Psoriatic Arthritis & the Obese Patient

Dr Ogdie

Weight also factors in when considering the patient’s potential responsiveness to drug therapy. M. Elaine Husni, MD, MPH, is a rheumatologist at the Cleveland Clinic’s Department of Rheumatic and Immunologic Diseases, and a researcher at its Lerner Research Institute. “If we focus on psoriatic arthritis patients, there are a lot of disease-modifying anti-rheumatic drugs [DMARDs] available,” she says. “In general, we know that certain medications don’t work as well when you have an elevated BMI, and that outcomes for surgery and other procedures are not as positive when patients are overweight or obese. For example, with anti-TNF [tumor necrosis factor] inhibitors, there is research showing that patients with an elevated BMI will take a longer time to reach minimal disease activity when compared to patients with a normal BMI. We also know that if a patient reduces their elevated BMI down to a normal one, that the drugs work better.”^4,5

In addition to maximizing the effectiveness of medications, weight reduction can help patients with PsA in other ways. “All of your cardiometabolic comorbidities may escalate when you have obesity, and, because psoriatic arthritis has a higher burden to begin with, due in part to an ongoing low-grade inflammatory state, the higher BMI just adds to this issue,” explains Dr. Husni. “We consider weight to be a modifiable risk factor and that’s why we really want to help change this factor.”

Broaching the Subject

Once a diagnosis of PsA has been reached, the issue of obesity becomes more central to the conversation of what to do next. This can be a difficult and sometimes delicate aspect of the patient’s care. No one goes to a doctor to receive a lecture on weight loss. For people struggling with obesity, such conversations are often painful and anything but helpful because they have likely heard it all before. Both Dr. Ogdie and Dr. Husni emphasize the importance of fostering a safe, nonjudgmental relationship with these patients. For the first visit, that means providing as much objective information as possible before venturing into more sensitive areas.

After an initial assessment to identify the patient’s comorbidities and health history, a physical exam to understand what is happening with the joints, and a discussion of appropriate medications to address symptoms, Dr. Ogdie talks to obese patients about their cardiovascular risk based on their lipid profile.

Dr. Ogdie then proceeds to a discussion of body mechanics. “We can take care of joint inflammation, but that doesn’t address how well their body is moving,” she says, noting that her patients are usually referred to physical therapy for that. From there, she moves on to talking about depression or anxiety. Patients with psoriasis and psoriatic arthritis have an elevated risk of mood disorders, which increases the likelihood of unhealthy lifestyle habits.⁶