Alexis Ogdie, MD, on The Burden of Comorbidities in Inflammatory Disorders

Dr Ogdie gives a recap of her presentation at the 2022 Interdisciplinary Autoimmune Summit on common comorbidities to be aware of in patients with inflammatory disorders.

Alexis Ogdie, MD, is an Associate Professor of Medicine and Epidemiology in the Perelman School of Medicine. She is also Deputy Director of the Center for Clinical Epidemiology and Biostatistics and Director of the Penn Psoriatic Arthritis and Spondyloarthritis Program. 

TRANSCRIPT

Alexis Ogdie, MD:
I'm Alexis Ogdie, I'm Associate Professor of Medicine and Epidemiology at the University of Pennsylvania. And today I'm going to give you a quick snapshot of something I just talked about at the Interdisciplinary Autoimmune Summit this past weekend.

One of the talks I gave was about comorbidities in rheumatic diseases. I do most of my work within rheumatoid arthritis, psoriatic arthritis, and axSpA. I focus mainly on those diseases. But some of the themes are actually pretty consistent across the different autoimmune conditions. So in this talk, I talked about the concept of treating the whole patient. And if we're not thinking about comorbidities, we can't possibly be thinking about treating the whole patient.

Why is this important? Well the patient is experiencing all kinds of things, and our disease is really just one piece of that. So we have to keep in mind all the other things that might be influencing their health related quality of life. In addition, we know that several of these comorbidities also affect treatment response or the likelihood of achieving minimal or low disease activity.

Within this talk, I talked about a variety of different comorbidities in more detail. So one of the sets of comorbidities we talked about were depression and anxiety. We know that these are very common conditions in our diseases, across rheumatic diseases. And that was true prior to COVID. Since COVID, this is obviously a much more weighty issue. Many people have depression and anxiety that was not present potentially before this pandemic.

Within depression and anxiety, one of the things we need to worry about is also suicidality, which is thought to be increasing in our patient populations, but in the U.S. in general. How do I approach that in clinical practice? Well, the first thing I do is I try to just keep it as a part of my review systems and I talk about it at every visit. This is important because someone may not respond to you the first time you ask, but if they understand this is a normal part of what I ask and what I'm going to talk about, then they know that they can come to you with this.

One of the things that people often bring up is why would you ask about depression, anxiety, if you can't do anything about? It's so hard to get a therapist for patients these days. What am I supposed to tell a patient? I usually respond to that by saying that identifying the condition is about 50% of the problem. So if we can identify that the patient has depression or anxiety, we can send them back to their primary care physicians to help manage that. Or the patient can start looking for resources on their own as well. Additionally, I tell them to call the back of their insurance card to see what kinds of services they may be eligible for. There's many places where people can get these services. I always also say to get on a list. So if you're trying to get a therapist, just call, get yourself on a list that might be six months from now, but at least you have it. And you can always back out of it later. In any case, depression, anxiety are very important to identify because they do have a substantial impact on response to therapy.

All right, so we talked about depression and anxiety. That next thing that usually follows that is talking about central sensitization or fibromyalgia. We also know that having fibromyalgia or central sensitization is associated with a lot more cycling of therapies. When you have cycling of therapies, patients quickly run out of different therapy options, and you're trying to make these complicated decisions about what might be next. So one of the goals is to keep patients on their therapy as long as possible and deal with the central sensitization as a separate problem. If you do that, you can often improve their pain levels, improve their overall wellbeing, and then keep them on their drug longer. Because if we're treating the morning stiffness, that's prolonged for several hours, and the high pain levels, and the absence of joint swelling. Then we may not be doing the best thing for the patient if we're switching biologics in that particular patient.

So in this talk, I talked about managing central sensitization by bringing up the fact that you need to deal with the sleep. You need to deal with any depression, anxiety, PTSD, or any other psychosocial aspects that are ongoing. Any high stress levels. And also, the pain sometimes through medications or alternative medicine or therapies like acupuncture, for example. As well as dealing with the disease itself.

I also talk about the importance of aerobic exercise and exercise in general and building that into the schedule. I also talk about the fact that this is really hard. It's not like you do this all at one time. This is a very slow process, and we have to slowly improve these things, and targeting all of them is actually equally important, even if you're just targeting them little bits at a time.

All right. So next is obesity. I talked more extensively about obesity and cardiometabolic disease. Obesity is an increasing problem in all of our diseases. It is particularly a problem in psoriatic arthritis. And both in psoriatic arthritis and axSpA is associated with decreased responsive therapy. We also see this in IBD.

How do you manage weight? Again, this is often done in multiple different ways. You can refer back to primary care. You can refer to nutrition. We all know that nutrition is hard to get access to in the United States if you don't have a cancer diagnosis, and it can be expensive. It's generally out of pocket and not covered by insurance, so that is a problem. We talked about the fact that sometimes there are certain healthy lifestyle changes, like eating a Mediterranean diet or a dash diet, for example, that can help with weight loss. If you're focusing on the eating change, as opposed to focusing on the weight itself, that can help. But there are a variety of weight loss programs out there that patients may look at.

Finally, we talked about cardiovascular disease and screening for cardiovascular disease and the importance of at least talking to the patient about this. Ideally, sending the lipids and then referring back to primary care. But I went through the steps through calculating the ASCVD risk score so that you can have all the information for the patient and at least kind of send up the flag that this needs to be dealt with. Either with preventative cardiology or primary care.

Now not all of these things happen in one visit. They help over the longitudinal of care. So this is not saying that we need to deal with all these things at one time. You can deal with this by having this as a list in your note template. And then, some days, you might address one piece of it. Some days you might not be able to address any of it if there are other concerns that you're trying to work through. But at least then you have a checklist for future visits. You'll come back to this later.

I hope you get to watch this talk on the IAS platform, but otherwise, thanks so much for listening today.