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.