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- [00:02]
A
Welcome to season two of Derms on Drugs, a video podcast brought to you by Scholars in Medicine, the best educational platform in dermatology and provided at no cost medical providers. Germs on Drugs is where cutting edge derm meets hit or miss comedy. I'm Matt Zyrus from Docs Dermatology and each week I'm joined by my residency buddies, Dr. Laura Faris from the University of North Carolina and Dr. Tim Patton from the University of Pittsburgh. And we use our 60 years of combined derm experience to discuss, debate and dissect the hottest topics in dermatology. It is everything you need to know to be on the cutting edge of derm and you'll actually have some fun listening. New episodes drop every Friday on Scholars of Medicine, Apple Podcasts, Spotify and other major podcast platforms. And a reminder that there is a video component that has the key figures and tables from the articles that we talk about every week. And this episode is supported by Lilly, a medicine company. We are so excited this week to have Dr. Shanthi Narla with us from the Medical College of Wisconsin and we are going to get into obesity in dermatology and we couldn't really help it. Like, we were super excited to finally do an episode where we're going to talk some about GLP1s in dermatology, since everyone in the world talks about GLP1s all the time nowadays. So before we get into Dr. Patton and Faris's first articles, I wanted to just talk very, very briefly about kind of the role of obesity in inflammation. And so just to give everybody very quickly up to speed, right, so you've got these things called adipokines that are basically cytokines released from fat cells. There's one called leptin, one called adiponectin, one called chemarin, one called resistin, one called omentin. And then IL6, TNF alpha, CCL2 and IL1 beta are also produced by fat cells adipocytes in psoriasis. Leptin directly drives IL17A adipose tissue directly releases resistant TNF IL6JAK STAT or doesn't release JAK stat but can drive it. There's decreased adiponectin that down regulates Treg so it might play a role in atopic dermatitis. There are adipose macrophages that switch from M2 which is anti inflammatory to M1 and pro inflammat. And then there's this MTOR, which is mammalian target of rapamycin 1 that that is related to fat might be relevant to psoriasis and HS as well. And obesity affects the skin and the gut microbiome. So it. They just wanted. I know that was really quick, but just wanted to give people kind of an idea of the mechanistic way of how we think of fat as affecting inflammation and immunologic diseases. So that out of the way. Let's go ahead and get started. So, Dr. Farris, what do you got?
- [02:57]
B
Okay, so I have a recent paper published in the British Journal of Dermatology. GLP1 receptor agonists and reduced mortality, cardiovascular and psychiatric risks and psoriasis. A large scale cohort study. So if we're going to talk about a large scale cohort study, you know, it's probably going to be trinetics, which is. Yes, from a U.S. so this is a U.S. database, although it's in the British Journal, but we do still have the best databases here in the good old US of A.
- [03:31]
A
Biggest databases. The best databases. The most beautiful database. Yeah, yeah.
- [03:37]
B
So what did they look at here? They looked at adults who had psoriasis and obesity or type 2 diabetes, all of whom were on systemic anti psoriasis medications. And then they looked at them, sort of split them into two groups. GLP1 receptor agonist users like semaglutide, liraglutide, and then other metabolic meds for diabetes or weight loss, things like metformin, SGLT2s, sulfonylureas. So you know those drugs. And so they did propensity score matching and came up with a little over 3,000 patients in each group matched for demographics, comorbidities, insulin use and followed them for two years. And the outcomes of interest were mortality, MACE events, psychiatric events and autoimmune sequelae. So, you know, what do we not have? We don't have things like PAZI score. So we really don't know disease severity. We just know enough, severe enough that somebody put them on a systemic therapy. So what did we find? The GLP1s actually had a pretty significant reduction in the comorbidities that we talk about a lot in our psoriasis patients. So if you compare patients on the GLP1s versus those on the other diabetic or obesity drugs, all cause mortality, reduced by about 78%. Yeah, I know, I know. They. So it's a 78% reduction. Right. This is still going to be a rare event. Mace events, 44% reduction. This was, you know, driven like the two big ones. Stroke reduced by about 65%, heart failure by about 45%. Those were the two that were statistically significant, they also threw in there alcohol and substance abuse. And you know, I think this is interesting because there is evidence that the GLP1 receptor agonists also, you know, they, they basically give a signal of early satiety. So it's like they decrease your craving for food. But there's some evidence that they also decrease. Decrease craving for things like alcohol and drugs. So a 65% reduction in. And again you're looking at coding for alcohol abuse and 50% for, you know, substance abuse as well. So decreasing shots of insulin and shots of alcohol. So I thought that was pretty. I'm always looking for a bad joke, bad dad joke.
- [06:25]
A
So that was, that was, that was.
- [06:27]
C
A very funny joke.
- [06:28]
A
That reminds me, if I have I told you guys my, my farmer joke.
- [06:33]
B
No, but let's hear.
- [06:35]
A
Was about the best farmer in Ohio. Like literally won an award for being the best farmer in Ohio. He was outstanding in his field.
- [06:45]
B
Yeah. Okay. I don't know that the GLP1s can do anything for sense of humor, but. Okay, what happens?
- [06:54]
A
So they did.
- [06:56]
B
Yeah, go ahead.
- [06:57]
A
The biggest thing that kind of struck me about this. So in that one like forest plotty thing, they showed the impact on all of these things in people with psoriasis versus the impact on people who don't have psoriasis.
- [07:18]
B
Yes.
- [07:18]
A
And they had bigger, you know, because this is all stuff that you think of the GLP1s has probably helped with anyways. But it had a bigger impact on all of that stuff in the psoriasis. In psoriasis than in people with not on psoriasis, which that was.
- [07:34]
B
So I guess it's maybe a little more. And I was wondering about that too. I mean we think about this as being like a very, you know, you talked about all the inflammatory mediators. We know there's a lot of systemic inflammation associated with obesity. We also know there's systemic inflammation associated with psoriasis even in non obese patients. So I was like kind of thinking it's the double whammy of two causes of inflammation. And so you know, potentially to me that would suggest that there's actually an anti inflammatory impact of the drugs. Not just obesity reduction but. Or you know, you're so inflamed when you've got bad inflammatory disease. You know, think about like hs, you know, those patients, you just look at them and they, you feel like they're so they've got rampant systemic inflammation. You look at CRPs in patients who've got bad HS or really bad Psoriasis, you know, they're off the chart. So that was kind of what I took into that.
- [08:28]
A
Dr. Narla, do you. Because the question to me has always been like, okay, it's because when the data started coming out that the GLP1s really help with psoriasis. And so this is not, we're not looking at do they help with psoriasis? And this already would have helped with the comorbidities. But similarly, you know, trying to dissect out the. Is it just you lose weight so you're healthier versus the GLP1s having direct effects on the stuff that we were just talking about, you know, do the GLP1s affect the ADIPA kinds, you know, separately from just, you know what I mean, what do people think about this?
- [09:19]
D
So that's like the million dollar question I think that we run into. And also when I looked at this study, is that so right now, basic science wise, I think even just starting with are there GLP1 receptors on keratinocytes? You'll see very conflicting evidence. And then when it gets to psoriasis. So I think there was, there's one paper that's always cited in a lot of the GLP1 like skin disease papers. It's the mention of how they took, I believe it was psoriasis, human biopsies of psoriasis. But they see that like gamma delta T cells were found like they were decreased. I'm not completely remembering the gist of it right now, but from that paper they make this hypothesis that the GLP1 receptors that are found in the skin are found on these T cells or killer cells and those are migrating to the skin and they're not necessarily on the keratinocytes itself.
- [10:24]
B
Okay.
- [10:25]
D
But I don't think anybody knows the exact GL. Like I, I think GLP1, honestly in my, in my brain is kind of like dupilumab. I think. No, it's just magical. It works on a lot of different things. And so, and no one actually knows what it, how it works. And so I feel like GLP1, if you look in the literature, there's like, oh, GLP1 modulates the, you know, conversion of M1 back to M2, which is anti inflammatory in the macrophages. You'll see, oh, it works on these natural killer cells, it works on these delta gamma cells, it reduces TNF Alpha IL17 and whatnot. But I think that goes back to both of the questions that you and Laura were asking, is that, yeah, I think there is Anti inflammatory effects but, but like when it comes to us, right? Psoriasis, atopic dermatitis, hs, those are all metabolic syndrome, obesity. But in my mind it's like the chicken before the egg. Is this severe obesity, what is predisposing you to these skin conditions? And by helping the obesity, helping the metabolic syndrome, is it helping your psoriasis and your skin disorders or is it a combination of both? And I think that's where we really need like more basic science to help us out. I don't think we're just going to be able to from doing like chart reviews, observational studies. I don't know if we're ever going to be able to separate those in the way that we want to.
- [11:50]
B
So I think like prospectively following these patients will be helpful. So one of the things that they did look at was like what is their impact on other inflammatory disease? So they did say that they did not see a reduction in fatty liver disease, sleep apnea, Crohn's, ulcerative colitis, uveitis or interestingly incident psoriatic arthritis. Although I believe I've seen studies that suggest that you know, GLP1 use can be associated with reductions in incidence of psoriatic arthritis. I think what will be really interesting is over time like if it's, if it, you know, do you drive like reduction in the incidence of psoriasis and I don't know that I've seen that study study although it may be out there or somebody will be doing it tonight and trinetics and put it out there.
- [12:44]
D
Everything that's interesting that you mentioned that because now One of the GLP1 inhibitors I think is FDA approved for like liver disease format.
- [12:53]
B
Yeah, yeah. Yes.
- [12:54]
D
So it's like why aren't you seeing. Why didn't they.
- [12:56]
B
Why, why did you not see it in that population? I think it's the devils and the details and you know also they only did the GLP1 receptor agonist so they didn't do the newer like combined G. I like terms tirzepatide which has two targets. So you know it's like we're going to need to redo all of this when we as we have more and more drugs that have different targets, you know and we know that like for example like the tirzepatide, you know weight loss is way more, it seems to be significantly more effective than just like the GLP1, you know, receptor agonist. I'm assuming it's because there's two targets although that may not, I'm not an expert in that area. So I think it's going to be interesting as we have more like a lot of these have liraglutide, which was sort of first generation and probably I think a drug that's not used quite as often anymore.
- [13:46]
A
Dr. Garlic. So educate me just in the very basic way of like, how did glp. So there is a normal protein in your body called GLP1. Yes, this is correct. And it, when it is elevated, makes you not hungry. That is the basic idea.
- [14:10]
D
So it's actually when you take in. I wrote this down because I had a feeling that someone was going to ask me this question. I wrote it down here. I have, you know, I wrote it down. I have, I, I can go, I can literally read off the things that I've written too. But essentially GLP1 and GIP1, they're increments. So essentially what that means is they're hormones that respond to increased like sugar, increased food intake.
- [14:37]
C
Okay.
- [14:38]
D
And so what happens is there's this whole convoluted pathway, right? The main activity of GLP1, G IP1 or especially GLP1 is they release insulin from your pancreatic beta cells.
- [14:51]
A
Okay.
- [14:52]
D
And then they lead to decreased glucagon. But they have, there's receptors, there's GLP1 receptors on actually a lot of organs. Brain, heart, kidneys, liver, pituitary, it's everywhere. Bone, adrenal, cortex. And so the other ways that I think are important to, you know, think about with GLP is that yes, there are receptors on the vagus nerve, there's receptors on the stomach, and when it stimulates the vagus nerve, that's what's leading to delayed gastric emptying.
- [15:25]
A
Oh, I got that. I was on. I'm going to interrupt you there for a second. I was on some compounded tirzepatide for about eight months and well, it was great. I didn't eat anything, but I got this awful cough and it took a while to figure out it was asymptomatic GERD caused from delayed gastric emptying. That was irritating. My, like, I, I was coughing so bad I passed out at one point from like coughing. It was, it was horrendous. And then so finally maybe it's the, you know, I went to see an ENT and I was like, oh my, your vocal cords are all irritated. And I stopped the stuff and I immediately, like, first I tried taking like high dose protonic, high dose PPI and high dose H2 to see if I could stay on it, but I just went off it and the cough went away. So yeah, the, the late gastric emptying I'm very familiar with.
- [16:23]
D
Yes. And so I think also it works on the receptors in the brain which leads to the release of leptin and then you also have increased adiponectin and all these other. So I think we always focus on this whole, you know, it leads to, it kind of works on the brain, but actually it's working on pretty much every organ in your body in certain events, all simultaneously leading to decreased metabolic syndrome. Syndrome.
- [16:50]
A
Let's move on to our next article and you know, the, one of the things that I'm going to be really interested in us having a discussion about it some as we get through these is if there's ever going to be a world in which derms are actually prescribing GLP1s as opposed to, you know, educating patients on, hey, this would probably help your whatever, you know, maybe talk to your primary care doctor about it or go to some, you know, wonky compounding pharmacy or whatever. But let's pat, what do you got?
- [17:23]
C
All right, so my deep dive paper was titled glucocon like peptide 1 agonists reduce surgeries and hospitalizations and Hydradenitis Separativa. A multi center trinetics cohort study by Gupta et al. It was in September 2025, Journal of Drugs and Dermatology. It was a trinetics analysis which we've talked about, talked about lots and lots, millions and millions of charts. So the main thing they looked at was HS patients on GLP1 receptor agonists versus HS patients not on those drugs and outcomes of HS surgery and rates of hospital admissions. They also did some other analyses. They looked at Tirzepatide that was the dual GLP1 GIP1 receptor agonist. They compared the GLP1 inhibitors to adalimumab and infliximab and they looked at outcomes in patients with HS who didn't have type 2 diabetes. So table 2 shows that HS patients on GLP1 have lower rates of HS surgeries and hospitalizations, larger effect on surgeries than on hospitalizations and that this is true even in non diabetic patients. Reduction in surgery was pretty big, like about a 2/3 reduction overall and a 75% reduction when just looking at the non diabetic patients. Table 3 showed the same sort of reduction when just looking at tirzepatide, except it was like a 95% reduction overall in, you know, overall HS surgeries. It also that that Same table showed that the GLP1s reduce surgeries more than either adalimumab or infliximab. So like it's, they're better HS drugs than what is FDA approved. Is any of this believable? I mean, we, we've talked about Trinetics a lot. How reliable is it? Who knows? I, I talked to somebody who worked with Trinetics and they said, I, like they've published on Trinetics and they said, I don't even know if what we published is, is legit. Like, it's just so much data and you don't know. There's just so much we don't know about, you know, when you're looking at those charts. So like this was just, okay, this is interesting. I think obviously it's, it's obvious that this just needs to be replicated in prospective controlled trials, things like that. But does Anyone think that GLP1s are more effective at reducing surgeries than TNF alpha inhibitors?
- [19:54]
A
Do we know that they weren't also like, did they, do we know if they excluded, like, if you're on a GLP1 and a TNF, they didn't count you.
- [20:02]
C
If you, so when they compared those two and this didn't make any sense, but if you look at the category, the columns, it was like, okay, HS patients on the GLP1, what percent of them were on adalimumab? It was zero. But the problem with that, that chart, and we talked about this and it still didn't make sense to me is the percentage of patients in the, this patient had HS and was on Adalimumab. The percentage of those patients that are reported as being on adalimumab was 22.21. According to the, the paper. It didn't make any sense.
- [20:36]
A
So that is a weird thing about how Trinetics reports state. And I, I, I started trying to do some work with somebody on Trinetics and after like a couple emails back and forth, I was like, this just doesn't make any sense. I can't figure this out. I'm not putting my name on anything that comes from Trinetics because I don't understand how they're reporting the data.
- [20:56]
C
And I, I tried to get explanations and they're like, right, that's what they said. This is just how Trinetics reports it. And I'm like, what does that number mean? If, if 100% of the patients aren't on adalimumab, then you can't make a comparison about reduction of surgeries. Of patients on the GLP1 RAS versus adalimumab. So I. I don't know what to make of this. That's not believable to me. It could absolutely be true. But the.
- [21:22]
A
The. So. Right. It's not. It's. Yes, it got. It quickly got hard to believe. Right. So that, like, there was not, you know, outcomes in all patients with HS with comparisons made. Patients taking tirzepatide, not a single one had a, you know, simpler intermediate cyst repair compared to 40. And the people not take, like, it just. Something's weird here. Yeah, Something is weird.
- [21:53]
C
Dr. Narla, what did you think of the HS paper?
- [21:57]
D
Yeah, I agree. I mean, you know, I think we can all say even in our clinics, I do see a lot of HS here being in Milwaukee, and a lot of my patients are on, like, mojaro or tirzepatide and all these different things. So that's hard for me to believe. I agree. I think it would have been a better paper if they compared Adalumab to. And then adalumab and a GLP1. I think that would have been. Because, again, I don't think that GLP1s will ever be used as monotherapy for any of these, you know, any of our skin disorders. And so it just, you know. I agree.
- [22:34]
C
Yeah. And it's not like they couldn't be on anything else. And, you know, fair number of patients were on clindamycin, a tetracycline antibiotic, and they matched those percentages pretty well, but it was. None of them were on adalimumab compared to the people on adalimumab. And there was this huge difference that I just. It's not believable, but I guess. And it goes back to the psoriasis question is, and I don't think the psoriasis paper looked at this either. Do you find these benefits independent of weight loss? If. If you find these benefits independent of weight loss, does that, like, do you see the patient staying on those drugs? You know, you have a. Maybe a patient who's overweight, psoriasis, you have them on a biologic, their skin's much better. You have them on this weight loss medication and they're not losing weight. Do you keep them on it? Because you're like, well, it should show these other benefits. And I know you're not losing weight, but we showed this improvement in cardiovascular. Like, I can't see that happening. I can't see the patients continuing to take the drug if they're not seeing the benefits of like the weight loss, which. Or you know, type 2 diabetes.
- [23:44]
B
Yeah. I, I think it's hard to get patients to stay on a medication for an unknown thing. Like maybe this will reduce your risk of having a heart attack or stroke. Right. If they have something tangible like your blood sugars are down, you're not on as much insulin, you're losing weight, your disease is getting better then that probably, I think that if it makes the dis a disease, the, that they can quantify better, they'll probably stay on it. I think if it's like you would have a 35% reduction in your stroke rate, that's going to be a tough sell.
- [24:16]
A
Yeah.
- [24:16]
B
For patients to stay on. You know, the other thing that's interesting, Matt, because you talked about being on compounded tirzepatide is I always wonder like, you know, these things are so prevalent out there and so none of these are going to be captured in trinetics.
- [24:33]
D
Right.
- [24:33]
B
They're only looking at pharmacy prescriptions and pills. They're not going to capture the people who are on compounded medication. So I don't know the answer to what percentage of people on GLP1s are on the real deal or those that are kind of getting it off the Internet. Compounded.
- [24:53]
A
Interesting. Well, let's, let's. So the, I think the takeaway from Dr. Patton's article sounds too good to be true. Probably is. And you know, part of me thinks, you know, if you think about what we're saying, somebody who's got the wherewithal to get on a GLP1 but has never been on a biologic for HS and has HS that probably is selecting for a pretty mild HS group. Right. So they're people who are competent to get themselves on an expensive drug, have a horrible disease and never got on an expensive drug for their horrible disease. So it's, it strikes me that it's probably. That's gotta be a big part of the explanation is, is something like that.
- [25:43]
B
You know, and I guess I go back to like, I'd like to see incidents. So what I would like is people who don't have HS who then go on these drugs, you know, versus another drug and like does that. Another weight loss drugs specifically and does that or you know, another diabetes drug. Is there a difference in the incidence of hs?
- [26:05]
A
Interesting.
- [26:06]
B
I mean it would be interesting to see. And yeah, I think surgical intervention for HS is very directly correlated with like how long standing or how severe or how what your early stage is. Right.
- [26:17]
A
Like, so I saw a P.A. this reminded me, I saw a patient today for HS who was like, oh, I started going tanning and my HS is getting better. And initially it's like, been doing great. I don't have any lesions. And I was like, initially, like. So you're like, you're standing in there with your arms above your head, like, I've never heard of this. I've. I didn't think, you know, tanning could cause skin cancer. And then I look at her meds and she's on Manjaro and Metformin and she's like, oh. I was like, oh, so when did you start those? Oh, right around the time I started tanning. And now she had fairly mild HS to begin with. So. But yeah, it was just an. It's hard to ferret all this stuff out, right? It's hard to ferret out what, like, is really the underlying cause of stuff. Like, it's fascinating. Fascinating. So we're gonna just. I'm very briefly gonna touch on my article. The. So mine was association of GLP1 Agonists with atopic Dermatitis in Obese Patients. A retrospective cohort study. And what I will tell you is I think this article showed that it doesn't work, that it doesn't make a difference in atopic derm. What they showed was that people with atopic derm and obesity who went on GLP1 had like an 8% reduction in their use of topical or systemic steroids. So, you know, given the whole trinetics thing and everything else, I'm like an 8% reduction, like in your use of topical steroids or systemic steroids makes me be like, if there's an effect in atopic dermatitis, it is very, very minimal. Which, you know, we've always kind of like, everybody always knew psoriasis nhs, like, you didn't need a study to be like, that's happens to people that. More commonly to people who are overweight. AD is not a disease like that where you, you know, we look at it and say more likely than people who are overweight. So it, Yeah, I, it. Once I read the study carefully, I was like, eh, eh. Don't really buy it. Don't buy it. So have you. Do you prescribe GLP1s? Have you? I. I can't imagine any derms do other than like, if you've got some kind of a wellness spa or something, you know, could you imagine prescribing a GLP1?
- [28:43]
D
I can. Because I mean, I think the first thing is, you know, we see a lot of different other specialties, you know, all levels of providers prescribing them. So I think as doctors or even dermatology providers, I do think we have enough training to prescribe them. And similar to yourself, Matt, full disclosure. I use a GLP one for my own health problems and things like that. So I feel like I'm probably more uniquely positioned as a clinician scientist and, you know, to be prescribing these in conjunction with it. And, you know, as far as I know, you know, my own physicians that have given me that, they're not really monitoring anything other than, you know, check in with me if you have any side effects. Like, for example, something that I think a lot of doctors or providers in general don't know is there is a warning. It's no warning, but like a recommendation right on tir's appetite because it leads to delayed gastric emptying. A woman of childbearing age, you're supposed to incur. You're supposed to tell them not to be on an oral contraceptive because that can lead. It's. It's on the product insert.
- [29:57]
A
Why?
- [29:57]
D
Because delays gastric emptying of the pill.
- [30:01]
C
So they don't get.
- [30:02]
D
You have.
- [30:03]
B
You don't get regular absorption.
- [30:05]
D
Correct. And so they tell you in the product insert they need to be on other. Some form of systemic birth control like an IUD or patch or whatnot. Because, you know, how they attributed in the beginning the baby boom of Ozempic. It's hard to say if that was from, you know, reducing PCOS from weight loss or is it because you had all these women who are on oral contraceptive pills and even though it was written on the label and no one knew about it. So I guess this is all to say, I feel like.
- [30:37]
A
See, I. I had always assumed that the baby boom from Ozempic was just that people were like feeling good about themselves and feeling frisky. And so there was a, you know, that kind of. That's why I always. A little nervous when you start somebody. I'm always surprised there isn't like a big increase in pregnancies whenever we start people on Doopie or like Skyrizi, where like, people who have just felt good, ungood about themselves suddenly feel great about themselves and.
- [31:13]
B
Yeah, thank God all he got was a cough from your hooray.
- [31:17]
C
Yeah. Fortunately, the cough drove most women away from you, so you didn't really have that problem. That's good to know.
- [31:25]
B
Yeah.
- [31:25]
D
You know, pregnancy for you, Matt.
- [31:27]
B
Yeah.
- [31:30]
C
Yeah.
- [31:30]
A
So it's, you know, it's an interesting I. I do. I would. I've been, like, waffling if I want to bring this up, right. So it's. It's interesting. There's now the deal that if you're on a certain biologic for psoriasis, you can get Manjaro or. I don't know if it's Manjaro or whatever. The.
- [31:54]
D
The tears.
- [31:55]
C
Appetite.
- [31:56]
A
Appetite for 25 bucks a month. That seems like it has to break some kind of a rule, but it obviously doesn't because it's not like. It's not like it's been kept under the rug.
- [32:13]
C
Yeah.
- [32:13]
A
Or something like that.
- [32:14]
C
Yeah.
- [32:15]
A
Like, it's. I mean, has that. Or would that affect your. You guys prescribing of. You know, do you tell patients this? Hey, you know, we got, like, a bunch of different drugs we could put you on. They all work great. If we put you on this one, you can get, you know, a GLP1 drug for 25 bucks a month.
- [32:37]
B
Well, they still have to meet the criteria, right? Like, it's not like I could be like. And by the way, you'll also get tirzepatide. They would have to meet the criteria of having obesity or type 2 diabetes.
- [32:50]
A
So.
- [32:50]
B
But.
- [32:51]
A
So do you tell. Are you going to start telling your obese patients this? Like, technically, by BMI, I count as obese, right? So I was a BMI third. Just. Just over 30. I think 27 is overweight. I think 30 is obese. I think, like, lots of people count as obese. Like, it's. It's an interesting thing. Patton, what do you think you would. You. Are you going to start telling your patients who could benefit from a GLP one that if they choose to go on talts, they can get a GLP1 for 25 bucks a month?
- [33:29]
C
I don't think so. Unless that came up in the conversation. If they said, I'd also like to lose weight and I. I wouldn't be something that I would pursue. I'm. I'm just not ready to do the GLP gip. They. They have primary care physicians that have just more overall experience in managing those diseases. So I think it's. I mean, I. It doesn't make any sense to me personally that I would jump in there and be like, hey, I know you're seeing your PCP and he's been managing your diabetes for a long time, but guess what? I can give you, you know, this. This other medication you may have seen commercials for, like, let. That's just not our.
- [34:08]
A
Do you have to. So Dr. Nola, do you know about the. I know nothing about the program other than somebody told me about it, and I was like, what?
- [34:15]
D
Yeah, I think it's for private insurance.
- [34:18]
A
Okay.
- [34:19]
D
And they have to get the Ixacizumab approved.
- [34:22]
A
Okay.
- [34:23]
D
And then I think if it's approved, I'm not sure exactly if there is specific criteria. I think it's just if they want it, it's, I think, like, 25.
- [34:35]
A
Yeah.
- [34:36]
C
And presumably it would be like, you'll. You'll lose weight on this drug.
- [34:40]
D
Right. And they don't actually have an active clinical trial right now where they're also doing that combination.
- [34:46]
B
They do have. They do have an active clinical trial.
- [34:49]
D
They do have an active clinical trial.
- [34:52]
C
Just so, like, for the audience, too, when we're talking about Tirzepatide, there are two separate drugs, Right. Manjuro and Zepbound. Manjuro, FDA approved to treat type 2 diabetes. Zepbound to FDA approved to treat weight loss. And are there dosing differences there?
- [35:09]
D
Okay, yeah, it's the same exact drug. It's just that with the one with chronic weight management, which I think is Zepbound, it goes up to like 2.4mg versus with the other one. It just cuts off. That actually took me a really long time to figure out. It's the same thing with Ozempic and WeGovy. It literally just has to do with the dosage that's allowed for that indication.
- [35:34]
C
Right. Same, same drug, different dosing, depending on the indication.
- [35:39]
A
So in that program, do you. I mean, could patents say, hey, go talk to your primary care doc if they want to prescribe? Like, maybe there's. I don't know, maybe there's a handout that you can give to the patient and tell them to go see their primary care doc.
- [35:53]
C
Yeah. Or does it have to come from the same prescriber that's doing the TULs?
- [35:57]
A
Right. That'd be weird. I don't know.
- [36:00]
B
I will say there are enough benefits of these drugs. I mean, and they are, like, clearly shown to lower hemoglobin A1C lower. Like, you know, a lot of the bad outcomes that even if we're not saying I'm doing this for psoriasis, I mean, we've spent years and decades talking about comorbidities of psoriasis. So, you know, I'm not opposed. This is a class of drugs that's turned out to be relatively safe. Right. I mean, there's some little nuances, but, like, relatively safe. And we've been talking about Comorbidities and we actually have data for, you know, reducing comorbidities. I don't know but I, I always.
- [36:42]
C
Have opposed the whole comorbidity thing with derms getting as much into it as what some of the experts on comorbidities want us to get into it. I. Your psoriasis patient. Yes, there are comorbidities. These comorbidities are managed by primary care physicians. Make sure you have that discussion. That's the end of it. Going beyond that and saying, well, let's follow up with it. Like we don't, we've got enough to do. I don't want to follow somebody's hemoglobin A1C. I don't want to follow their BMI.
- [37:18]
B
Primary care docs are just lollygagging around at the beach all the time.
- [37:23]
C
I think you're bad mouthing PCPs and our listenership is going to plummet now after this.
- [37:29]
D
Hey, well, I guess Tim, I have a question though, like if they're so that, so actually going back to something that you said, the studies that in I think it was psoriasis, do some of them say that the, the benefits of it are independent of weight loss. I'd have to pull up the exact study on my laptop, but there's like always a line in there. So I guess would you be okay like you know, a 30 year old HS female, otherwise healthy, other than her HS just has obesity? No. Not a brittle diabetic. I completely understand. I would not touch the true diabetics. But would you? Okay in the sense of like again going back to. I think the whole theme of the show is it just helping the obesity which is indirectly helping the hs. But again hs, we still don't have great treatments. We have treatments but you know, we still need more. So would you be okay then give it prescribing it or no. Even then in those cases you'd be like go back to your primary care doctor.
- [38:24]
C
Yeah. So if, if they showed the data and actually did a study where they said look, with these GLP1 inhibitors in HS for instance, they have shown it doesn't affect weight loss, doesn't affect type 2 diabetes. It is FDA approved to treat HS because we see these benefits. I'm fine with that because I can like, I can manage HS and that's how I'm going to be clinically following the patient. I think when you get into, you're on this drug for weight loss, there's a whole other way to manage weight loss that I think as Derm. I've never really done that, and I'm not going to start.
- [39:02]
A
You know, what about, what about the cost effectiveness of it, Pat? And this is orders of magnitude more cost effective than any other drug we have for hs.
- [39:13]
C
I mean, but is it, is it effective? Effective.
- [39:17]
A
Right. That's, that's if they, if they really showed. If there was, you know, it's, it's a fascinating thing of doing that clinical trial.
- [39:24]
C
Yeah.
- [39:25]
A
Of, you know, monotherapy. Or maybe you put them on. Yeah, just monotherapy with the GLP1 for AHS. Like, it would be a, like so cost effective.
- [39:38]
C
I haven't had any, like, I haven't had that conversation with any of the HS patients. You know, they've never said to me, hey, there's these new drugs that cause weight loss, and I've been struggling with my weight, and I think that'll help HS because of certain things, you know, guide me through that process, help me there. I, I, that conversation hasn't come up. If they're Talking about the GLP1s or the GIP combination, it's because they've already been discussing that with their pcp. That's not been a conversation that I've instigated. Will I start doing that? I don't know. Yeah. I don't know. Okay.
- [40:14]
A
All right. Well, Dr. Nerla, I did. I don't think I warned you. We always close our episodes with a little trivia. A little trivia section here. It'll be, it'll be vaguely related in some way to what we've been talking about.
- [40:34]
D
Okay, good. As long as it's not 12 boards.
- [40:36]
A
Yeah.
- [40:37]
D
I can't do any. I would be done.
- [40:39]
A
No, here's.
- [40:40]
D
Okay, good.
- [40:41]
A
So it. Now here's the only rules you got. You got to let Patton finish reading the question before, but as soon as he's done reading the question, the first person to shout out the answer gets the point.
- [40:54]
C
These are people who may have benefited from the use of GLP once. Fictional and non fictional. Am I going to make this anything personal? Matt? You already benefited, so we've already had that discussion.
- [41:08]
D
Does this go back to the conversation you guys were having before I came on?
- [41:11]
C
A little bit. This second question, I think. Well, we'll see.
- [41:17]
D
All right, I'm ready.
- [41:19]
C
This man was believed to have been over 300 pounds at the time of his death. He was survived by his sixth wife, Catherine Parr.
- [41:28]
A
Babe Ruth.
- [41:29]
C
No. Marlon Brando, Historical.
- [41:38]
B
One of the Russian czars.
- [41:41]
C
No. It's an overseas country, though, who famously had six wives.
- [41:51]
D
Yeah, I know. King had her. Yeah.
- [41:53]
C
Yeah, that's it. Henry.
- [41:54]
A
Yay.
- [41:54]
B
Okay. Oh, I got it. With only, like, 18 clues. Okay.
- [41:57]
A
I was gonna guess there was a one of the old. One of the original. One of the emperors of the Holy Roman Empire. After Charlemagne, there was a Charles the Bald and a Charles the Fat.
- [42:09]
C
Oh, yeah.
- [42:10]
A
I thought you might have gone with Charles Theat.
- [42:13]
C
I don't know how many wives he had.
- [42:14]
B
I should have known from the. The famous musical Six that should have been mine.
- [42:20]
C
If you read about Henry vii as he did get older, he. He was a mess. He probably had, like, horrible stasis, ulcers, and he needed. He needed, like, mechanical things to, like, lift him on his horse and just get around. It was. It was brutal.
- [42:37]
A
Poor horse.
- [42:38]
C
All right, who is the title character of the animated series that ran from 1972 to 1984? 5. Starring the Junkyard Gang with members like Russell Mushmouth, Rudy, and we. Weird. Harold Albert. This was the one where I'm like, there's no way. This was before you were born.
- [43:01]
B
Probably you've never heard of Fat Albert. Oh, gosh. Okay.
- [43:05]
C
I know. Can you believe that?
- [43:07]
D
Hey.
- [43:08]
B
Hey. Yeah, this is where the generational divide.
- [43:13]
D
Family matters is probably like. Family matters.
- [43:15]
C
Oh, yeah, yeah. We. We grew up with Fat Albert because.
- [43:20]
B
You couldn't have a show called Fat Anybody now. But, yeah, this was the stuff of our childhood.
- [43:25]
A
Fat Albert was like. He was wise. He was wise.
- [43:29]
C
They all looked up to him. Yeah, all the gang looked up to him. He was their leader.
- [43:33]
A
Yep.
- [43:34]
C
All right, which U.S. president who served from 1909 to 1913 is widely considered to be the most overweight president?
- [43:42]
B
Garfield.
- [43:43]
C
No.
- [43:45]
B
100 years after that.
- [43:49]
C
No.
- [43:49]
A
Teddy Roosevelt.
- [43:51]
C
No, it was William Howard Taft.
- [43:56]
A
Oh, he's from Ohio.
- [43:57]
B
He was even the president. Yeah, you should have known that. Ohio.
- [44:00]
A
I should have known that.
- [44:02]
C
You know, interesting thing about William Howard Taft. There's probably this apocryphal story about how he got stuck in a White House bathtub and so he had to get a special one brought in. That's probably not true, but did you know he went on to serve as the Chief justice of the Supreme Court after his presidency?
- [44:20]
B
I forgot he was even president, so I certainly didn't know that part.
- [44:23]
C
Poor guy.
- [44:25]
D
President 2000s and beyond.
- [44:27]
B
No, this is. This is why when you have a trivia team, you need people of many different generations.
- [44:34]
C
You know what? So the whole overweight issue is. Is it can be difficult to talk about. And I didn't want to bring up anybody who like was a lot. So I had to pick like dead people or made up people.
- [44:46]
B
Okay.
- [44:50]
C
So yeah, sorry about that. I'll write through through three new ones with more modern take. I'll email it to you.
- [44:57]
A
Yeah. All right. Well, I would. Dr. Narla, I want to thank you for joining us this week. This was a really fun and, and interesting discussion. And I want to thank all of our listeners for joining us. I hope you learned a few things. I hope you laughed once or twice. But mostly I'm hoping you're planning to join us next week. And until then, I'm Matt Zyrus.
- [45:19]
C
I'm Tim Patton.
- [45:20]
B
And I'm Laura Farris. And we are Derms on Drugs.