QD Clinic: Treat to Target Obesity Save
Transcription
Hello, welcome to QD Clinic for RheumNow. This is the obesity month with RheumNow. And today I'm going to talk about actually two cases rolled into one as we talk about treat-to-target obesity. We are very familiar in rheumatology with treat-to-target approaches and I'll talk about two of the cases in which we have treat-to-target autoimmune or rheumatic approaches for this, and in what cases should we add obesity management to that algorithm and treat-to-target approaches for obesity as well.
First case is a patient I saw last week for gout management. He had uric acid of 6.2, non-tophaceous gout. Our goal has been getting him below 6.0. He's had mild symptoms for which he had to take colchicine intermittently about twice a month with some improvement. It's a little bit unclear exactly how controlled the gout symptomatically is because he's still requiring treatment for it.
We talked about what options would be. 6.2 is pretty close to the goal of 6.0. We can increase the uric acid-lowering therapy. He was only on 200 milligrams. Lots of room that we could safely go up. We talked about that being a very good approach. We can do that. And again, our goal would be to bring him down below six.
When I spoke with him, he said, "I can't. I've been on more and more medications. I can't do anymore. It's been too much. I just feel unhealthy." And increasing the dose makes me feel that way even more so.
So I gave an opportunity to take a step back, look at the big picture, and we talked about his metabolic syndrome. He has pre-diabetes. He has hyperlipidemia. He has blood pressure issues. He has all these comorbidities and it all stems within the metabolic disease. We know again gout is part of metabolic syndrome as well. His BMI was 33 and we talked about his goal of coming down under 30. We talked about medical pharmacologic approaches like the GLP-1 inhibitors, but he wanted to decrease his medication list and he wanted to work on decreasing his weight and make himself overall healthier.
So we partnered together and we set treat-to-target goals of under six for uric acid and under 30 for his obesity. And he came back at that next visit. He had gone to the gym. He had changed his diet. He had been feeling really well. And his BMI was right at 29. His uric acid came down to 5.8. So these lifestyle interventions are a tool in our toolbox that we can go to when medication changes either aren't appropriate or aren't desired by the patient.
Same patient — or next patient, same story. Very different case though. This is a patient with rheumatoid arthritis on biologic treatment with adalimumab monotherapy, takes it every two weeks. CDAI score was 11, indicating moderate disease activity just above the low disease activity threshold. Overall feeling pretty well but definitely had a couple of swollen joints. I talked about adding a csDMARD or changing the adalimumab to weekly administration — same reluctance of the patient to say, you know, I'm overall feeling well, but I really want to not go on more medications.
So we discussed once again the weight. We also discussed in this patient the smoking contribution to RA. And so we set goals of decreasing their BMI, decreasing cigarette consumption or quitting smoking, and overall improving the disease control. And I said we don't need to go up on pharmacologic agents yet. If we can partner together and work on these non-pharmacologic contributors — and again the BMI is a huge contributor with RA, we definitely know smoking is as well, exercise, lifestyle interventions, all these play a big role — and that patient is doing much better on follow-up. We will continue to follow, we'll continue to see if that is enough to control the RA and keep them in that low disease activity. The patient was able to cut down on smoking, has not been able to completely quit, but that is something we will continue to work on.
But when it comes to obesity management, a lot of the conversation on RheumNow this week is about the pharmacologic treatments, but there's also the non-pharmacologic approaches. There are some patients who want to be aggressive with their treatment and there are others who do not want to be on more and more medication. So it's important to understand who your patients are, what their goals are. Partner with them and approach health in general, and not to be focused on a uric acid number or CDAI score. See the patient as a larger individual and not focus just on treat-to-target by escalation, but on that health goal in general.
So these are two cases that nicely illustrated that point to me. Lots more information on RheumNow for all of obesity month. Check out the other QD Clinics and the other lectures and great content on RheumNow all month long.
First case is a patient I saw last week for gout management. He had uric acid of 6.2, non-tophaceous gout. Our goal has been getting him below 6.0. He's had mild symptoms for which he had to take colchicine intermittently about twice a month with some improvement. It's a little bit unclear exactly how controlled the gout symptomatically is because he's still requiring treatment for it.
We talked about what options would be. 6.2 is pretty close to the goal of 6.0. We can increase the uric acid-lowering therapy. He was only on 200 milligrams. Lots of room that we could safely go up. We talked about that being a very good approach. We can do that. And again, our goal would be to bring him down below six.
When I spoke with him, he said, "I can't. I've been on more and more medications. I can't do anymore. It's been too much. I just feel unhealthy." And increasing the dose makes me feel that way even more so.
So I gave an opportunity to take a step back, look at the big picture, and we talked about his metabolic syndrome. He has pre-diabetes. He has hyperlipidemia. He has blood pressure issues. He has all these comorbidities and it all stems within the metabolic disease. We know again gout is part of metabolic syndrome as well. His BMI was 33 and we talked about his goal of coming down under 30. We talked about medical pharmacologic approaches like the GLP-1 inhibitors, but he wanted to decrease his medication list and he wanted to work on decreasing his weight and make himself overall healthier.
So we partnered together and we set treat-to-target goals of under six for uric acid and under 30 for his obesity. And he came back at that next visit. He had gone to the gym. He had changed his diet. He had been feeling really well. And his BMI was right at 29. His uric acid came down to 5.8. So these lifestyle interventions are a tool in our toolbox that we can go to when medication changes either aren't appropriate or aren't desired by the patient.
Same patient — or next patient, same story. Very different case though. This is a patient with rheumatoid arthritis on biologic treatment with adalimumab monotherapy, takes it every two weeks. CDAI score was 11, indicating moderate disease activity just above the low disease activity threshold. Overall feeling pretty well but definitely had a couple of swollen joints. I talked about adding a csDMARD or changing the adalimumab to weekly administration — same reluctance of the patient to say, you know, I'm overall feeling well, but I really want to not go on more medications.
So we discussed once again the weight. We also discussed in this patient the smoking contribution to RA. And so we set goals of decreasing their BMI, decreasing cigarette consumption or quitting smoking, and overall improving the disease control. And I said we don't need to go up on pharmacologic agents yet. If we can partner together and work on these non-pharmacologic contributors — and again the BMI is a huge contributor with RA, we definitely know smoking is as well, exercise, lifestyle interventions, all these play a big role — and that patient is doing much better on follow-up. We will continue to follow, we'll continue to see if that is enough to control the RA and keep them in that low disease activity. The patient was able to cut down on smoking, has not been able to completely quit, but that is something we will continue to work on.
But when it comes to obesity management, a lot of the conversation on RheumNow this week is about the pharmacologic treatments, but there's also the non-pharmacologic approaches. There are some patients who want to be aggressive with their treatment and there are others who do not want to be on more and more medication. So it's important to understand who your patients are, what their goals are. Partner with them and approach health in general, and not to be focused on a uric acid number or CDAI score. See the patient as a larger individual and not focus just on treat-to-target by escalation, but on that health goal in general.
So these are two cases that nicely illustrated that point to me. Lots more information on RheumNow for all of obesity month. Check out the other QD Clinics and the other lectures and great content on RheumNow all month long.
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