patient care perspectives

Strategies for Managing Patients With Rheumatoid Arthritis and Comorbid Obesity

by Alvin F. Wells, MD, PhD

Overview

Obesity can adversely affect response to disease-modifying antirheumatic therapies, with anti–tumor necrosis factor (anti-TNF) agents among the most studied in this regard. Patients with obesity who achieve significant weight loss are more likely to experience a better response to their rheumatoid arthritis (RA) therapy, in addition to all of the other well-known benefits of weight loss.

Expert Commentary

Alvin F. Wells , MD, PhD

Visiting Foreign Professor, Karolinska Institute
Director, Rheumatology and Immunotherapy Center
Adjunct Assistant Professor, Duke University Medical Center
Clinical Assistant Professor, Marquette University
Franklin, WI

“In a 300-pound patient, I am still going to treat the RA aggressively, but we also want to achieve significant weight loss. There are several US Food and Drug Administration–approved drugs for weight loss, and I am very comfortable prescribing them, when appropriate.”

Alvin F. Wells, MD, PhD

We know that patients who are overweight will not respond as well to their biologic medications, including anti-TNF agents, compared with patients who are not overweight. Other metabolic effects of obesity include abnormal cholesterol levels and an increased risk for type 2 diabetes, as well as associated hypertension and osteoarthritis in the hips and knees. In a 300-pound patient who is not responding to multiple RA therapies, do you continue with that approach and the added expenses, or do you take a step back and put him or her on a 3- to 6-month weight-loss program? Now, I am an outlier with respect to weight control in patients with RA because we have an active weight-loss clinic in my rheumatology center. But, when we get their weight under control, they are likely to respond better to the RA therapy and will experience all of the subsequent health benefits of weight loss, such as lower cholesterol levels and blood pressure, improved glucose control, and a decreased need for diabetes medications. While rheumatologists do not necessarily have the time or capacity to manage all of the internal medicine issues in our patients, we do want to ensure that individuals with obesity are treated appropriately to achieve significant weight loss in the interest of their RA and their general health. So, in a 300-pound patient, I am still going to treat the RA aggressively, but we also want to achieve significant weight loss. There are several US Food and Drug Administration–approved drugs for weight loss, and I am very comfortable prescribing them, when appropriate. None of these weight-loss drugs impact the treatment of RA, and I find that if patients lose 30 or 40 pounds, multiple expensive RA medications may not be required to achieve the same degree of control. We also work with bariatric surgeons for surgery in appropriate patients. But it is important to emphasize to patients that weight loss is a lifelong process that requires lifelong lifestyle modification.

Regarding drugs that are influenced by obesity, the anti-TNF agents have the most data and there is a clear decrease in efficacy in patients with obesity. We are beginning to see some data with respect to the interplay between obesity and the efficacy of various RA therapies, but we need more data on the newer agents to determine, for instance, whether interleukin 6 inhibition might be preferable to Janus kinase inhibition in patients with RA and obesity.

References

Goossens J, Coustet B, Palazzo E, Dieudé P, Ottaviani S. Overweight and obesity affect clinical assessment of synovitis in rheumatoid arthritis: comparison of ultrasonography and clinical exam. Clin Exp Rheumatol. 2018 Jun 7. [Epub ahead of print]

Linauskas A, Overvad K, Symmons D, Johansen MB, Stengaard-Pedersen K, de Thurah A. Body fat percentage, waist circumference and obesity as risk factors for rheumatoid arthritis - a Danish cohort study. Arthritis Care Res (Hoboken). 2018 Jul 5. doi: 10.1002/acr.23694. [Epub ahead of print]

Philippou E, Nikiphorou E. Are we really what we eat? Nutrition and its role in the onset of rheumatoid arthritis. Autoimmun Rev. 2018;17(11):1074-1077.

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