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Leveling Up Obesity Management in IBD: Multidisciplinary Patient-Centered Care

Dr. Gold: I am so excited to get to talk to you a little bit about how to build a multidisciplinary program for our patients who are living with IBD and obesity. This is a topic that is near and dear to my heart, and would be happy to pass on any information from what we have learned in our practice.

Laying the Groundwork Across Visits

When we first think about this multidisciplinary care, you really want to lay that groundwork across visits. It is about building rapport and trust first and foremost with your patients. You never want to rush into that discussion about weight. I know we have talked about that already today, how we can highlight, make sure that we are asking permission.

We want to assess readiness. That is why I like to start off with asking patients to tell me a little bit about their weight, because then patients will often go into a discussion of, "I have been trying to lose weight or I am trying to gain weight." That allows patients to tell you where they are in that weight journey without you having to ask specifically. As I said, we have talked about this asking permission.

You also want to look back at their weight history and ask them about those experiences. Because as I have mentioned before, earlier today, a lot of our patients with IBD have this yo-yoing of their weight. It increases when they are feeling well, decreases when they are having systemic inflammation, they may be hospitalized, reduced oral intake, and so they have really been on a journey with their weight.

You want to listen to their concerns and really talk to patients about what the realistic expectations are and the goals, and do all of what we have talked about using neutral, unbiased, non-judgmental language. You want patients to feel supported and motivated to engage in these changes and to make them happy.

You always want to make sure that you assess where a patient is, as we have talked about on that journey and meet them where they are. You want to understand what are the barriers to changes, what is going on in that patient's life? What is their activity like? What is limiting them? They have joint pain, as we talked about, difficulty with oral intake, and make sure that we can provide them the resources to meet them where they are and provide them with the care they need.

Interrogating Your Own Assumptions

You also want to make sure you are checking in with yourself and your own assumptions. Asking yourself things like, am I assuming there is a lack of willpower or motivation? Am I focusing only on weight rather than patients’ overall health? I know I mentioned this earlier, but I love the lines, tell patients, I am not here – we are not here to talk about getting you thinner, we are here to really get you healthy. I think just emphasizing that for patients so that they hear it. I tell patients the goal is to get them healthy and keep them healthy.

Remembering that your IBD patients are generally young, otherwise healthy patients, and so you may be the only provider that they have contact with, so it is crucial that we are able to provide that care because they may not be seeing somebody else.

You want to make sure you are thinking about the biologic, physiologic and the social factors. As I mentioned, what is their job like? I ask patients a little bit about their job. Are they seated during the day? Are they walking around? Are they working for the post service, and they are running around walking 20,000 steps? Are they seated at a desk? That is going to make a big change.

How do they get to work? A lot of times we will ask patients, maybe they do not have a lot of time to get to a gym or the cost of getting to a gym, maybe they can take the subway one less stop and be a little bit farther on the way home if that feels safe and like something they can do, so that they get some extra steps in during the day. These are all things you want to talk about.

What their social lives are like. Who do they eat dinner with at night? Are they cooking for a family? Are they cooking for one person? Because they are not going to be able to modify meals for everybody else if they are cooking for five or six people.

You really want to approach these patients with curiosity and not judgement. Have this conversation. Ask them what their lives are like. Patients want to tell you. They want to engage when they have a provider who is providing the supportive care. I cannot tell you the number of patients who have told me they were really nervous about coming in for an obesity visit or for a weight management visit, and how pleasantly surprised they were by the care they received. There is nothing that is more heartwarming or more supportive for the reasons why we do this.

As we talked about, understanding the context, the values, asking people also about cultural preferences in terms of what they are eating, these things are really important. We screen all of our patients for food access and food insecurity. It is very hard to make dietary recommendations if you do not understand what is going on in a patient's life outside of the office, so really important to be asking these questions.

Applying the 5 As Model in Weight Loss

We often talk about the five As we are using for any assessment process for any change for patients, but you can use this for weight loss. We have hammered this home I think this morning. But the first is to ask, asking readiness to change. My favorite line, as we have said, is, tell me a little bit about your weight history or take me through your weight history, and patients are usually pretty open to that.

We advise. We talk about clear, non-judgmental recommendations. You want to teach patients. Our IBD patients are usually generally very medically literate, and they have known about their disease for years. They want the information. They want to know what is going on with their bodies. We teach them about the impact of obesity, as we have talked about today on IBD outcomes, on cardiometabolic disease, fatigue, quality of life, all of these things, and talk to them a little bit about what we know we have in terms of treatments.

You want to assess your goals together and come up with reasonable goals in order for patients to be able to achieve them. You want to make sure that you are assisting with resources and support. You have identified those barriers and to be able to provide support to overcome them.

I know, Amy, you mentioned this earlier, it is so important arranging a scheduled follow-up to maintain progress. These are not patients where you are going to give them all of their doses of tirzepatide and say, call me in six months or a year. I am giving out in my own practice, a single month at a time, and patients are messaging me. I want to know they are safe and I want to know they are feeling well, and then we will make a decision together three or four weeks in as to whether or not we stay at that low dose or if we are going to escalate the dose. It is really a collaborative process between myself and the patient.

“Just the Facts:” Objective Evidence

We really also want to focus on evidence-based facts. As I said, our patients are reading the literature, they know what is out there. We know the weight-related health risks. We have talked about the cardiometabolic disease, diabetes, hypertension, we see a fair amount of metabolic liver disease as well in this patient population, obstructive sleep apnea. Talking about all of those things.

You want to talk about the benefits of weight loss. 5% to 10% of weight loss can lower their A1C, reduce their blood pressure, improve their joint pain and overall well-being, and make it easier for us to treat their IBD and keep their IBD and deep remission.

I also always talk about treatment options. Instead of the older ways of thinking about maybe a stepwise approach where people started with lifestyle, if that was not enough move to a pharmacologic therapy, and if that was not enough surgical, I try to think about lifestyle management as the underpinning for all of these interventions that we have, so more of a Venn diagram where lifestyle is that bottom base, that big circle.

Then patients may need a boost from something else, a pharmacologic therapy, endobariatric, or bariatric procedure. All of those are going to be in combination with lifestyle therapy. For those of you who are IBD providers, we talk so much about combined combo therapies in IBD, and so I talk about this as my combo therapy. It is lifestyle plus potentially like a GLP-1 or other intervention.

Assessing Patient Preferences and Treatment Goals

We want to assess patient preferences and treatment goals. This is really, really important for our patients. You want to talk about perceptions on body shape and how cultures can celebrate larger bodies, smaller bodies, how we understand this to relate to fertility, thinness, and illness.

As I said, a lot of our patients really struggle with this. When they are super thin, when they are not feeling well, they are very sick, they can lose a lot of weight unintentionally, and society may tell them that they look great because they have lost a lot of weight. Yet when they are feeling well and able to eat finally and recovered and they are gaining weight, society may look negatively on that. It is really important in this multidisciplinary model, to make sure you have either a psychiatrist or psychologist who patients can talk to about these perceptions of body image, because this comes up so frequently.

We talked about cultural awareness. Health care proxies really should be – providers should be aware of their own perspective on ideal weight. That may not align with some patients’ backgrounds and what they are interested in. Ask your patients. Sometimes if I am struggling to get a sense of where a patient is, I will ask them, if I had a magic wand, where would your weight end up? That is not because I am worried about a number on the scale that we are going to target, but I just want to get a sense of where they felt healthy. Was there a weight where you really felt healthy? Tell me about when and where that was, and that is very helpful.

We know that food and identity are cultural practices, and this is so crucial for our patients. You want to talk to them about, as I said, who they are cooking for, what culturally prepared meals are important to them, how we can involve families in this process. We have learned a lot by doing this, but what I can tell you is a lot of patients will come back and tell me that, after starting a GLP-1, their whole family is eating healthier, and they have made family weight-based choices. They go out for a walk after dinner, they are all eating differently and eating more balanced meals. It is actually a really nice thing to see. We know that what patients are making for their families impacts what they are eating as well.

Talking also about gender differences and cultural norms and how this can vary, we know that women and men are going to have different bodies and the cultures to be thin are very different. Just making sure I think all of this really assesses the concept of, we want to provide thoughtful care for each individual patient.

Multidisciplinary Care Pathways: Enhancing Patient Outcomes

When we think about these multidisciplinary care pathways, we know that the care team can include certainly somebody from obesity medicine and IBD, mental health providers, we talked about super important, a registered dietitian. This came up in our case, but having a physical therapist is incredibly important for those patients who have joint disease.

It is very, very hard, Amy, as you mentioned, to recommend exercise for a patient who can barely walk because they are having terrible joint pain. The reality is that the GLP-1s are going to improve their joint pain most likely, regardless of weight loss, so independent of the weight loss. Nonetheless, getting that started is so hard, and I think a lot of our patients are fearful that they might actually make their joint pain worse or they might cause some damage. Getting them involved with a physical therapist who can show them what to do and can engage with them and work with them carefully, is crucial.

It is that collaborative approach between primary care, the specialists, that really makes the difference for our patients, and it reduces the burden on the care for them. We see patients in a single session all together. Myself, a hepatologist focused on metabolic disease, we have support from endocrine nutrition, we have a physical therapist we can call, and so they get a whole plan before they leave for the day, which is really nice.

You want to make sure that you are talking also with your surgeons in terms of your IBD related surgical care, because a lot of this discussion about GLP-1s, weight loss is really going to involve the surgeons. Perhaps a patient is planning a surgery, such as a second stage of their J-pouch, and so you want to be coordinating the timing of that with the surgical team that you are working with.

All right. And with that, I am going to hand it back to Amy.

Skills Building III

Amy Stewart: Thank you so much, Dr. Gold. Let us go back into some skills building. Get those poll fingers ready here.

Patient Case 2: José M, 52-Yr-Old Man With UC

Let us meet another patient now. José is a 52-year-old man with ulcerative colitis. He was diagnosed with UC. Right now, he has minimal symptoms. He does have some increased fatigue and some intermittent loose stools. José is Latino. He works two jobs and he eats most meals at convenience stores, and he avoids vegetables because he is worried that those vegetables are going to trigger diarrhea.

José has hypertension, pre-diabetes, as well as hepatic steatosis. He is currently on vedolizumab. We do not have any recent nutrition labs. José does have an elevated CRP and his BMI is 34. He says in clinic, "I want that shot that helps people lose weight", which I do think we hear this in our clinics as well.

Poll 12

Let us move on to a poll here. Which assessment plan is most appropriate before recommending a specific obesity intervention for José?

A. Confirm UC remission endoscopically before starting obesity treatment because symptom control alone is insufficient to determine whether pharmacotherapy is safe

B. Begin a reduced-calorie diet and GLP-1–based therapy because BMI plus metabolic complications establishes candidacy and delays may worsen cardiometabolic risk

C. Assess IBD activity, cardiometabolic risk, nutrition adequacy, dietary restriction beliefs, medication history, and patient goals before selecting therapy

D. Refer to bariatric surgery because hepatic steatosis and prediabetes indicate high metabolic risk and lifestyle-based interventions are unlikely to be sufficient

All right. Looking at our answers here, about 88% of you chose option C, which is that assessing IBD activity, cardiometabolic risk, nutrition adequacy, dietary restriction beliefs, medication history, and patient goals all need to be assessed before selecting therapy.

I think we are really hitting home that point, of thinking José as a whole person, not just the IBD, but also the obesity, his cultural beliefs, his work, all of the things that are going into this. Any comments here from either Dr. Gold or Dr. Sepulveda about why A, B or D would be not the best choice here.

Dr. Gold: One thing I would just mention, because it looks like it is come up in the comments and the questions that I am sure we will talk about it again, but you do not need to confirm you see remission in order to engage in this discussion and to start the process.

I do not want people to feel that they have to – that they can only provide a weight based management therapy if the underlying IBD is in remission. These two can coexist at the same time, so you do not need to delay to get a scope and to see what things are happening. Get that whole workup done and get started, I think is the best plan.

Dr. Sepulveda:  Yeah, I agree. The other part is, we have to think of obesity and IBD as a multidimensional disease process. I think it is important to just do the assessment and then proceed with the patient centered options.

Amy Stewart: I think with part D, referring to surgery because lifestyle-based interventions are unlikely to be sufficient, we do not know if we have not tried yet. Really just thinking about everything together.

Dr. Gold: Absolutely. Especially that hepatic steatosis part. I will just throw in a little part here. We know we can reverse hepatic steatosis with weight loss and with these medications, so that should not be a barrier. That should be something that we talk a lot about that with our patients and say this is actually highlights the need for a weight intervention. It is a nice teaching point for patients.

Amy Stewart: Absolutely. Thank you so much for that.

Patient Case 3: Chris B, 38-Yr-Old Man With Stable CD

Now let us meet Chris, who is a 38-year-old man with stable Crohn's disease. He was diagnosed with Crohn's. He was clinically stable. He does have some increased fatigue and intermittent loose stools. He asks about semaglutide and tirzepatide. He has obstructive sleep apnea, hypertension, and a family history of type 2 diabetes.

He is currently on ustekinumab, and he has an elevated CRP with a BMI of 39. He heard that these drugs slow his gut down. Could they make his Crohn's disease flare? What is a conversation we would have about Chris with that?

Dr. Gold: Absolutely. I am happy to start here as well. We talk a lot about safety data, as we have already talked about this morning. We know that there has been multiple studies now retrospectively showing that there is no increased risk of disease flares in patients who are starting on GLP-1, no increase in need for steroids, hospitalizations, emergency room visits, no worsening need for change in biologics or surgery. That is not a worry.

I talk to patients because I think they sometimes do not understand that the bowel habits are changing, but their inflammation it is not necessarily related. We talk a lot about the fact that this drug is a very good antimotility agent. It slows everything down. In doing so, it may actually slow the bowel down, but not necessarily through an inflammatory process. Just making sure our patients understand the difference between those two.

Amy Stewart: I want to bring up a question here. I am throwing a little curveball in for you, Dr. Gold. We just talked about how you do not need to confirm endoscopic remission before thinking about a GLP therapy, right? If you needed to optimize therapy or change an IBD therapy, would you start a GLP at the same exact time, would you give it a couple of weeks or a month, or what is your timing on that?

Dr. Gold: It is a great question. I will say, well, we do not need to confirm endoscopic healing on imaging. I do like to have a sense of where the IBD is, as you have mentioned, before we start. That is more so that I know where things are. If a patient were to develop diarrhea or some side effect that I need to know about, I have in the back of my head where their IBD is and what is happening.

The question about either escalating or starting a new therapy, the data suggests that it is fine to do both and that you do not have to be concerned, but I find patients are anxious about it. They may be worried that what if they do not know the difference between a side effect from one or from the other, which is very reasonable.

What I usually tell patients is, let us prioritize getting you on to either your dose escalation or your new therapy. We will work on the prior offs and all that stuff while that is happening, so patients feel like this process is happening. Then let us give it a week or two, see how you are feeling on your new dose or depending on whatever drug you are giving the time interval there. Once patients feel comfortable, then we start.

What I often recommend is that we go through the lifestyle modifications we are going to recommend while on a GLP-1, but patients can get started on those lifestyle modifications while we are waiting to get the drug started. This way they are starting on their weight loss journey, they do not have to feel like there is a delay, but yet we are also giving them some time to make sure that if we are either dose escalating or changing drug, that they are tolerating that drug, and then we go ahead and start the GLP-1.

Amy Stewart: Perfect. Thank you so much for that.

Poll 13

Which counselling statement addressing Chris’ concern is most accurate?

A. “GLP-1–based medications should generally be avoided in Crohn’s disease because gastrointestinal adverse effects make flare assessment unreliable”

B. “Data suggest GLP-1–based medications can support weight loss in patients with Crohn’s disease without a clear increase in flare rates, but we should plan for GI adverse effects and monitoring”

C. “These medications are reasonable only if Crohn’s disease inflammation is inactive because the reduction in adipose-driven inflammation is most effective at this time”

D. “They can be used safely only if biologic therapy is held temporarily, so that nausea, diarrhea, or abdominal pain can be attributed to one treatment at a time”

All right. About 88% of you chose option B, which is that data suggests GLP-1-based medications can support weight loss in patients with Crohn's disease without a clear increase in flare rates, but we should plan for GI adverse effects and monitoring.

I think we have talked through this pretty extensively today. As we just talked about with D, we are certainly not holding biologic therapy or IBD therapy for starting weight loss therapies as well. We have talked through all of the other ones too, particularly with C only confirming that Crohn's disease inflammation is inactive. We do not need to do that as well, but rather getting an assessment of where we are.

Patient Case 4: Debbie, 43-Yr-Old Woman With CD and Obesity

Now, let us meet Debbie. Debbie is a 43-year-old woman with Crohn's disease and obesity. Debbie was diagnosed with Crohn's disease, which is currently in clinical remission, and she has obesity as well. She does not have any recent corticosteroid use, hospitalizations, bowel obstructions, or planned surgeries. She wants to start an incretin-based anti-obesity medication. She does have hypertension, she is currently on ustekinumab, and she has a BMI of 36.

Poll 14

Which incretin-based therapy would you consider for Debbie to start?

A. Liraglutide

B. Orforglipron

C. Semaglutide

D. Tirzepatide

You can choose all that apply here.

43% and 42% of you chose C and D respectively. Does anyone want to talk through C here as an answer for the poll?

Dr. Gold: I do not know, Dr. Sepulveda, do you want to talk about your practice?

Dr. Sepulveda:  I can go.

Amy Stewart: Yeah. Whatever works.

Dr. Sepulveda:  I think, in general, C is the incretin-based therapy that we have more data in patients with IBD at this time. We have to also think that semaglutide has been available for a little bit longer in comparison to tirzepatide. That is part of the reason why we have a little bit more data, but tirzepatide is also a viable option for this patient, specifically.

Dr. Gold: I can just comment on my current practice. In my practice, I actually probably would have picked tirzepatide, just as what we do. The reason for that is mostly comfort because we have been using it a lot and we know it is effective. There was some question early on as to whether or not some of the anti-inflammatory property may be GIP-driven versus the GLP, nobody really fully understands.

The question is, if you can choose the dual mechanism, should we? And I think this is an answer that we do not have an answer for. A lot of times some of this is dictated, unfortunately, by insurance preferences, and so we have to do what is available and feasible for our patients. My first choice is usually tirzepatide, but it is a little bit patient-specific, for sure.

Amy Stewart: Perfect. Thank you for that. I think the take-home point is that either is reasonable here for this patient.

Dr. Gold: Absolutely.

Amy Stewart: Just looking back, I think also in the poll, it is highlighted because more people chose it, not that it is the correct answer. I also want to clarify there. By 1%, it just eased out.

Dr. Gold: That highlights the fact that both are great options.

Amy Stewart: Yes.

Posttest 4

Looking at posttest four here. Your patient is a Southeast Asian woman with UC, stable on adalimumab but with loose stools and elevated CRP. BMI is 32, she does have type 2 diabetes and dyslipidemia. She eats traditional rice and lentil-based meals with her family. Which multidisciplinary plan best aligns with culturally sensitive obesity and metabolic health care for her?

A. Recommend a low-carbohydrate diet because diabetes control requires reducing rice, lentils, and flatbread regardless of cultural food preferences

B. Recommend delaying weight-management counseling until UC remission is confirmed endoscopically because dietary modification may be misinterpreted as IBD treatment

C. Prioritize pharmacotherapy because culturally tailored nutrition changes are difficult to implement and may place additional burden on the patient and family

D. Refer to a dietitian familiar with IBD and diabetes to adapt her usual foods and avoid unnecessary restriction

All right. In the pre-test, about 75% of patients – 75% of participants rather, chose option D, referring to a dietician. Then in the post-test, about 81% of participants chose that.

Let us take a look here and look at the rationale. The goal is not to replace the patient's food culture with a generic diet. I think keeping that in mind is really important as we talk to our patients about lifestyle changes.

The right pathway is culturally adapted medical nutrition therapy that accounts for UC, diabetes, protein intake, micronutrients, family meals, and patient preferences. Obesity care is most effective when it addresses stigma, feasibility, patient priorities, and contextual barriers. I feel like that is one of the most take home messages of today. Obesity care is most effective when it addresses really the whole person, as well as the stigma and feasibility as well.

Dr. Gold: 100%.

Amy Stewart: [01:25:25]

Patient Case 6: Susan, 41-Yr-Old Woman With CD

Moving onto Susan. Susan is a 41-year-old woman with Crohn's disease. She was diagnosed with Crohn's, which is currently in remission. She reports increased fatigue and intermittent loose stools. Her insurance denied coverage for an incretin-based anti-obesity medication. I am sure we have never seen this in our practice, and the chat has a lot of questions about it, so I think we will get to that here a little bit.

Susan does have depression, osteoarthritis, and food insecurity. She is currently on adalimumab. Key findings, she does have an elevated CRP and a BMI of 42. Before we get to insurance, I actually want to pause for a second and talk about elevated CRP. Every single one of our cases today, these patients had an elevated CRP, and some of them were in remission and some of them were not. Let us talk about CRP in this context, if we could.

Dr. Gold: Yeah, absolutely. We know that obesity is a systemic inflammatory disease, no different than when we talk about IBD. I think the key here is to make sure we understand what is driving that CRP because it is so generic. That is the moment when getting a calliper, as you talked about, super helpful, getting an intestinal ultrasound, scope, MRE, something to be able to say, okay, this disease is truly quiescent and in remission, and so the CRP is not being driven by their inflammatory bowel disease.

That is also super helpful as you are going to trend that CRP on the course of their therapy so that you know that if they have a bump in CRP, it may not specifically mean to you that the Crohn's is all of a sudden active. It is important to take the whole patient into perspective.

Amy Stewart: I think that is really important, and also understanding what that CRP is at the time of endoscopic remission too. Understanding timing wise that we cannot rely on CRP alone to tell us about disease activity, so getting those biomarkers at the time of scope so that we can correlate timing of what is going on together. Thank you for that.

Now we get into her insurance denied coverage for an incretin-based anti-obesity medication. Susan says, it feels like the system only helps people who can pay out of pocket. Dr. Sepulveda, any thoughts here on that and how we can help patients like Susan?

Dr. Sepulveda:  I am always a fan of appealing. That is my motto. At least in my practice, we try to appeal every single case mostly because sometimes it is a misunderstanding in terms of documentation or misunderstanding of the urgency in the cases. It is very important to make sure that all the documentation is as specific as we can, and that usually in an appealing process tends to result in an acceptance of the medication. That is from my experience in my practice. What about you, Dr. Gold?

Dr. Gold: I completely agree, document. The only other thing I think about is that these drugs are not only approved for weight loss, and so is there some other way we can get the drug? For example, a BMI of 42, I ask all of my patients, do you snore at night, and do you have a history of sleep apnea? Because there are potentials for the insurance, but maybe we will cover tirzepatide for sleep apnea, and so therefore we can get the drugs in other ways.

I try to be as creative as I can within what we can do for our patients, and then work with them as much as possible. I think the system is really challenging in terms of getting – and I know I saw there are a bunch of questions about insurance coverage in the chat today.

Amy Stewart: I think we also talked about how either semaglutide or tirzepatide could be reasonable options. Also, reasonable if you can get one covered to start there with your patient, unless, of course, there is a contraindication. Thinking about being flexible and maybe not choosing an agent right away until you understand what that insurance coverage is going to look like, I think it is just a practical tip, too.

Dr. Gold: 100%.

Amy Stewart:

Poll 15

Another poll question here. Which management pathway is most appropriate for Susan?

A. Explain that medication access is unpredictable and focus instead on lifestyle counseling because repeated prior authorization attempts may reinforce frustration

B. Build a plan with obesity medicine or primary care, dietitian, behavioral health, social work, and physical therapy for joint pain

C. Refer directly to bariatric surgery because BMI ≥40 kg/m² makes medication access less important and surgical pathways are generally easier to obtain

D. Address her depression and food insecurity first because adherence to pharmacotherapy or lifestyle changes is unlikely until those barriers resolve

All right. Looking at answers here, about 66% of you chose option B, which is, building a plan with obesity medicine or primary care, dietician, behavioral health, social work, and physical therapy for joint pain.

About a quarter of people did choose option D, so I want to talk about why addressing her depression and food insecurity is not wrong. We want to do those things, but would we hold off on therapy until those things are done first? I think is the take home point. Dr. Gold, do you want to talk about that?

Dr. Gold: I was just going to say exactly what you are saying. The first part of that statement is incredibly important. We need to address the depression and we need to address the food access because we need to be able to give our patients - we talked about those resources for them to be able to make these changes - but you just do not want to be holding off and do not want to be prioritizing one over the other.

It is really about the multidisciplinary approach. I like the fact that D does address the depression and the food access. I would say I like parts of D, but B is the better overall answer.

Amy Stewart: Absolutely. Thinking about really that multidisciplinary care, how can you get all members of the team involved in order to get this patient feeling well.

Patient Case 7: Jackie, 49-Yr-Old Woman With UC

Now, let us meet Jackie. Jackie is 49. She has ulcerative colitis. Her ulcerative colitis is in remission. She is interested in starting an anti-obesity medication. Jackie does have hypertension and pre-diabetes. She is on Vedolizumab. Jackie has a normal CRP and fecal calprotectin. Her BMI is 38. She wants the option with the strongest expected weight loss benefit, but she is worried about nausea and diarrhea because of her ulcerative colitis.

I think we have talked a lot about this and how we are going to monitor this throughout. In Jackie, who does have a normal CRP, I think it would be helpful here to know, does her CRP rise when she flares? We do not know that, but that is something that could be helpful. Then also certainly that fecal calprotectin. Any thoughts there, Dr. Gold, anything to add?

Dr. Gold: No. That is perfect. If you do have access to an ultrasound, that is a nice moment to be able to document that there is no bowel wall thickening, no hyperemia, and then, as you said, using that to trend so that if she were to not feel well, could you get a quick ultrasound or repeat calpro, or if she does mount a CRP or CRP.

Amy Stewart: Understanding is that, are those symptoms coming from a medication side effect, which we can mitigate? Or is there an actual flare here? Understanding those perspectives.

Posttest 3

Moving on to a posttest. Our patient has ulcerative colitis. It is in remission on vedolizumab with normal labs and a BMI of 38, hypertension, and pre-diabetes. She wants a weight loss medication that has the strongest weight loss benefit, but worries about adverse events. What is the most appropriate option for her?

A. Liraglutide because daily dosing allows rapid discontinuation if GI symptoms occur and it has the longest history and most clinical data among incretin-based therapies

B. Oral semaglutide because oral administration decreases GI adverse effects and therefore is preferred for patients with IBD

C. Tirzepatide because it has high expected weight loss efficacy and may be considered in patients with stable IBD

D. Avoid all incretin-based pharmacotherapy because nausea, diarrhea, and abdominal pain cannot be clinically distinguished from IBD activity

All right. About 62% of participants here chose option C, tirzepatide, because it has high expected weight loss efficacy and may be considered in patients with stable IBD. I would love to hear from Dr. Sepulveda why you would not choose A or B as a first-line option, potentially.

Dr. Sepulveda:  In terms of adverse effects profile, there is the concept that oral semaglutide or liraglutide do not have the same profile of GI symptoms. Even oral incretin-based therapy can cause gastrointestinal adverse effects. Obviously, avoiding all incretin-based pharmacotherapy would not be a correct option because the patient basically can benefit treatment from incretin-based therapy. Given the fact that we want to give the opportunity to the patient to lose a higher percentage of total body weight loss, tirzepatide would be the best option.