to suspend my dumbbell resistance training. But she said a half-hour of cardio daily would be fine.

The physical therapy outfit gave me a very cool app called MedBridge GO, which directs and records my daily exercise progress. To keep me honest, it can optionally send the daily record to my therapist, which I enabled. In for a penny, in for a pound. The exercises are not difficult, but they work some muscle groups I haven’t accessed for a while, so I feel sore all over, but pleasantly so.

Physical Therapy Begins

Last week, I had my first physical therapy session. Aside from additional targeted exercises and stretching, the therapists strap me onto a traction table to stretch my lower spine. Despite my mental image of Medieval torture I visualized when my therapist briefed me beforehand, it did not turn out to be unpleasant. When the traction session ended, I asked Julie, my sadomistress, whether I was now 6’2″. “You wish!” she quickly retorted.

I hope this physical therapy approach works. I know that my back will never completely heal–it is far too screwed up–so what I am hoping for is pain at a tolerable level. This will allow me to do resistance training, which is essential to combat the muscle loss I described above. If PT doesn’t do the job, the next step will be x-ray-guided epidural injections. The last resort is surgery, a possibility I’ll try to avoid. Although minimally invasive procedures are available, I don’t expect miracles, given the MRI report I shared with you. That’s why I’m pursuing the prescribed exercises and physical therapy with fervor.

How about the Numbers?

Aside from physical therapy, I had a busy week. The high point was Jenny’s birthday on Thursday (she’s thirty-nine again), which we celebrated with a very pleasant three-hour lunch along with friends visiting the Orlando area from Canada and Michigan.

In the old days, a long lunch meant lots of food and booze, but not anymore! I have eschewed alcohol for a couple of years due to yet another one of my old fart ailments, chronic erosive gastritis, and I straightened out my diet in combination with Mounjaro therapy and diabetes. Additionally, considering our guests’ request to avoid spicy food, I chose a restaurant that prides itself on an innovative menu with entrees all at 575 calories or less. I had a delicious cedar plank salmon dinner but I passed on their small, but tasty, desserts. The lunch company was excellent and the banter superb. The food was fine, too, and it had no significant impact on my glucose. Winner, winner, salmon dinner!

Morning blood glucose as measured with a traditional glucometer averaged 94.7 mg/dL for the week. This is up about 1.3 from the prior week, within the margin of error. My Dexcom Stelo reports 114 mg/dL overall average glucose measured from the interstitial fluid, which corresponds to an estimated HbA1c value of 5.6. Man, I’m getting there! I should mention that I am taking Metformin ER 500 mg once daily aside from the Mounjaro.

Since my COVID-19 episode, my first-thing-in-the-morning blood pressure had been elevated. It now, finally, seems to be settling down. Average for the week was 122/73. Note that I am taking losartan at the 100 mg dose.

Finally, my weight fell 0.6 lbs during the week. I am hovering just over 200, where there seems to be a support level. My goal is 165, which I hope to achieve gradually at the rate of one to one-and-a-half pounds per week.

See You Next Week

I enjoy writing these updates, and I hope that those of you who read them can gain from my shared experiences, if not from my kvetching about body aches. Next week, if I look back here to jog my aging brain cells, I might write about my current project, namely, selecting a Medicare Part D prescription drug insurance plan for 2025 that will be the most efficient and economical. Thanks to the misnamed Inflation Reduction Act, lots has changed with Medicare. Taking an expensive drug like Mounjaro makes the annual choice much more consequential to the budget.

Until then, stay healthy!

(sung to the tune of “Margaritaville”, with apologies to the late Jimmy Buffet)

Wastin’ away in my Mounjaroville
Searchin’ for my lost avoirdupois.
Some people claim that their genes are to blame,
But I know… it’s my own damn fault.

Mounjaro Update: Week 20

How do you like our latest musical plagiarism? I think one verse of the Margaritaville chorus qualifies as fair use. The purloined lyrics reflect my personal feelings that being fat is my own damn fault. If I initiated drug therapy just wanting to lose some weight, it would be a cop-out. However, in combination with Metformin, Mounjaro is doing an excellent job of controlling my blood sugar. So, I’ll shamelessly take the weight loss as a by-product.

As I explained in last week’s update, “Mount Kilimanjaro Travelogue“, I must avoid using the bare word “Mounjaro” in my title. I must also avoid including photos of Mounjaro injectors, as an accommodation to Facebook’s spam detection algorithm. They think I’m leveraging the vogue drug’s name as clickbait. The only clickbait I offer here is commentary from personal perspective with Mounjaro. It works for me and could work for others. I am not seeking millions of clicks, just desiring to share my story and add a few editorial comments. If I can help one or two people who happen into my weekly rants, I feel good. Furthermore, penning my thoughs keeps me focused on my goals. Thus, it is a win-win for all of us.

(Except the Facebook morons).

This week, I will write about cost issues and insurance changes affecting the future of my Mounjaro therapy. I touch on insulin resistance, a precursor to Type Two diabetes. I will tell you how to determine whether you have this metabolic disorder, a result of our crappy Western diet. Next, I have long suffered back pain. The situation is getting worse, so I share recent MRI results and potential treatment plan. Finally, as always, I’ll report on my progress since the beginning of my Mounjaro therapy.

My Mounjaro Story

This is Week 20 of Mounjaro therapy. For those of you who are new to my blog, my background follows. I am a Type Two diabetic with a history of attempts at dietary control and associated up-and-down weight patterns. I am also a veteran of drug therapy. At various times, I have taken Janumet, metformin, and glipizide (but never insulin). In June, my doctor felt that Mounjaro would be “right for me”, as the direct-to-consumer ads go. Since then, I inject it weekly, concomitantly with a 500 mg daily dose of extended-release metformin.

My current weekly Mounjaro dose is 5 mg, which is a low dose. If you are wondering about side-effects, I am past that point, at least with respect to detectable adverse effects. When I started with the drug, I had some appetite suppression. This disappeared after the first six weeks on the 2.5 mg starter dose. I never experienced nausea or indigestion, but I had some constipation, which has abated. The only side-effect I notice is a slightly metallic taste in my mouth within an hour or two following an injection.

As I mentioned, I am taking a low dosage. Furthermore, we are all different, so my experience might not be representative of what you can expect. People on doses of 10 mg and higher (usually those are people who seek rapid weight loss), might experience some more serious side-effects.

Risks vs. Rewards

Mounjaro therapy is a risk because it has not been studied thoroughly enough to discover many likely side-effects, particularly long-term ones. This drug, along with its GLP-1 cousins, took the fast track to market with the complicity of a well-greased FDA and several Big Pharma funded studies. Anything one injects into one’s body needs to be well studied and needs a demonstrated positive history. Therefore, I know I’m taking chances, especially at my advanced age. So, I’ll gladly ditch the drug when I can.

New Mounjaro Cost Considerations for 2025

One good non-medical reason to get off Mounjaro is the cost. My insurance situation is changing with respect to Mounjaro as of the new year. Because of what I call the Great Misnomer Act, better known as the Biden Administration’s Inflation Reduction Act, the Medicare Part D drug situation will change significantly in 2025. The so-called “donut hole”, in which one must pay for expensive drugs on a cost-sharing basis with one’s insurer until reaching an annual spending limit, goes away.

I had been paying $11 for a four-week supply of Mounjaro until I reached the “donut hole” this month. Mounjaro will now cost me about $250 per four weeks until the end of 2024. Beginning next year in my current Part D prescription drug plan, Mounjaro will move from a Tier 6 drug to a Tier 3, meaning that I will pay 25% of the cost of the drug. That’s about $250 per four weeks, too, but the difference is that it will be every month. So, my annual cost will rise significantly.

That’s all the more reason to try to get off Mounjaro when my progress on it is sufficient. While Eli Lilly & Company, manufacturers of the drug, would prefer that I am dependent and addicted for life, I have no such desire. The stories I’m hearing about people left in a lurch by Lilly’s attempts to protect its patent because those individuals are “dependent” on tirzepatide (the generic name for Mounjaro and its weight-loss approved co-product, Zepbound), reinforce my belief that I sure as hell do not want to become dependent on Mounjaro–or any other drug.

Addiction, By Any Other Name

Addiction, by any other name, would smell as foul. Drug dependence, whether it is to legitimate, semi-legitimate, or illegal drugs, is still undesirable addiction. Big pharma will not put me in that cage. My heart goes out to those who have unwittingly succumbed to the addictive potential of these drugs much like they succumbed to the addictive Western ultra-processed food diet that put them in a position to need them. I hope these victims will stop funding both Big Pharma and the parasitic compounding pharmacies, which I call “little pharma”, and get on with their drug-free lives.

But for some, it’s not sufficient to feel marvelous. One must look marvelous.

Insulin Resistance

The underlying feature of Type Two Diabetes as well as porking up from ultra-processed food is insulin resistance. By eating the crap that dominates supermarket shelves and fast food restaurants, we have set ourselves up for developing insulin resistance, metabolic syndrome, and Type Two Diabetes. Obviously, changing our crappy diet is the first key to ameliorating that negative situation. However, some of the damage we do to ourselves by eating Doritos and M&Ms–or even nibblin’ on sponge cake–is irreversible.

Determining whether you have insulin resistance is the key to heading diabetes off at the pass. Thus forewarned, we can empower ourselves to take a healthier approach to what we shove in our mouths going forward.

HOMA-IR

Some of the signs of increasing insulin resistance are subtle. If your belly is getting bigger, or if you experience “sugar highs” and “dawn phenomenon”, like my friend Mike, you might want to do a simple lab test to determine your degree of insulin resistance. The test is HOMA-IR, which stands for homeostasis model assessment for insulin resistance. HOMA-IR is a combination of two tests: fasting glucose and fasting insulin. Its value, denoting one’s degree of insulin resistance, can be predictive of Type Two diabetes and metabolic syndrome.

Many doctors do not apprise patients of this simple screening test. However, our modern medical system, particularly in the United States, is broken. Preventive medicine takes a backseat to ex post facto treatment, a favorite of Big Pharma. Middle-aged and older people should get it, especially if they suspect insulin resistance. The good news is that you do not even need to get a prescription from your doctor for blood tests anymore.

Disclaimer: I’m not a doctor, so please take my medical assessments with a grain of sodium chloride. (I’m not a chemist, either, and I don’t play one on TV). While a diagnosis of diabetes might not be in your immediate future, getting there is not an overnight process. HOMA-IR will tell you whether you’re heading in that direction. I wish I had this simple diagnostic tool years before my diabetes diagnosis. I could have cleaned up my damn diet before it did its damage.

How to Do It

HOMA-IR is indeed an early predictor of new onset Type Two diabetes and chronic kidney disease, regardless of HbA1c in non-diabetic individuals

Clin Diabetes Endocrinol. 2023; 9: 7.

So, how do you get this test without a doctor’s prescription? You can deal directly with Ulta Lab Tests, LLC, ordering your tests through the internet. You order the test from them, they have a rent-a-doc write a lab order, and then Quest or another service can draw blood for the test. You’ll receive your results in a day or so. My link will take you directly to the test package, which costs about $46 and includes insulin, glucose, and HbA1c tests, and Ulta frequently offers discount “deals”.

Upon receiving your results, HOMA-IR is the product of the insulin and glucose values divided by a constant. Specifically, it is calculated by using the following formula: fasting glucose (mg/dL) X fasting insulin (mU/L) / 405 (for SI units: fasting glucose (mmol/L) X fasting insulin (mU/L) / 22.5). For those of you with math resistance to accompany your insulin resistance, calculators exist online where you can plug in your values and see the result. A value of two or greater strongly correlates with insulin resistance.

A 2023 study concluded that high HOMA-IR is indeed an early predictor of new onset Type Two diabetes and chronic kidney disease, regardless of HbA1c in non-diabetic individuals, although further research is necessary regarding the specific cut-off value.

Back to Back (Mine)

Last week, I told you I would be getting an MRI of my spine because of back symptoms resembling sciatica. The results are in. I’ll share them and tell you what my treatment plan will be.

The report contains a lot of medical terminology, but it boils down to severe degeneration in my lumbar spine, with nerve root compression in several areas. For those wanting the gruesome details, here are the findings:

1. Levoscoliosis with multilevel spondylolithiasis and extensive moderate to severe multilevel lumbar degenerative spine disease from T10 through S1 as above with moderate spinal stenosis at T10-T11 and at L2-L3 with severe spinal stenosis at L4-L5.
2. Impingement of the descending left L1, descending right L2, and descending bilateral L5 nerve roots.

My doctor and I agreed to schedule physical therapy first, hoping that those sadistic PT geniuses can fix my back and leg pain/numbness. If PT doesn’t do the job, obtaining an x-ray guided steroid injection is next. The last resort will be surgery, which I will carefully consider, weighing the risks versus the potential rewards. The outcome I seek is an abatement of pain and numbness, plus forestalling muscular atrophy in the affected leg.

I want to resume regular exercise, including resistance training. However, erring on the side of caution, I’ll await the exercise assessment from the physical therapists.

We’ll see…

And now, finally, my Mounjaro numbers…

We’re at that part of my weekly update where I let you know how I’m doing. No, really! Yes, I love to write. I hope you have stuck with me to this point and have not bolted due to boredom.

Stelo Shenanigans

I changed my Stelo glucose biosensor on Tuesday, so its numbers are wacko. It might be a little wacko anyway, because I noticed during my Yom Kippur fast that I had a minor glucose spike associated with taking a shower. Obviously, I was not ingesting any food or drink. The shower was the only significant event at the time the glucose began to increase. Accordingly, I am dubious that the Stelo device will be a useful long-term solution. By eliminating the $90/month cost of the Stelo, I could subsidize a third of the cost of my Mounjaro therapy, assuming that I continue on the drug.

I’ll stick with Stelo for another month or so to see what useful information I can glean from it, but right now it is pissing me off because of its divergence from my blood glucometer. A case in point presented itself during my Yom Kippur fast. My glucometer measured 79 mg/dL, while the Stelo read 102. Whereas I was originally more interested in relative values (peaks and valleys), I wish the device was more accurate with absolute values. Thus, the device might turn out to be an expensive, slightly disfunctional educational toy.

The Week in Review

Several significant events during the week affected my glucose, blood pressure, and weight. Hurricane Milton, named after Jerry Chait’s father (inside joke), raged through Central Florida, where I live. The Jewish holy day of Yom Kippur and its required twenty-five hour fast also occured during the week. Finally, I removed the Stelo for the MRI and installed a new one, so as I mentioned above, the numbers are wacky.

My morning glucose, measured by my glucometer, averaged 93.4. I am still pleased with my glucose results. My blood pressure has been doing better, too, averaging 126/75, which improved from 134/76 last week. It had been high ever since I returned from my August/September vacation with a case of COVID-19.

Finally, I lost 4.2 pounds during the week. This is an unsustainably high rate, which I hope will settle down. If not, we’ll need to start looking for some underlying pathology. Since starting Mounjaro therapy, I have lost 44.4 pounds.

That’s Enough Overshare!

I hope that by sharing my Mounjaro experience and my intimate medical details, I have provided useful information. Furthermore, I hope people who have not (yet) been diagnosed with Type Two diabetes or with metabolic syndrome will develop an interest in the subject of insulin resistance, for which I suggested a simple lab test. Awareness of how our bodies function is empowering. If you know what’s going wrong, you can do something about it!

I’ll be back next week with more. In the meanwhile, stay healthy!