QD Clinic: Managing Obesity: By PCP or Rheumatologist? Save

Hi everybody. I'm Mike Putman. I'm a rheumatologist at the Medical College of Wisconsin and I'm coming to you today for RheumNow. Excited to talk about GLP-1s and a couple cases that I think illustrate how I have changed my practice to incorporate these new therapies.

So I have two cases I want to share. The first is a 74-year-old female patient of mine who had giant cell arteritis with large vessel involvement. We did the usual things, steroids, tocilizumab, and she responded beautifully. Went into remission. 14 months into her taper, she came back to me and she said, "I wish I could just go back and suffer the consequences." The steroids had caused horrible, horrible changes to her body and her self-image, and she'd gained 45 pounds, and she just felt like it hadn't been worth it. And for me, this is heartbreaking. I'm here to try and help people live longer, live better, and we stamped out the GCA, but she was definitively not living better.

And so I said, you know, there's these new medicines, these GLP-1s. I'll refer you to your primary care doctor. Sent her to the PCP. They said, here's some dietary changes. And she came back to me and said, you know, I tried and it's not working. So I went back and forth and I said, you know, we need to try GLP-1. They said, okay, we'll consult endocrinology. So she went to endocrinology. Got referred. It was denied. She tried another round of diet and exercise. Did not make progress. Six months later, maybe nine months, I finally got her on a GLP-1. But at that point she was going for a TKR and the whole thing was so frustrating and I just felt like I failed. You know, I gave her all the steroids that caused the weight gain. I tried to make the right things happen and have the primary care doctors handle the GLP-1s and do all the things in the way that the healthcare system does, and it just didn't work.

So let me tell you another vignette. It's a little bit later. I had a 58-year-old gentleman with rheumatoid arthritis. He came in to me with knee swelling. I aspirated a joint. He had 2,300 white cells in the joint, so mostly inflammatory. I injected it. He got mostly better but not all the way. We increased his methotrexate. He was also on a TNF and hydroxychloroquine. So, three drugs, difficult to control RA. Got an X-ray. He had moderate to severe DJD. So I referred him to orthopedics and said, "Hey, you know, this guy might need a knee replacement." They said, "Sure looks like it." Put him on the schedule for a little ways in the future after he tried some physical therapy. And they said, "Maybe he should lose some weight." And I said, "All right, that sounds great, but you know what? I've been down this road. I'm going to try something different." And so I prescribed him a GLP-1 myself, went through, got approved, he went on GLP-1.

Four months later, he came back to my clinic and I have never seen him this happy in my entire life. He about gave me a hug. And for a couple different reasons. Number one, the knee replacement was cancelled because he'd lost 45 pounds and his knees felt great. He said, "Hey, I don't need a knee replacement. I'm working and running better than I've run in 20 years." He had also self-discontinued the methotrexate. He said, "I felt great. Everything was going so well for me. I stopped the methotrexate." He showed me his hands and he had a CDAI of zero. He had no disease activity. His inflammatory markers had also completely normalized, which had never happened in my entire time of seeing him. His ESR had always been like 40s, 50s, you know, passively elevated. CRP always like 0.9, you know, not high, but not normal — and completely normalized. His ESR was in the 20s and his CRP was stone cold normal. And this is despite him stopping methotrexate, which is usually the kind of thing that would instigate a flare.

So, a couple of take-home points from these vignettes. The first one is that I think we own this. If you give someone steroids and they gain a bunch of weight, that is a problem that you caused. Maybe you had to cause it, but you should participate in the solution, right? We give PPIs to prevent GI bleeds. We give calcium and vitamin D, which doesn't really work, to try and prevent fractures. I mean, GLP-1s work and we cause the problem.

The second thing is that I don't know why we wouldn't own this. Like, we have the prior authorization pathways. We're always running prior authorizations for super expensive medicines already. This is our thing. We know how to do this. And so I think we should do it. [laughter]

The third reason I think you should do this is that patients just love it. I mean, patients love this. I've had many, many patients that I prescribed a GLP-1 to now who lost a ton of weight, came back and said, you know, you really changed my life. And I'm like, is it the
methotrexate? They're like, no, no, no, no. It's the GLP-1. And then the fourth thing is that you know this is on brand for us because we really do think there are probably some anti-inflammatory effects of the GLP-1. So you know the TOGETHERPSА — the TOGETHER PSA study was just published, you know, that showed that people with psoriatic arthritis had better disease control independent probably of uh uh of DMARD with GLP-1. So, you know, I think that there's definitely something here and I think that that probably crosses different disease areas where giving GLP-1s, cutting weight, uh, cleaning up diet really, really has some anti-inflammatory effects and could help you get people on less DMARD. I think that's still to be seen in a lot of disease areas, but boy, there's so many other benefits to these drugs that I think it's worth considering.

So, uh, that's my pitch for why rheumatologists should be prescribing GLP-1s. Hope you thought that was interesting. Uh, if you want more information about this, please uh check out all of our great coverage at RheumNow. Thanks so much. Have a great day, everyone.