QD Clinic: Obesity: Escalate or Reassess? Save

Hello, welcome to Obesity QD Clinics for RheumNow. My name is Dr. Marini Day. I am a fellow in rheumatology and internal medicine working in King's College London in the UK. And today's case is entitled "Obesity: Escalate or Reassess."

So this is actually a composite case based on several clinical situations I have faced within the rheumatology clinic that will be familiar to many rheumatologists.

So our patient is a lady in her early 50s with an 8-year history of psoriatic arthritis. Her disease had previously involved peripheral joints, entheses and the skin. And she also had obesity with a BMI of 39.

She had initially received treatment with a TNF inhibitor with only a partial response and eventually had changed to an IL-17 inhibitor. After 12 months on that, her psoriasis was almost completely clear and the swollen joints seen before her treatment with the IL-17 inhibitor had resolved.

However, despite this, she continued to report considerable pain, fatigue and difficulty with everyday activities. Her walking was limited. She had stopped exercising. And she was struggling at work as well. So these symptoms were starting to affect almost all parts of her life. Her disease activity score remained high enough to suggest that there was inadequate treatment response.

So on that basis it would have been easy to conclude that we need to go for another advanced therapy and that her second mode of action biologic had also not worked.

However, when we separated the components of the score, it was actually more complicated than all her symptoms being attributable to PsA alone. So she had 12 tender joints but no swollen joints. Her pain and patient global scores were both eight out of 10 while her CRP was only mildly elevated. There was no dactylitis. Her psoriasis, which she previously had very active disease, remained well controlled and her examination didn't show any convincing active enthesitis, which she had also previously had.

We then went on and did an ultrasound scan of the most symptomatic joints. And this found no significant power Doppler activity. So no evidence of an inflammatory process going on. Some knee radiographs were also done because she was complaining of significant knee pain. And those showed some osteoarthritis.

She also, in addition to all of this, described unrefreshing sleep. Her partner, who was with her in clinic, also reported that she was snoring now. And she herself said that she was
herself said that she was getting quite sleepy during the day. So what you'd describe as daytime somnolescence.

When asked about her mood, which is of course very important in our patients with rheumatic diseases, she reported very low motivation, um loss of enjoyment, um and feelings of hopelessness. Um so quite depressive symptoms as well.

Subsequent assessment identified obstructive sleep apnea, um and of course the clinically important depressive symptoms. So there's several pathways by which to go now. So should we change her biologic because she's not — she appears not to have achieved the treatment target? Should we continue with the same treatment um and accept that nothing more can be done at this point, or should we actually step back and reconsider what's driving her symptoms?

Um and of course the third option is the key thing to do here. So rather than immediately changing her biologic, um the absence of objective inflammatory activity should make you question whether or not another change in immunotherapy would address the outcomes um that actually mattered to her. So instead, we discussed the findings with her. Um importantly, we didn't tell her that every symptom is caused by her weight because that's not true. We explained that her PsA appeared reasonably controlled, but that osteoarthritis, sleep disturbance, mood, reduced activity, and obesity were probably all interacting to amplify her pain and her functional limitation.

So, in these cases, it's quite important to discuss obesity as a chronic treatable health condition, um which as we've suggested interacts with other symptoms and other co-morbidities that the patient may have in order to ultimately um contribute to the symptoms the patient is experiencing.

So for our patient she was referred for sleep assessment and subsequently began treatment for her OSA, obstructive sleep apnea. Um her depressive symptoms were addressed through um primary care, although we did also refer her to our um liaison psychiatrist who works within the department as well um for additional help and support, and she received physiotherapy focused initially on achievable low um impact activity, so a graded exercise therapy program, since there was also symptoms of fibromyalgia here as well. She was also referred to a specialist weight management service um to discuss behavioral, nutritional and pharmacological treatment options. And of course, weight management services do vary in terms of accessibility and um the type of um support they can provide the
type of um support they can provide depending on where you are um not just in the UK but around the world as well and the health care system you work in.

At followup, she was not pain-free. However, her sleep, energy, and walking tolerance um had improved um and she had begun to lose weight. um and there was still no objective evidence um of recurrent inflammatory arthritis.

So when we reflect on this case, it is firstly important to remember that um disease activity score is a prompt for clinical assessment and should certainly not be a substitute for it. Clinical assessment is is is really key um particularly when people have multiple coexisting conditions as well that may be contributing to symptoms.

Um composite measures are obviously essential but tender joint counts, pain, fatigue and patient global assessment can be influenced by other conditions such as osteoarthritis, sleep disturbance, mental health conditions, central pain mechanisms um and obesity as well. Of course, and a high score should make us ask what else could the person be experiencing that is contributing to these symptoms.

The relationship between obesity and psoriatic arthritis itself. If we just take those two aspects is very complex. Obesity is associated with um greater symptom burden, poorer physical function and lower probability of achieving some treatment targets. It may also influence response to biological therapy, particularly TNF inhibitors. This has been shown in multiple real world studies including one that I was involved in within the international METEOR cohort. Um it's been shown um many many times and specifically adipose related inflammation can contribute to modest elevations in CRP while mechanical loading may worsen pain at the knees, feet and entheses just to name a few.

At the same time though, obesity should not become an explanation for every symptom that a person is experiencing. So people with obesity can still have genuinely active PsA of course and undertreating inflammation is just as problematic as unnecessary escalation of advanced therapy. So the aim is to assess inflammation carefully while recognizing the additional factors shaping the patient's experience.

Obesity in itself is complex and the management involves shared decision-making um potentially the involvement of many specialties. Um as we've seen in this case, it is of course important to ask a person's permission before discussing weight especially the relevance to their own priorities whether those are pain, own priorities
whether those are pain, mobility, fatigue or cardiovascular health. So in this case for example um her symptoms were affecting her ability to work and so that might be a priority for her. We should also ask about sleep, mood, eating behavior, um medication um and also barriers to physical activity as well.

Rheumatologists don't need to be the ones providing every component of um obesity care. Um but our role may be to recognize the problem given of course how frequently we also see our patients and monitor them. Um but the key is to avoid stigmatizing language and connect the patient with the appropriate multidisciplinary support.

It's also worth mentioning here very briefly um about difficult to manage psoriatic arthritis which deserves a whole video in itself. But persistent symptoms after several advanced therapies may result from continuing inflammation, but they also may be driven by comorbidities as we've discussed. Uh as well as structural damage, psychological factors or persistent pain. Um the term treatment refractory disease should be reserved for patients with convincing objective inflammation despite appropriate therapies.

So clearly the coexistence of obesity and psoriatic arthritis is clinically complex but does require careful assessment um to ensure treatment is escalated when appropriate but also management of coexisting conditions um are also offered in a partnership with a person living with the condition. Um thank you for listening to this case. If you'd like to find out more about RheumNow's um coverage on obesity um QD clinics, then do uh continue to check out the website for more cases and more coverage. Thank you.