Obesity, Surgery, and Optimizing Patient Care Save

Rheumatologic care involves multidisciplinary approaches and collaboration with specialties to treat complex, systemic diseases. While many Pods at RheumNow Live are disease specific, the Pod II focused on Advancing Practice on important and emerging areas affecting rheumatologic patients. This session focused on two major areas of need: obesity and peri-operative management.

 

Dr. Uzma Haque of Johns Hopkins Rheumatology defined the problem by stating "obesity is common and obesity is expensive."  By the year 2030, the United State population is projected to reach 49% prevalence of obesity, as defined as body mass index (BMI) of greater than 30. This issue, along with a plethora of metabolic complications and co-morbidities is estimated to cost $1.71 trillion in the United States from chronic diseases associated with obesity. Dr. Haque described adipose tissue as an active endocrine organ, producing cytokines, chemokines and adipokines which can lead to a pro-inflammatory state. Obesity is a risk factor for rheumatoid arthritis (RA), increasing risk at a rate comparable to smoking. Obesity is also known to be a risk factor for high disease activity, poor drug response, and decreased remission rates.

 

In addition to conventional lifestyle and behavioral interventions, is there a role for the emerging therapeutics of glucagon-like peptide-1 (GLP-1) receptor agonists in affecting rheumatic risk? Dr. Haque reported new research from the TOGETHER-PsA study which compared ixekizumab (IXE) monotherapy to combination ixekizumab with tirzepatide (IXE-TIR) in patients with active psoriatic arthritis (PsA) and a BMI >27 plus one weight-related comorbidity. This 36 week phase 3b study randomized 271 patients and assess ACR50 responses along with >10% weight reduction. This study showed an improvement of ACR50 in 33.5% of IXE-TIR patients, compared to 20.4% in IXE alone, p<0.05. Not surprisingly, weight reduction was markedly improved in the tirzepatide group with 31.7% of patients meeting weight reduction goal, compared to only 0.8% on ixekizumab alone. This study shows significant promise that GLP-1 receptor agonists can improve disease control as well as improve co-morbid obesity. This research prospectively shows similar findings to prior works by David Kellner et al who retrospectively showed improvements in a RA cohort with improvement in RA disease activity, visual analog pain score, along with weight, cholesterol and hemoglobin A1c. In this study, however, nearly one-third of patients discontinued therapy due to side effects (most commonly gastrointestinal), highlighting the side effect profile of this therapy. Furthermore, retrospective research in systemic lupus erythematosus (SLE) patients show GLP-1 receptor agonists show improvements in lupus patients with diabetes with major improvements of major cardiovascular event (hazard ratio 0.66), venous thromboembolism (HR 0.49), kidney disease progression (HR 0.77), and all-cause mortality (HR 0.26).

 

The GLP-1 receptor agonists also appears to be helpful in the treatment of non-inflammatory arthritis. Dr. Haque reviewed the results of the STEP 9 Trial, a 68 week double-blind, randomized, placebo-controlled study of 407 obese patients with knee osteoarthritis. This study randomized semaglutide to placebo in a 2:1 ratio. The study demonstrated improved WOMAC pain score of 41.7 points, compared to 27.5 points in placebo (p<0.001), along with improvement of SF-36 physical-function score.

 

Next, Dr. Susan Goodman from Hospital for Special Surgery discussed pre-operative optimization for orthopedic surgery. Patients with inflammatory arthritis can have success with arthroplasty, but are at increased risk of red blood cell transfusion (odds ratio 1.39), infection (OR 1.64), and readmission (OR 1.46). Hip arthroplasty Is also associated with mechanical complications (OR 1.30) such as post-operative dislocation.

 

Dr. Goodman reviewed specific risks related to the diverse field of rheumatic diseases. Ankylosing spondylitis (AS) patients should be monitored for increased pulmonary risks with increased respiratory complications (OR 1.7) and pneumonia (OR 2.18). Chest wall restriction should be evaluated in AS patients and scalene blocks are relatively contraindicated. Lupus surgical risks include renal failure, pulmonary embolism, sepsis, stroke and 30-day mortality and are directly associated with pre-operative disease severity and activity. Recent hospitalization within 24 months, or particularly within 6 months are large risk factor for severe post-operative complications. In psoriatic arthritis, adverse events most attributed to the co-morbidities in this disease rather than directly to the PsA features.