iiinova — where your digital self keeps evolving

David W (aka Flex NP) @rnflex.bsky.social · 7h

Prior auth for rosuvastatin. WTF are we actually doing here CVS "Care"mark

David W (aka Flex NP) @rnflex.bsky.social · 06/10/2026

Meanwhile GLP1 trials have moved on to "what it we could prevent obesity and diabetes in the first place?" clinicaltrials.gov/study/NCT077...

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David W (aka Flex NP) @rnflex.bsky.social · 03/10/2026

Beautiful article. Could see the yellowed edges on my run today as well. The sun is still warm but the cool breeze is a foreshadow for what's to come

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David W (aka Flex NP) @rnflex.bsky.social · 02/10/2026

Well it finally happened. Insurance required a prior authorization for Telmisartan. A medication that cash pay is anywhere from $13 to $40 a month. The system is just so broken

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David W (aka Flex NP) @rnflex.bsky.social · 02/10/2026

Same. That we've shifted so rapidly in how we treat diabetes is astonishing. Researching my next blog post and stumbled upon these slides from 2015. A year later we got the first CVOT data on semaglutide and EVERYTHING changed.

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David W (aka Flex NP) @rnflex.bsky.social · 30/09/2026

And as I shared with you earlier but now I will publicly GLP1 + flozin even in established DKD can really delay progression!!

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David W (aka Flex NP) @rnflex.bsky.social · 30/09/2026

These 24 hours will go down in medical history. A 4 act play. What's more incredible is ONE company did all of this in the last 5 years! 3 purposely designed drugs and suddenly we've solved essentially our oldest self inflicted ailment.

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David W (aka Flex NP) @rnflex.bsky.social · 30/09/2026

Additionally they showed a few details from a phase 1 trial in obese patients with Eloralintide and Tirzepatide and it basically provided better weight loss than even retatrutide. Low dose EloraTirz 3mg/5mg causes 17% weight loss in 16 weeks 😳😳 insanity.

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David W (aka Flex NP) @rnflex.bsky.social · 30/09/2026

Blood pressure showed modest reductions. Side effects were dose dependent. Higher doses had more side effects. Discontinue rates were 10-27% but Lilly didn't give details. We're probably in the retatrutide weeds again. Bunch of people have excessive body weight loss.

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David W (aka Flex NP) @rnflex.bsky.social · 30/09/2026

A1c reductions were even more wild. There was an additive effect of Elora + tirzepatide with a reduction up to 2.9%!! Rate of diabetic remission was upwards of 70% in some arms 😳😳😳 @mikejohansenmd.medsky.social

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David W (aka Flex NP) @rnflex.bsky.social · 30/09/2026

The weight loss results were as good OR BETTER THAN RETATRUTIDE in only 48 weeks with many of the combo arms still losing weight at the 48 week mark. Weight loss was roughly additive My mind is blown.

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David W (aka Flex NP) @rnflex.bsky.social · 30/09/2026

This was a phase 2 trial in diabetics. Average A1c was 8.1, it was about 50/50 male/female split, and average BMI was 38. Dosing was mixed. Some Eloralintide alone, then various combos of the two drugs combined.

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David W (aka Flex NP) @rnflex.bsky.social · 30/09/2026

It has been a remarkable 24 hours in the world of diabetes and obesity medicine. First we saw the full readout of retatrutide for obesity. Then this morning retatrutide for type 2 diabetes. Both with historic weight loss. Now we can add Eloralintide+Tirzepatide combo to that list.

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David W (aka Flex NP) @rnflex.bsky.social · 30/09/2026

Side effects were again in line with every other incretin out there. Dysesthesia rate was 7% nausea signal was fairly muted and diarrhea was actually the leading SE. Minimal hypoglycemia and no ketoacidosis signal.

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David W (aka Flex NP) @rnflex.bsky.social · 30/09/2026

An LOL reduction in inflammation, 40% drop in triglycerides again, ~10% drop in LDL cholesterol even tho average LDL was 90md/dl is still a big deal. UACR dropped and GFR again rose as measured by Cystatin-C. It's fixing everything.

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David W (aka Flex NP) @rnflex.bsky.social · 30/09/2026

Worried about blood sugar because it contains glucagon? Worry not and laugh again @mikejohansenmd.medsky.social ending fasting glucose was ~100. Fasting insulin dropped 45% !!!! As noted 40% of 9mg/12mg ended up in diabetic remission HOMA IR dropped >50% again.

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David W (aka Flex NP) @rnflex.bsky.social · 30/09/2026

Just bonkers weight loss again. 1/3 of patients on the higher doses lost >25% over 50% of patients went from obese to just overweight. (BMI<30) The waterfall plots go so hard here again.

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David W (aka Flex NP) @rnflex.bsky.social · 29/09/2026

Consistent with all other glp1 meds. Only difference is slightly lower rates of constipation and slightly higher rates of diarrhea. But as you can see it tapers with time

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David W (aka Flex NP) @rnflex.bsky.social · 29/09/2026

Finally it reduces hepatic insulin resistance so far that I'm not sure it can go much lower. A 55-60% reduction in fasting insulin. Also it raised Cystatin-C based GFR by 6-10ml/min. Legit a medical miracle/fix it all/Mary Sue ass drug as @proptermalone.bsky.social would say.

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David W (aka Flex NP) @rnflex.bsky.social · 29/09/2026

If you were a woman, you generally lost upwards of 30% of your body weight. Men lost less around 23% overall weight loss was incredible.

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David W (aka Flex NP) @rnflex.bsky.social · 29/09/2026

If you were pre-diabetic prior to starting the trial, you most likely were not pre-diabetic at the end of the trial. If your blood pressure was high, it worked as good or better than available blood pressure medicines

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David W (aka Flex NP) @rnflex.bsky.social · 29/09/2026

The weight reductions are incredible, a noticeable fraction of people lost more than 40% of their body weight. And yet there were still a few people that did not lose weight which bears further investigation

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David W (aka Flex NP) @rnflex.bsky.social · 26/09/2026

3 years and one day since my first injection in my retatrutide trial. Gave myself that first shot in the trial and donated 19 vials(120ml!) of blood. Life altering day for me!

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David W (aka Flex NP) @rnflex.bsky.social · 26/09/2026

75lbs of freshly groomed Dolly(Parton) Step sister Jolene also looking shiny and fresh

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David W (aka Flex NP) @rnflex.bsky.social · 26/09/2026

Coonie can't be bothered after a day of chasing rabbits and squirrels in the backyard.

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David W (aka Flex NP) @rnflex.bsky.social · 25/09/2026

Happy Friday morning. Dang beautiful sunrise.

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David W (aka Flex NP) @rnflex.bsky.social · 20/09/2026

We're in a revolution not only with GLP-1 meds, but also drugs that are kidney protective. It appears we can add orforglipron an oral GLP-1 small molecule to the list of kidney protective in diabetes. This data will be presented in full at EASD in 10 days. This is an eye opening graph #NephJC

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David W (aka Flex NP) @rnflex.bsky.social · 19/09/2026

How you find me on a rainy Saturday morning. 4 hour clinic shift! But I'm excited for my new work keyboard!

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David W (aka Flex NP) @rnflex.bsky.social · 15/09/2026

2 weeks until we get this full data readout and full phase 2 data for Eloralintide+Tirzepatide in diabetics. Results are going to be wild. Even this data in obese patients is crazy. 17% weight loss in 4 months is better than retatrutide in the same time frame! And these are the low dose results!

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David W (aka Flex NP) @rnflex.bsky.social · 13/09/2026

I'm putting the finishing touches on my newest blog article about insulin sensitivity. Why does it matter? How are GLP1 drugs involved? What the heck is an M-value and what's this graph all about? Find out tomorrow!

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David W (aka Flex NP) @rnflex.bsky.social · 13/09/2026

6 years and counting on this thing. Was 350 bucks in 2020 Mechanical switches. Only thing fancy is the led lights to tell you which part of the cycle it's on.

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David W (aka Flex NP) @rnflex.bsky.social · 05/09/2026

My rescue Smokey just can't be bothered on GameDay. (Also her name is Dolly Parton) Also also Go Blue tonight!

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David W (aka Flex NP) @rnflex.bsky.social · 04/09/2026

Florida in summer is brutal. But get out early enough into some of the preserved woodlands for a trail run and you can find some magic.

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David W (aka Flex NP) @rnflex.bsky.social · 03/09/2026

*taps my own slide on women's health* Listen and believe women. Listen and believe women. Listen and believe women.

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David W (aka Flex NP) @rnflex.bsky.social · 30/08/2026

The one slide I deleted was the anti inflammatory stuff. So dose dependently reduces hsCRP by about 50% (Ph3 showed 60%, Tirz is similar 50-60%) Also reduced IL-6. Some benefits are seen in Tirz. More so with triglyceride lowering, less so with ApoB/LDL. Would be additive CRP reduction w/statin

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David W (aka Flex NP) @rnflex.bsky.social · 30/08/2026

That leads to the other calling Reta what it is, at minimum a moderate intensity statin drug. That's fun since it was designed for weight loss and diabetic control! As noted it also functions like drugs from other lipid lowering therapeutics namely fibrates, ApoC3 and ANGPTL3 inhibitors

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David W (aka Flex NP) @rnflex.bsky.social · 30/08/2026

Statins on the other hand do the opposite. They lower LDL more than ApoB because they're targeting LDL essentially directly. Reta is going upstream of that to clear out ALL the atherogenic particles as the authors note here. They also call out Reta is doing the work of multiple other drugs combined.

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David W (aka Flex NP) @rnflex.bsky.social · 30/08/2026

Going FULL #cardiosky nerd 🤓 it also reduces particle counts. Again, it's full scale clearance on TRL-C but very importantly it decreases small dense LDL particles. These two findings are probably why the ApoB reduction is LARGER than the LDL reduction in Phase 2 & 3 with Reta.

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David W (aka Flex NP) @rnflex.bsky.social · 30/08/2026

Here's the crux of it. Non-HDL-C, ApoB, TRL-C(triglyceride rich lipoprotein) and ApoC3. 20-26% reduction in ApoB & non-HDL-C is approaching moderate intensity statin reduction. ApoC3 decrease matches the drop in TRL-C(they move together) Basically a large scale clear out of atherogenic particles!

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David W (aka Flex NP) @rnflex.bsky.social · 29/08/2026

Whenever I take the kids to the zoo we always give thanks to our lord of GLP1, the Gila Monster.

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David W (aka Flex NP) @rnflex.bsky.social · 29/08/2026

Some of these graphics are gonna get printed out and laminated to show to patients when we discuss risk, primary prevention and progression of ASCVD. Man. Great study.

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David W (aka Flex NP) @rnflex.bsky.social · 29/08/2026

Fun that in this graphic, one can arguably SEE when women go into menopause, lose the cardio protective effects of estrogen signalling and suddenly they gain calcium in their arteries at a similar rate as men.

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David W (aka Flex NP) @rnflex.bsky.social · 28/08/2026

Ironically going upstream all the way back to glucagon ended up being the trick with ACC. This slide from the phase 3 trial of retatrutide (GLP1/GIP/GCG triple agonist) showing the bonkers 40% trig + 20% LDL reduction is the proof in the pudding. Clears hepatic fat in a flash too.

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David W (aka Flex NP) @rnflex.bsky.social · 27/08/2026

And now I have that exact molecule in my office right now as a couple of my patients were interested in trying it out for their high cholesterol. Never forget the chemists!

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David W (aka Flex NP) @rnflex.bsky.social · 25/08/2026

Our child received books from the imagination library. Books she loves. We named our two dogs Dolly and Jolene because we rescued both in Tennessee. Rest in peace queen. You were a great one until the very end.

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David W (aka Flex NP) @rnflex.bsky.social · 25/08/2026

I'm a little bit loathe to share some of these real world evidence trials because the caveats and confounders can be numerous but still fun to see what they find...and again a trial showing an outsized all cause mortality benefit for tirzepatide. This keeps happening and it's making me go 🧐🤔

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David W (aka Flex NP) @rnflex.bsky.social · 24/08/2026

One of the greatest parts of the internet, genuinely, is the ability to order stuff you had on vacation on an empty white sand beach in Baja California Sur and have it delivered to your house

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David W (aka Flex NP) @rnflex.bsky.social · 24/08/2026

Monday morning clinic vibes when you've got 18 patients on the schedule and know that food intake time will be limited

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David W (aka Flex NP) @rnflex.bsky.social · 16/08/2026

Running 32.5 miles burned A LOT of freaking calories yesterday!

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