Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Our final case brings together everything we have discussed, but adds the system level challenge of actually coordinating care across disciplines in the real world. James is a 58 year old. With moderate PSA disease activity, a BMI of 39, hypertension, and early type 2 diabetes, his rheumatologist recognizes that weight management is clinically necessary but is uncertain whether to manage this within rheumatology or refer to an obesity specialist or establish a shared care arrangement. Let's come to polling question 7. In your current practice, who typically leads weight management in your PSA patients with obesity? I manage it within the rheumatology clinic I'm in. I refer to an endocrinologist or obesity specialist. C. I co-manage with another specialist. D. It is not systematically addressed in my practice. Or. It depends on the patient. No consistent approach. Thanks for these responses. To all of us, uh, for a patient with moderate PSA, BMI 39, and early metabolic comorbidities, how do you decide whether to manage weight within rheumatology practice, refer out, or establish a shared care arrangement, and what does good coordinated care actually look like in practice? OK, so this is a patient who doesn't have necessarily diabetes, right? This is A moderate PSA, BMI 39, and early metabolic comorbidities. So I don't have a problem myself writing for GLP-1 receptor, uh, agonists, assuming I can get them. That doesn't, I, I, I don't refer many of those out, but the most, many patients of mine don't have a primary care doctor. And so the, my first step is get them a primary care doctor. This is bread and butter for uh primary care. You know, you know, basically weight control. Um, the metabolic consequences you're probably talking about are hypertension, right? Um, if, uh, prevention of stroke, heart attack, things like that. This is in the realm of primary care, as is mild diabetes in many cases. So I want to make sure that they have a primary care doctor. I don't need to manage their hypertension, but I do need to know that they have a primary care doctor who's seeing them, and I tell them sometimes, I sometimes say, actually this, you know, I can be your worst hemorrhoid. Every time you come, I'm going to ask you whether you saw your primary care doctor, and uh I don't have to be the one doing it all, but personally, I have no trouble, uh, writing for GLP-1 receptor agonists, and when I was at Mount Sinai, I was actually uh in dermatology, I had to strong arm people to let dermatology write for these uh drugs, and I did, and we succeeded. Yeah, I, I'm happy to jump in as well. I, I think 11 of the um Uh, comments you mentioned was, was real world. So I'll tell you, I, fortunately for me, I don't have to, I, I don't, I don't live in the real world, uh, presently. I'll share our, our arrangement, but then, you know, maybe my take as well. So, um, we're very fortunate at UT Southwestern, at least here, to have a very unique arrangement. So we have, uh, and this is definitely, you know, outlier, but we have, for example, a cardio dermatology, cardio rheumatology program. We have a. Person who's embedded in our, you know, in our department who's, you know, cardiologist, preventative cardiologist, and imaging guru to whom I can refer patients who have cardiovascular risk and have these inflammatory diseases, right? That's not common. There's a couple of places around the country, North America and the world that have that, so I'm, I'm biased, OK? I think that's an idealized model it's wonderful to have, um, you know, right, but that, but that's unique. I also have no trouble prescribing these agents. I do them, I do it routinely. Um, we also do have a pharmacy tech embedded in our clinic, and that's a huge help because we can ask for help with some of the paperwork and such, but as was previously mentioned, you know, uh, outside of, uh, more likely covered, uh, indications, these, you know, can pose challenges and, and so that's, you know, that is carries its burden. Uh, but we absolutely do prescribe them, I've been increasingly doing so, um, and, and owning these, um, I'll tell you that one of the things we're looking at is increasingly pathways to partner with APP colleagues for the management of both, um, either the initial um prescription, but also and alternatively, the titration of dose and side effect management because I will say I have no trouble writing upfront, and I certainly know how to, you know, uh, do the titration. But it's really helpful if there's someone else who can help with the, you know, the, the burden of messages or follow-up that may come um following, you know, following the initiation and, you know, I, I'll just highlight some data, which is, you know, going back to um the, the Together PSA trial, which we talked about earlier. You know, something like in that study, um, there was very low discontinuation rates for GI side effects, it was like 3% compared to 1%, you know, in the, in the um in the two groups. Um, so it was very low, but, you know, about a third of the patients, 20-30% had GI side effects, they had nausea, diarrhea, constipation, and, you know, etc. So, someone has to be on the other end of the phone, you know, to help manage some of that and talk them through. So I think being able to partner with, you know, allied colleagues, whether it's APPs, whether it's nurses, you know, well-trained staff in the office, I think can really facilitate this and lower the burden. On the physicians, but I, I do think we as dermatologists, rheumatologists, etc. seeing these data and seeing that it impacts not just weight but our com our, you know, comorbidities, but also our diseases directly. I'm, I think, I think we really can and should be prescribing them. The question is how, you know, we get the support to do so and that, that is a, that is a, that, that's not an insurmountable burden. That's not that, you know, that's not as easy as it, as it sounds. Uh thank you all for these comments. What we do in our clinic is all of the above, uh, and things are changing for us over time. Uh, as we're learning more about the GLP-1 receptor agonist group of medicines, we're becoming more comfortable with prescribing them ourselves and counseling patients through how to Uh, initiate the medicines, uh, uh, gradually increase the dose, how, how to counsel, counsel about side effects and manage them. And so, uh, each of us are becoming more comfortable, um, and when I say each of us, I mean both myself as well as the nurse practitioners that I work with. Uh, and that's, I think, very helpful for the patient, but we also are recognizing that many of our patients are coming in already prescribed these medications by their internist or endocrinologist, and so we're now in a, in a process of co-managing the patients with those other practitioners. So this last slide, uh, we're discussing who leads and who refers in terms of weight management and PSA. If the patient has a BMI of 30 to 34, and this is potentially contributing to PSA-driven inflammation, then we are actively involved with Both administration and management of standard immunomodulatory medicines for their disease, but also looking after their metabolic health, including recommending exercise and nutrition and potentially use of GLP-1 receptor agonists, not only for weight loss, but also reducing PSA inflammation, managing their diabetes, as well as cardiovascular risk. And then we may well end up sharing care with other specialists like endocrinologists that are specialized in weight management or their PCPs. Uh, and, uh, the, uh, it's also possible that we could handle this ourselves, uh, but, uh, if the patient already has, uh, others involved as part of the team, then of course we're going to share management with them. If the patient has a BMI that is higher of 35 to 39, then they definitely need counseling about their metabolic comorbidity. We may well initiate the discussion in our clinic, as well as monitoring and reassessing along the way, but we're going to strongly consider team management, including specialists in weight management. And if quite complex, then letting that specialist really guide their their care. And if the BMI is greater than or equal to 40, we'll of course be managing their PSA, but in this case, hopefully weaving in