Tackling Obesity in Psoriatic Arthritis: Key to Better Outcomes and Overall Health

Co-Chairs and Presenters, Alexis Ogdie, MD, MSCE, Robert H. Eckel, MD, FAHA, FACC, and M. Elaine Husni, MD, MPH, prepared useful Practice Aids pertaining to psoriatic arthritis for this CME/AAPA/IPCE activity titled “Tackling Obesity in Psoriatic Arthritis: Key to Better Outcomes and Overall Health.” For the full presentation, downloadable Practice Aids, and complete CME/AAPA/IPCE information, and to apply for credit, please visit us at https://bit.ly/3U52v5K. CME/AAPA/IPCE credit will be available until October 23, 2026.

1. Optimizing PsA Outcomes in the Context 
of Obesity: A Rheumatologist’s Toolkit 
Full abbreviations, accreditation, and disclosure information available at 
PeerView.com/CKQ40 Dentric cells
DAMPs and
PAMPs
M1 Macrophage
TNFα
IFNα
TNFα
TNFα
IFNγ
Th1 cell
CD8 cell
Cell recruitment
(eg, M1, fbroblast,
chondrocyte,
keratinocyte)
Synovitis, enthesitis,
skin hyperproliferation,
systemic infamation
Visceral fat
IL-12
IFNα
IL-23
IL-6
IL-23
IL-6
IL-17
IL-22
TNFα Th17 cell
IL-6 IL-6
IL-23
TNFα
Leptin
Leptin
Common Comorbidities Associated With PsA
1,2
ObesityMetabolic syndromeHypertension
T2DDepressionDyslipidemia
Patients With Comorbidities Report
•  More severe disease
•  Poorer quality of life
•  Increased discontinuation of treatment
Proinfammatory cytokines from adipose tissue and psoriatic infammation create a
bidirectional cycle, worsening both psoriatic disease and obesity-related comorbidities
3,4

2. Optimizing PsA Outcomes in the Context 
of Obesity: A Rheumatologist’s Toolkit 
Full abbreviations, accreditation, and disclosure information available at
PeerView.com/CKQ40 (excess fat mass)
Treatment goal
Risk
reduction
Treatment goal
Therapeutic
intervention
Clinical obesityPreclinical obesity
No Yes
Obesity is defned as excess body fat, and another measure (eg, waist circumference)
must be used in addition to BMI to measure body fat
5
Risk of T2D, HTN, and CVD
by Waist Circumference
Comorbidity
Risk
BMI, kg/m
2
Diagnosis
≥102 cm (men)
and ≥88 cm
(women)
b
<102 cm (men)
and <88 cm
(women)
a
AsianNon-Asian
f–f–
Low but
other problems
<18.5<18.5Underweight
f–f–
Average18.5-22.918.5-24.9Healthy weight
HighIncreasedIncreased23.0-27.925-29.9Overweight
Very highHighModerate≥2830-34.9Class 1 obesity
Very highVery highSeveref–35-39.9Class 2 obesity
Extremely highExtremely highVery severef–≥40Class 3 obesity
Lancet Commission Diagnostic Model Diferentiates Preclinical From Clinical Obesity
7
Clinical confrmation of abnormal fat mass
(by anthropometric measures or direct body fat measurement) 
Screening: BMI at or above age, gender, or ethnicity thresholds for obesity
No obesity
(no excess fat
mass—eg, athletes)
Obesity
Assess for clinical obesity
Obesity-related organ
dysfunction, limitations of
daily activities, or both
No Yes
Diagnosis and Classifcation of Obesity—AACE/ACE, 2016
6

3. Optimizing PsA Outcomes in the Context 
of Obesity: A Rheumatologist’s Toolkit 
Full abbreviations, accreditation, and disclosure information available at
PeerView.com/CKQ40 Treating Obesity Improves Outcomes in PsA
Obesity Associations With PsA
Increased incidence in PsA
Increased likelihood of transition from PsO to PsA
Increased disease activity and severity; poor outcomes
Increased pain
Decreased response to treatment;
less likelihood of remission
8
Increased need to switch therapy because of obesity AE
• Obesity is an under-reported predictor of inferior
response to anti-TNF agents (except abatacept and
tocilizumab) in patients with select IMIDs
10,11
• Obesity can increase the risk of methotrexate toxicity
12
Increased comorbidities
(especially MASLD, T2D)
Benefts of Weight Loss in PsA
Reduced incidence
Potential to reduce likelihood
of transition
c
Reduced severity/outcomes
Reduced pain
Improved treatment response;
achievement of MDA
9
Potential to reduce need
to switch therapy
d
Potentially reduced
comorbidities
d
a
BMI ≥25 kg/m2 in Asian individuals.
b
BMI ≥27.5 kg/m2 in Asian individuals.
c
Observational data.
d
Proposed.
1. Ogdie A et al. Curr Opin Rheumatol. 2015;27:118-126. 2. Gupta S et al. Rheumatol Int. 2021;41:275-284. 3. Siebert S et al. Joint Bone Spine. 2025;92:105904.
4. Williams JC et al. Ther Adv Musculoskelet Dis. 2024;16:1-15. 5. Garvey WT et al. Endocr Pract. 2016;22(suppl 3):1-203. 6. https://pro.aace.com/files/obesity/toolkit/classification_of_obesity_and_risks.pdf.
7. Rubino F et al. Lancet Diabetes Endocrinol. 2025;13:221-262. 8. Leung YY et al. RMD Open. 2023;9:e003157. 9. Di Minno MND et al. Ann Rheum Dis. 2014;73:1157-1162.
10. Singh S et al. PLoS ONE. 2018;13:e0195123. 11. Juan S, Jiabi Z. Joint Bone Spine. 2019;86:173-183. 12. Patel S, Kumthekar A. Rheumatol Ther. 2021;9:49-71.

4. Counseling Patients on Weight Management
and Incretin Therapies
Full abbreviations, accreditation, and disclosure information available at PeerView.com/CKQ40 ASK Permission


“Would it be all right if we discussed your weight?”
• Shows compassion and empathy
• Builds patient–provider trust
ASSESS Their Story
• Determine goals that matter to the patient
• Measure and classify (BMI and waist circumference)
• Stage disease severity (Edmonton Obesity Staging System)

AGREE on Goals
• Collaborate on a personalized, sustainable action plan
ASSIST With Drivers and Barriers
• Focus on patient-centred health outcomes versus weight loss alone

Medical Nutrition
Therapy
• Utilize personalized
counseling by a
registered dietician
• Focus on healthy food
choices and evidence-based
nutrition therapy

Bariatric Surgery
• Facilitate a
surgeon–patient
discussion


ADVISE on Management
3
4 5
1 2
Exercise
• Recommend 30-60 min of moderate
to vigorous activity most days or an
appropriate change in physical
activity depending on patient’s
functional capacity



Psychological
• Employ a cognitive approach
to behavior change
• Manage sleep, time, and stress
• Recommend psychotherapy
if appropriate


Medications
• Consider for
weight loss and
to help maintain
weight loss

5. Counseling Patients on Weight Management
and Incretin Therapies
Full abbreviations, accreditation, and disclosure information available at PeerView.com/CKQ40 11
33
22 Before
Dose Escalation or Maintenance Phase
Dose Escalation
Save time to speak
with the patient
•Convey realistic expectations 
regarding treatment results
•Inform about GI efects, pointing   
out that they will soon pass
•Highlight the importance of 
following the available guidelines
Strategies for dealing with persistent or severe GI AEs
•Consider diferential diagnosis to rule out underlying conditions that may be responsible 
•Reinforce dietary and lifestyle guidance
•Start measures specifcally focused on the troublesome symptoms 
-Additional patient guidelines (provided on next page)
-Pharmacological support can be considered (short-term use only)
If GI AEs occur,
slow down the
planned dose
increments to
reach success
If GI AEs persist
beyond normal
in time/severity,
implement
additional
measures
Print the following page about healthy habits and adverse events
and share with your patients when prescribing a GLP-1 RA or GIP/GLP-1 RA
Strategies for slower dose escalation
•Extend phase for 2-4 more weeks before moving 
forward to next dose 
•Suspend treatment temporarily
•If GI AEs appear just after escalation, go back to prior 
dose for a few days and then increase dose gradually
•If problem persists, consider setting up as maintenance 
therapy a dose lower than the maximum one
Nausea
•Antiemetics
•Prokinetics 
(domperidone)
Vomiting
•Antiemetics
•Prokinetics (domperidone)
•Standard procedures for severe cases 
(do not rule out IV rehydration)
Diarrhea
•Probiotics
•Antidiarrheals (loperamide)
•Consider metformin dose reduction 
when needed
Constipation
•Stool softeners
•Consider reducing 
GLP-1 RA or 
GIP/GLP-1 RA dose

?

1. Wharton S et al. CMAJ. 2020;192:E875-E891. 2. Gorgojo-Martínez JJ et al. J Clin Med. 2022;12:145. 3. Vázquez LA et al. Diabetes Ther. 2024;15:1501-1512.

6. 11 Eating Habits Nausea
22 Food Composition and Preparation
Healthy Habits What to Know About Potential Side Efects
Eat
slowly
Eat only 
if hungry
Smaller 
portions
No lying 
down 
after meal
•Eat crackers, apples, mint, 
ginger-based drinks 
•Avoid strong smells
Vomiting
•Generous hydration
•More frequent meals 
in smaller amounts
Constipation
•Enough fber in diet
•Increase physical activity
•Healthy balanced diet
•Generous hydration 
(water, sugar-free liquids)
Diarrhea
•Generous hydration 
(water, lemon)
•No high fber content foods 
(gradually restore them upon 
improvement)
•Yes: chicken broth, rice, 
carrots, ripe peeled fruit, 
baked fruit
•Minimize: dairy products, 
laxatives, cofee, alcohol, soft 
drinks, very cold/hot foods, 
products with sugar alcohols 
(ie, sweetners ending in “ -ol”)
Stop
when full
Smaller, more 
frequent meals
No 
straw
No 
distractions, 
enjoy 
savoring
Not too 
active after 
meal
No meals 
near 
bedtime
Low-fat diet
Boil, bake, roast, griddle
Clear drinks (small sips, not too much)
Water-rich foods
33 Lifestyle
Fresh air, light exercise
Food diary to identify what works better
Mindful eating
In case of severe/persistent 
nausea/vomiting, no drinks 
during meals; take drinks 
30-60 minutes before 
and/or after meals
Should any GI efects be 
severe/persistent in spite 
of following all guidelines, 
contact prescriber 
as soon as possible

7. Treating Obesity: Screening and Dosing Strategies 
Full abbreviations, accreditation, and disclosure information available at PeerView.com/CKQ40 NO
YES
Clinical confrmation of abnormal fat mass by
•Anthropometric measures (eg, waist circumference, waist-to-hip ratio)
Or
•Direct body fat measurement
No obesity 
(normal fat 
mass)
Preclinical 
obesity
Clinical 
obesity
•No signs or
symptoms
•No limitations of
daily activities
•Signs or
symptoms
•Organ
dysfunction
Limitations of
daily activities
fffffff fffffff fff ffffffff fffffffffff
Screening: BMI at or above age, gender, or ethnicity thresholds for obesity
Assessment 
of adiposity
Assessment 
for clinical obesity
Not
obesity related
Obesity related
Further diagnostic assesment
Medical history and physical examination

8. Treating Obesity: Screening and Dosing Strategies
Full abbreviations, accreditation, and disclosure information available at PeerView.com/CKQ40 In the case of drug shortages or drug switching, clinicians should know the comparative doses for
interchanging GLP-1 RAs as well as how to adjust dosing for individualized patient needs
Comparative Dosing of Available GLP-1 RA and GIP/GLP-1 RAs and GIP/GLP-1 RAs
Agent
Exenatide
Lixisenatide
Liraglutide
Exenatide XR
Dulaglutide
Semaglutide
Semaglutide
Tirzepatide
Dosing Interval
SC twice daily
SC daily
SC daily
SC weekly
SC weekly
SC weekly
PO daily
SC weekly
Comparative Doses
10 mcg – – – – – – – –
20 mg – – – – – – – –
1.2 mg1.8 mg – – – – – – –
– – 2 mg – – – – – –
–
– 1.5 mg3 mg4.5 mg – – – – –
– 0.5 mg – 1 mg 2 mg – – – –
7 mg14 mg – – – – – – –
– – – – 5 mg7.5 mg10 mg12.5 mg15 mg
5 mcg
a
10 mg
a
0.6 mg
a
3 mg
a
0.75 mg
a
0.25 mg
a
2.5 mg
a
Available Products and Dosage Forms
Exenatide
SC pen injector
(Bydureon)
Dulaglutide
SC auto-injector
(Trulicity)
Liraglutide
SC pen injector
(Saxendab, Victoza)
Lixisenatide
SC pen injector
(Adlyxin)
Semaglutide
SC auto-injector
(Wegovy
b,c
)
SC pen injector
(Ozempic)
Oral tablet
(Rybelsus)
Tirzepatide
SC solution in vial
(Zepbound
b,c
)
SC auto-injector
(Zepbound
b
,
Mounjaro)


a
Comparative efficacy of starting doses is not known; these figures are based on expert opinion.
b
FDA-approved for chronic weight management.
c
Available from the manufacturer at discounted cash price.

9. Treating Obesity: Screening and Dosing Strategies
Full abbreviations, accreditation, and disclosure information available at PeerView.com/CKQ40 Recommended Dosing Inte rval Manufactu rer Recommenda tions for Missed DosesAgent
Exenatide
Lixisenatide
Dulaglutide
Twice daily
Once daily
Once weekly
Skip missed dose and resume at the next scheduled dose
If a dose is missed, administer within 1 hour prior to next meal
Short-acting agents
Long-acti ng agents
Exenatide XR
Liraglutide
Once weekly
Once daily
Semaglutide
(injecta ble)
Semaglutide (o ral)
Once weekly
Once daily
Tirzepatide Once weekly
Administer as soon as possible if there are ≥3 days (72 hours) until next
scheduled dose
If <3 days before next scheduled dose, skip the missed dose and administer on 
the next scheduled day
Administer as soon as possible if there are ≥3 days (72 hours) until next
scheduled dose
If <3 days before next scheduled dose, skip the missed dose and administer on 
the next scheduled day
Administer as soon as possible within 5 days after the missed dose
If >5 days have passed, skip the dose and administer on the next scheduled day
Administer as soon as possible within 4 days (96 hours) after the missed dose
If >4 days have passed, skip the dose and administer on the next scheduled day
If a dose is missed, resume with the next scheduled dose
If a dose is missed, resume with the next scheduled dose
Manufactu rer Recommendations for Missed Doses of GLP-1 RAs and GIP/GLP-1 RAs
1. Rubino F et al. Lancet Diabetes Endocrinol. 2025;13(3):221-262. 2. Whitley HP et al. Clin Diabetes. 2023;41:467-473.