MDis a 51-year-old woman who first came to our practice approximately 12 years ago with complaints of diffuse joint pain. Her recent history included pain in her lower back, bilateral knee osteoarthritis, and hip pain. Her weight was certainly a significant issue—MD was 5 foot-3 and weighed 300 pounds, putting her BMI at a sky-high 53.3. MD’s weight-bearing joints, including her low back, knees, and hips, were undoubtedly suffering additional wear and tear due to her weight. Surprisingly, MD had no other pertinent medical history—no cardiovascular issues, no hypertension, and no diabetes.
What makes the evaluation of obese patients particularly challenging is that it can be difficult to tease out whether their pain is predominantly a result of obesity, osteoarthritis, or an underlying autoimmune condition such as rheumatoid arthritis (RA). Joint swelling of obese patients is also more challenging to assess on physical exam, making laboratory and radiologic findings vital toward reaching a diagnosis.
MD’s anti-citric citrullinated protein levels proved to be the key diagnostic clue, with results showing a highly elevated level of 60 μ/ml, leading us to diagnose her with RA. We initiated treatment with methotrexate (MTX) 10 mg weekly and oral diclofenac 75 mg twice daily.
MD’s symptoms remained stable for several years, although we increased the MTX dosage over the years to the maximum of 25 mg weekly. She complained of progressively worse pain in her hips over time, which were managed with corticosteroid injections every 3-4 months. Her bilateral knee pain was eventually chalked up to end-stage osteoarthritis, for which she was started on hydrocodone for pain management (her surgeon was leery about a knee replacement until MD had lost weight). While MD managed to retain her job as an insurance agent during the time she was a patient in our practice, she usually sat for hours at a time on the job and was unable to participate in activities or exercise as she wished.
Five years after her initial diagnosis of RA, the periodic hip injections were becoming less and less effective. There was more pain and swelling in MD’s joints. Her weight had ballooned to 315 pounds, and her blood sugars were now slightly elevated. MD was started on metformin, but it was obvious that something more needed to be done for her RA symptoms. Unfortunately, MD remained hesitant to initiate biologic therapy, limiting our options.
As her disease continued to slowly progress, MD came in for a regular follow-up visit one morning and informed me that she was contemplating having bariatric surgery and in fact had already set up an appointment with a surgeon to discuss her options. I was initially a bit surprised at the news but, truth be told, was so new to rheumatology at the time that I didn’t fully understand the potential impact that bariatric surgery can have on patients with an autoimmune disease. Nonetheless, MD impressed me with the research she had done—this clearly was not a snap decision. She knew the name of the bariatric surgery center she would be going to and understood the importance of meeting with a dietician and therapist prior to surgery.
Seven months later, MD went ahead with the surgery. Everything went smoothly without complications, which is not always the case in my patients who have bariatric surgery. I have seen patients develop infections following the procedure and some whose weight loss wasn’t nearly as substantial as they would have liked. MD was one of our more significant success stories.
Following the surgery, we switched MD to the injectable form of MTX and replaced her oral diclofenac with the topical gel formulation. Patients who undergo bariatric surgery should generally take as few oral medications as possible due to potential changes in the absorption, distribution, metabolism, and excretion of medications, which triggered our adjustments.
It’s been 6 years since MD underwent bariatric surgery, and I am pleased to report that she is doing great. Her weight is down to 191 pounds and her BMI is now 33.8, which still puts her in the obese category but it’s not nearly as significant an issue as it was in previous years. MD’s RA remains stable on weekly subcutaneous MTX 15 mg. With her drop in weight, MD was able to have both knees replaced and has discontinued use of both hydrocodone and metformin. Her physical and mental well-being are both significantly improved.
Mainly out of professional curiosity, I recently took a look at MD’s historical RAPID 3 scores. Immediately prior to bariatric surgery, she scored a 13, indicating high disease severity. Six months after surgery, her RAPID 3 score dropped all the way down to 3.2. Her scores since then have all been in the 0-3.0 range, indicating near remission.
Discussing the need for RA patients to lose weight is not easy. Patients know they are overweight and have likely been barraged by friends and family long before they come to our office for an evaluation. Nonetheless, weight control is so crucial to the management of RA and other autoimmune diseases that to avoid the discussion is unwise. As detailed throughout this issue of Rheumatology Nurse Practice, weight loss in obese or overweight patients with RA can result in reduced pain, less severe disease, and better overall health.
Losing weight comes easy for no one. It takes hard work and dedication. I always begin a discussion of weight loss with my patients by listening. Listening to what has worked and not worked for them in the past. Listening to how excess weight may have stigmatized them throughout their life and may be doing so now. I let patients vent to me if they are frustrated, knowing that they should lose weight but fearful of even trying because every movement of their body hurts. I let them know that they are not alone in their struggle and encourage them to start very slow. Take those few extra steps around the grocery store, park a little further from work than normal. Start with gentle stretching—range of motion exercises and yoga are all great ways to get moving.
For some patients though, the struggle has gone on for so long and they feel that they need more than a gentle kick start. This is where bariatric surgery may fit in, as it did for MD. Bariatric surgery can be risky, especially for patients with an autoimmune disease, but with appropriate preparation, counseling, and proper adjustments to a treatment plan, it can be a successful and life changing decision that we should support as best we can.
Carrie Beach BSN, RN-BC, is a rheumatology nurse with the Columbus Arthritis Center in Columbus, OH, and the current Historian for the Rheumatology Nurses Society.