Obesity in Rheumatic Diseases: More than just a Comorbidity
Transcription
My name is Marina Magray. I'm a professor of rheumatology at Case Western Reserve University, University Hospitals, Cleveland. And today I'm going to give my perspective about a very interesting topic, obesity and rheumatic diseases — more than just a comorbidity.
I have to admit that you know, few years ago when I would see a patient with rheumatic disease and had increased BMI, I would often document it as obesity and as a comorbidity and recommend weight loss, exercise, and move on. However, in the last few years there is emerging evidence about the role of obesity in these rheumatic diseases and also how it can be modified. Now my approach has actually changed.
We all know obesity is linked to inflammation, to metabolic syndrome, cardiovascular risk, and interestingly for us rheumatologists, there is growing evidence now that obesity in rheumatic diseases may impair disease activity, affects the treatment outcomes — some of these patients are not responsive to treatment — and overall impacts the disease outcome. You know, in my own practice, every day I see those patients who we call treatment refractory, that they don't respond to treatment, and often have elevated BMIs.
Now keep in mind, association is not causation, but definitely we see that there's definitely a link that obesity impairs response to treatment and outcome of the disease, and there is a reason for that. Obviously it may be impacting the drug bioavailability, but also leptin, which is a cytokine produced by adipocytes, has pro-inflammatory effect similar to an acute-phase reactant. It upregulates IL-6, TNF alpha, and all of these cytokines which also upregulate the disease activity in our diseases.
So now we can't just be telling these patients to eat less and exercise more, because we have entered into an era where obesity is treatable. The availability of GLP-1 agonists has revolutionized the treatment of obesity, and we're seeing many trials going on in rheumatic and musculoskeletal diseases with these agents. There's data — like in the STEP 9 trial about semaglutide — with the reduction in body weight and greater improvement in physical function in patients with osteoarthritis. The TPSA trial evaluated concomitant use of ixekizumab with tirzepatide compared to ixekizumab alone and showed there was weight reduction and the primary endpoint ACR50 was reached.
So these trials represent landmark findings for the rheumatology community, and ultimately it brings to an important question: should we as rheumatologists be prescribing GLP-1 agonists? Obviously favorable outcomes and results are being seen in our patients, but keep in mind these medications are not yet approved for rheumatic diseases. But definitely, as a rheumatologist, I collaborate with the patient's PCP, I make a concerted effort to get them in to see an obesity expert, and work together with these people so that the right patients get the right treatment.
Some of my colleagues are actually prescribing GLP-1 agonists, and I think one needs to keep in mind that we need to pick the right patients, understand the long-term safety profile, what are the comorbidities in these patients — we need to learn the art of escalating the treatment, being able to de-escalate — and it should be done based on evidence-based medicine. So I feel those rheumatologists who are comfortable doing it should be doing it, because at this point if we don't treat our patients we are basically keeping them away from something that's readily available and which may improve their disease scores.
I just recently saw a patient in my practice — which is anecdotal — with psoriatic arthritis who was started on a GLP-1 agonist. I had seen him four months ago and his disease was not well controlled, and this time the disease seemed to be well controlled. That's because these medications have some impact, and favorable results are seen in many of these rheumatological settings.
As awareness of these agents is growing among patients, I think we as clinicians need to provide accurate, evidence-based information to our patients to make informed decisions regarding their health and what to do in the future. Thank you.
I have to admit that you know, few years ago when I would see a patient with rheumatic disease and had increased BMI, I would often document it as obesity and as a comorbidity and recommend weight loss, exercise, and move on. However, in the last few years there is emerging evidence about the role of obesity in these rheumatic diseases and also how it can be modified. Now my approach has actually changed.
We all know obesity is linked to inflammation, to metabolic syndrome, cardiovascular risk, and interestingly for us rheumatologists, there is growing evidence now that obesity in rheumatic diseases may impair disease activity, affects the treatment outcomes — some of these patients are not responsive to treatment — and overall impacts the disease outcome. You know, in my own practice, every day I see those patients who we call treatment refractory, that they don't respond to treatment, and often have elevated BMIs.
Now keep in mind, association is not causation, but definitely we see that there's definitely a link that obesity impairs response to treatment and outcome of the disease, and there is a reason for that. Obviously it may be impacting the drug bioavailability, but also leptin, which is a cytokine produced by adipocytes, has pro-inflammatory effect similar to an acute-phase reactant. It upregulates IL-6, TNF alpha, and all of these cytokines which also upregulate the disease activity in our diseases.
So now we can't just be telling these patients to eat less and exercise more, because we have entered into an era where obesity is treatable. The availability of GLP-1 agonists has revolutionized the treatment of obesity, and we're seeing many trials going on in rheumatic and musculoskeletal diseases with these agents. There's data — like in the STEP 9 trial about semaglutide — with the reduction in body weight and greater improvement in physical function in patients with osteoarthritis. The TPSA trial evaluated concomitant use of ixekizumab with tirzepatide compared to ixekizumab alone and showed there was weight reduction and the primary endpoint ACR50 was reached.
So these trials represent landmark findings for the rheumatology community, and ultimately it brings to an important question: should we as rheumatologists be prescribing GLP-1 agonists? Obviously favorable outcomes and results are being seen in our patients, but keep in mind these medications are not yet approved for rheumatic diseases. But definitely, as a rheumatologist, I collaborate with the patient's PCP, I make a concerted effort to get them in to see an obesity expert, and work together with these people so that the right patients get the right treatment.
Some of my colleagues are actually prescribing GLP-1 agonists, and I think one needs to keep in mind that we need to pick the right patients, understand the long-term safety profile, what are the comorbidities in these patients — we need to learn the art of escalating the treatment, being able to de-escalate — and it should be done based on evidence-based medicine. So I feel those rheumatologists who are comfortable doing it should be doing it, because at this point if we don't treat our patients we are basically keeping them away from something that's readily available and which may improve their disease scores.
I just recently saw a patient in my practice — which is anecdotal — with psoriatic arthritis who was started on a GLP-1 agonist. I had seen him four months ago and his disease was not well controlled, and this time the disease seemed to be well controlled. That's because these medications have some impact, and favorable results are seen in many of these rheumatological settings.
As awareness of these agents is growing among patients, I think we as clinicians need to provide accurate, evidence-based information to our patients to make informed decisions regarding their health and what to do in the future. Thank you.
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