Kerry: 0:28

Hi everybody. Welcome back to the Get Healthy Tampa Bay podcast. I'm your host, Dr. Kerry Reller, and today we have a very special guest, one of our own Sarah Lakadawala, a doctor of nurse practitioner. She earned her doctor of nurse practitioning degree from USF and your doctoral project focused on GLP one therapy and autoimmune conditions. She was born and raised in Texas and a proud graduate of university of Texas at Austin, and yeah, she began her nursing career in critical care as an ICU nurse, and later transitioned into urgent care and family medicine. In her free time, she enjoys reading on her Kindle, traveling, hiking, and spending time with her family, and we are so happy to have you here today.

Sarah: 1:11

Yay. Thank you. So excited to be here and excited to chat about the topic.

Kerry: 1:15

Yeah. So first of all, congratulations on earning your DNP and I guess, what decided you to do that in the first place, and how did you pick your project? Do you have to do a project? Tell us a little bit about what getting a DNP means to you and to the rest of the population.

Sarah: 1:31

Perfect. Honestly it was news to me when I first started my nursing career too, to be completely honest it was more so when I first started school, I never wanted to go back to school, so it was the highest degree you could earn in nursing. So I was like, if I earn it, I don't ever have to go back, but when I started, like my bachelor's degree. And going into nursing, you have to get your master's to become a nurse practitioner. And then the DNP is basically one extra year added onto your master's. It's basically more research guided. You earn your doctorate degree of nursing practice. All of the students or colleagues that have earned their DNP basically choose a topic that either somewhere they work. Or something, a topic that they're very passionate about, something that's a little bit more relevant, and they choose a site somewhere they can do that site. It can even be at like we had some of our classmates do it at a local YMCA and integrity, certain certain topics there. So it doesn't have to be like a hospital, clinic or anything of that nature, but something that you're instilling that you're seeing like a medical need for, whether it be screenings, preventative visits, anything like that. So I started it to not ever be back in school. But then I realized when I was in my master's program, I was like, wait, I actually it's more academia. And I like looking up research articles and going on PubMed and seeing like latest evidence-based. So it was tying both of those things together. So that's why I continued with it as well.

Kerry: 2:58

Yeah, so that totally makes sense. I think I had the same thought. Again, if I keep like accumulating all these degrees in this education and one of the things starting the podcast was like I just keep learning more and more. So I think maybe I'm not getting a degree again from doing the podcast, but I think we never stop learning, especially in medicine. So I think what, what you've been through is amazing. And I'm sorry if I butchered the title of DNP, I usually just say DNP, so I didn't know how to say it properly. But that really gives us an idea of what, you have to do to get that degree. And tell us what you chose and why you chose it. For your project.

Sarah: 3:31

Obviously a lot of people have been heard of Ozempic, wegovy, zepbound, all of those buzzword names that have been around. My topic specifically focuses on GLP ones and with the specific population of autoimmune patients. So it's people that have been diagnosed with an autoimmune disease and integrating GLP one therapy into their regimens to help with their disease state and quality of life. So I can dive a little bit more into that as well. But that was my specific topic, so I, had it took over a year, maybe actually 11 months to gather like start introducing the project in the introduction, writing up seeing like different research articles, what I wanted to explore, what I actually wanted to do at the site. And then, there was a four month intervention period, and then there was another couple months where obviously you're analyzing the data and then writing up your proposal afterwards. And so all of those types of things took about a year. And then at the December of 25, I actually just submitted it for publication. So it'll probably be like eight or nine months before it gets accepted.

Kerry: 4:41

So what kind of study would this be classified as?

Sarah: 4:44

So it's going to be classified, it's technically a quality improvement. It is there's different basis, there is like randomized control trials, there's meta-analysis. So it's like an observational case study where I'm not obviously doing experiments on human subjects, so it wouldn't be classified as like that randomized control trial or collecting a bunch of different articles together where it's a meta analysis, but more observational recording my findings in a population after doing an observational period. And so that's where my article was classified as. And yeah.

Kerry: 5:19

That was a really good overview of what the other, studies are. Obviously, with evidence-based medicine we focus on those randomized controlled trials, but all these other studies are usually done beforehand to be able to do something like that. So you mentioned these, ozempic and things like that. And I guess, how did you come up with the idea of wanting to do that with autoimmune patients? And maybe you can tell us a little bit about what autoimmunity like disease is so that somebody can understand that and maybe why the connection is there.

Sarah: 5:47

To be honest, a lot of our patients, before I even started the project, a lot of the patients that we were seeing had very pro-inflammatory markers in the sense of they were struggling with something like PCOS. Or rheumatoid arthritis, lupus. And that was prior to me even starting the project. We saw this trend that a lot of the same patients were coming in and they were also on a lot of medications as well. It's help manage it as. And it wasn't like every single patient, but it was a consistent, probably 75%. And for those that don't know, an autoimmune disease is basically when your body is basically attacking itself, right? So it's something foreign and your body doesn't recognize it, so it's attacking it. And because of that, your body's constantly in this hyper aware, inflamed state, and a lot of those patients, they're, it's it's sad because they're just struggling with a lot of fatigue, sometimes pain. A lot of times it is obesity as well because obesity as we know is like very pro-inflammatory. It loves that kind of thing. Weight fluctuations is a big part of that population. So I felt after doing a lot of research obviously GLP ones is an umbrella term for ozempic Wegovy Zepbound and Mounjaro. It's called glucagon-like peptides. And so GLP ones have been known in their studies, obviously for diabetes and weight management, but there are certain markers now we're seeing in that it's helping for inflammation. And since obesity and these patients are in a high inflammatory state, we wanted to see is this medication GLP ones introducing it in their day-to-day basis, going to help with their inflammatory state?

Kerry: 7:26

So did you do like baseline lab work on these patients to find out what their inflammatory markers would be at baseline and then after using the

Sarah: 7:35

yeah, so I can dive into what I did.

Kerry: 7:38

The design of it? Yeah.

Sarah: 7:40

so basically my goal of my project wasn't specifically weight loss. A lot of the patients, they've been struggling with weight. Obviously they couldn't be at an underweight BMI to be introduced into my project. They had to be at a healthy weight or obviously in like an overweight obese BMI I hate that word. Just for that calculations. And then we introduced basically GLP ones for anyone that was diagnosed with an autoimmune disease by another provider. Or had a diagnosis of that and they were struggling with that. And obviously we knew they were on certain medications to help with their fluctuations of either Hashimoto's Graves disease and those are specific autoimmune thyroid medications. Or they had rheumatoid arthritis. And then basically we had a total of 22 patients. They entered our study and we introduced GLP one which is the semaglutide. We it's compounded form of Ozempic or Wegovy. And we introduced it usually when you start, you go to a clinic, sometimes you start at a lower dose and then you build your way up to a higher dose depending on how the patient does. So we started everyone on,'cause we knew the overall goal was not just weight management. They came in, they were feeling tired, they had a lot of pain. They weren't really, A lot of my patients didn't really even care if they lost the weight. They just wanted to feel better. Their quality of life was affected. So we introduced everyone's medication at 0.125 milligrams, which semaglutide starts at 0.25 milligrams. So it's half that normal dose and some might refer to that as like a microdose. I'm sure people maybe have heard that microdose buzzword before, but obviously it's not evidence-based quite yet. But. Ideally, we introduced it at a lower rate to hopefully help combat some of those physical factors that they're experiencing and a lot of them so we did baseline labs on them. We always do baseline labs just to, make sure they're safe to start it making sure they don't have any exclusion criteria or anything of that nature. So we did C-B-C-C-M-P and then specifically for a lot of our autoimmune we just did a CRP, something very basic just to see how that would instill in them. The big thing that I did in my study was, I used two evidence-based surveys. One of them was called a Fatigue Severity Scale, or FSS and the Promise 29. Both of those are like quality of life markers. We did it pre-intervention. So before they even started the project, we got baseline labs and they filled out the two surveys. And the Promise 29 basically checks five different domains. It checks, their anxiety level, their depression, it checks their physical function, fatigue and sleep. So it's like a series of questionnaires, very obviously controlled'cause it's very standardized and used across a lot of different studies. And we checked how they did before they started the GLP ones. And then at the end of the three months, and then a lot of GLP ones, I'm sure Dr Reller also knows, good exercise and like diet control was a huge part of it. So we really emphasized an anti-inflammatory diet. It wasn't a specific diet that they stuck to, but obviously'cause that would be another factor that would be in, into it. So it wouldn't just be one domain. But we really tried to actively work with them every week. I would have weekly phone visits or they would come in person dependent on where they lived. And we would talk about their diet and be like, okay, what are you putting into your diet? Those types of things. So I think just dietary counseling also made a huge impact of what they needed to eat and help with the medication as well.

Kerry: 11:24

Yeah, so one thing you mentioned was the CRP, so that is one, a non-specific marker of inflammation. So this is a great study to, get a baseline to see what's going on. However, you did mention they're already on medication when they came to you for their autoimmune condition, right? So sometimes I think we hear like all these immunosuppressive drugs, these biologics and things like that, where some of the patients on biologics or even like steroids for some of these conditions.

Sarah: 11:50

Yes. So many people were on when I first started. I wouldn't say so many. I only had 22 people in my study. But a good chunk of my patients that I had in my study were on long-term steroid use, and their body was just constantly, they felt the side effects. They just felt like they weren't sleeping well because of the side effects of insomnia and they just felt bloated and their body had a pretty high CRP marker. Some actually I will tell you, I, I will go into the results as well, but my CRP wasn't statistically significant in the sense of statistically significant is when it's commonality among majority of that population to report it. And it was ended up not being statistically significant.'cause some people were on certain biologics for say the rheumatoid arthritis. And their CRP was well controlled. And then some people that had like very high use of steroids or their autoimmune disease wasn't very regulated it was pretty high as well. So there was like a variance of that. I think in the future I would like to do, maybe just pick one autoimmune disease panel and that way I can really hone in on certain lab markers and see that trend throughout. But it was a little bit harder because it was any patient. So it was very different to standardize the labs that I drew. And since CRP was a very kind of generic and CRP is C-reactive proteins, very generic inflammatory marker. That was the one I like, looked for.

Kerry: 13:21

Yeah, we also know it's like already high, with obesity and other, metabolic states and obviously autoimmune too. But and if they're already on medicine for it, it was probably lower at the start. So it's almost like you would need a subset of patients who are on nothing to

Sarah: 13:35

Nothing I know.

Kerry: 13:37

Yeah. But like it's hard to get to do that, I think for sure. It's funny'cause when we see, patients with asthma, it's the same thing, right? They, we give them steroids and if, because they're really uncontrolled and then not only does. That cause potential weight gain and things like that, whether asthma might be controlled. But then you get the whole, comorbidities of the weight gain and the more inflammatory markers from that aspect is too. So I know I keep likening it to that'cause obviously we talk a lot about asthma in our office. But okay, so they had some nutritional counseling, obviously, support with exercise and behavioral things and you were using semaglutide. Did you ever go up in the dose?

Sarah: 14:17

Yes. So it was over a three month period, so everyone started for the first month at.12 5 milligrams. And then dependent on how they did, I did have some patients that stayed at 0.125 the entire way through. And I will say they're still being seen at our clinic and they're still on 0.125. They just liked the way they felt. And they didn't need to go up sometimes. Some people also I knew, I told them from the beginning, weight loss was not my primary goal. But obviously it's a healthy side effect if they wanted to experience it. So again, that was not something that was completely controlled in the sense of a few, it was a randomized controlled study. It would have to be this every single patient. So that's where turns into a case study observational. In the sense of if they had an like an elevated BMI and their weight was plateauing. They hadn't lost a lot of weight, they weren't feeling a lot of changes. Then I increased them to 0.25. For the entirety of my study, everyone was either on 0.125 or 0.25. Nobody was higher than that. And I will stay for my results, I did the two surveys. So the CRP kind of like we chatted about wasn't statistically significant. Things I would change was just hone in on one. But my surveys was where I saw a good changes in my quality of life. So the fatigue severity scale was it's just like a questionnaire survey and you get a score at the end of it. And I will say it was very statistically significant. A lot of my patients all had reported decreased fatigue that they experienced while on even just the microdose or the low dose semaglutide. And then for my promise 29 we saw statistical significance in our anxiety, depression, sleep, and fatigue improved, but wasn't statistically significant on that one. So it was really cool to see, and I don't know a lot of patients, I really got good feedback on it just'cause we developed a good relationship after the year that I worked with them. And so they gave me good feedback on how they felt and those types of things.

Kerry: 16:17

Very interesting. I was gonna ask, so I've had some patients on GLP one and it might just be the dosing situation, but that actually say they get a little bit fatigued from the medicine. So this is very interesting because it's like totally, the opposite. But I would say it's still a handful, right? Everybody has their different response to it, I think.

Sarah: 16:37

Yes, I did have I think fatigue is, we warn people about side effects when they first started and fatigue is one of the ones that I always warn people about. Sometimes I do think it's a little bit of under consumption as well. Like they're just not eating enough'cause their appetite gets so suppressed that they're like, oh yeah, I only ate one meal a day, but I'm like, that's maybe not enough. I always, I also say if you're feeling fatigued every single day, really hone in on your diet.'cause that could be an impact of why you're feeling fatigue of under consumption or I did have a couple of, actually, maybe not a couple, just one. And she specifically had ra. She felt very fatigued for pretty much the entire three month period. But she felt like her joints had less inflammation. Like overall things felt better. And after the study ended, she actually ended up switching from semaglutide to Tirzepatide, which is bound mounjaro, same micro dose dosing in the sense of half of what the initial starting dose was, and her fatigue is a lot better.

Kerry: 17:39

Interesting. Yeah. What about you mentioned sleep was improved in some patients, right? So no correlation between like sleep and fatigue or that you would know over?

Sarah: 17:50

no, I act, yeah, I unsure about that one. No correlation that I can tell you about.

Kerry: 17:56

Yeah, I feel like if someone's newly fatigued after starting the medicine, that's one thing. If they're chronically fatigued, there's other

Sarah: 18:03

Other factors into it.

Kerry: 18:04

Yeah, for sure. Very interesting. Okay, so you had the promise thing. Again, tell me sleep, anxiety, depression, that's what you're saying. I hadn't, heard much feedback on anxiety from anybody, but I have heard, some things about depression improving and things like that, but I've also heard, I think the opposite. Yeah.

Sarah: 18:23

I was very pleasantly surprised by that one. I wondered also, obviously this is me just inferring and drawing bias from it, but since they're qual, like they're less pain, less inflamed, they're feeling a little bit better that kind of improves that mental health. Component of it, of anxiety as well as depression.'cause a lot of the patients that I like initially asked or they filled out the survey and questionnaire when we chatted about it afterwards, they were like, yeah, I'm just like I can't do day-to-day tasks. And it makes them feel some type of way because they can't join their friends to go out or do something and then, this helps them a little bit. So it's not obviously going to cure their autoimmune disease, but it helps their symptom management.

Kerry: 19:06

Did anybody get to reduce medications of their auto, like the ones they were already on?

Sarah: 19:11

Yeah. I had, I can't remember the exact number. I'd have to look at my poster, but I had a good chunk of people, maybe not a good chunk, probably less than seven. But they reduced their either their levothyroxine, which is something that you take for your thyroid medication or their biologic dose went down for ra. Again. Is it because of that? Maybe. Possibly. Who knows? They felt a lot better. They're still on that reduced dose'cause they're still a patient of mine, just on either microdosing or low dosing of semaglutide. or they're on the steroid use was my biggest one. A lot of them mid, like probably month and a half-ish started reducing. They were finally able to titrate down on their steroid use. So whether they were on, like maybe a lot of them were on 20 milligrams, dropped it down to or sorry, five milligrams daily. But they would have burst packs that they would use when they would be feeling unwell and, I think I had my one patient finally said she had her first what is that called? Outbreak or,

Kerry: 20:14

flare.

Sarah: 20:15

For flare. She had her first flare since starting it. And usually she has three to four a year. I don't know if that was, a part of it, but it was very cool to see. So a lot of them reduced like whether they were taking every day, now they're taking it every other day, or they weren't having as many flares.

Kerry: 20:32

Yeah I'm sure that's the case. I'm thinking of these poor patients with PPMR polymyalgia rheumatica. Really the treatment is steroid. I just wonder,'cause this is in the autoimmune class, if, maybe treating in a different way could help them because they end up having some pretty significant metabolic outcomes because of the steroid need and some it takes sometimes a long time to get improvement on that. Oh man. I can think of so many different roles here, but what kind of things surprised you from your study? We, you mentioned some, but anything else you can think of?

Sarah: 21:04

Honestly, the low dose, I was, I really wanted to see if they could just, I didn't want a lot of people's big thing is like there isn't a lot of evidence about GLP ones quite yet in the sense of long-term use just because it hasn't been around for so long. So the biggest question I get is it safe to be on long-term? And obviously it's a medication. Any type of medication is going to have side effects. It's going to have adverse effects that we just maybe don't know, especially long term wise. We just don't have enough data for it. Surprising to me that these low doses helps these patients which was a win. And I was really excited to see that. And they had very much quality improvement, life changes that they could do. They were able to, go out with their friends and feel a little bit more like themselves and they're on a small dose. I know there haven't been a lot of studies for microdosing and even long-term use for it quite yet, just'cause it's a newer drug. But it makes me feel a little bit safer in the sense of they're able to continue this for a prolonged period of time on a smaller dose. So hopefully there's a little bit less adverse effects, side effects. Again, it's all we don't know yet,

Kerry: 22:14

Yeah,

Sarah: 22:15

it's nice to see.

Kerry: 22:16

we should say there is GLP ones have been around a while, but not 30 plus years if like liraglutide at least 10 years old, maybe a little bit more. So we do have, if that's long term, then we have that long-term data. But not. Like lisinopril, like a blood pressure medicine has been around forever. So that's a lot longer data. So we really still don't know the answer like you said, but I think it's, there's some long-term data out there, I think. Did you guys do any body composition or anything like that?

Sarah: 22:45

No, and I really wish we had. The scale we had it's not as exact as a full on body composition for you. It was mostly kind of one of those scales that kind of just checks biometrics of like water level muscle mass and those types of things. I was honing back, like things that I could improve on, obviously the lab factors, body composition and seeing like how their muscle mass or just different things improved. I wish I had done that or just invested, like I was so focused on like quality of life and those types of things that's where I was focusing, but I really wish I had done that.

Kerry: 23:20

That's why, we do these studies, you do one and then, do another, but to improve upon what you learned. But I mentioned that because as our body composition calculates visceral fat. And we associate visceral fat to be inflammatory. So I was wondering, maybe if they're visceral, fat went down, maybe that's also, why the inflammatory markers went down'cause the visceral fat, which is, the fat around the organs is, known to be where those inflammatory markers are coming in patients that have higher visceral fat numbers. So that would be cool. Something to add to it for sure. Also just maybe I know you said maybe you, you did measure muscle mass, but if the muscle mass got higher and I don't know. There's a lot. I think that could come from the from the body comp. If you could

Sarah: 24:02

I feel like there could be a whole study just on that. Like body

Kerry: 24:05

it could be, yeah. Yeah. Absolutely.

Sarah: 24:07

Yeah.

Kerry: 24:08

I feel like I had some more questions, but obviously I think your opinion on this question is gonna be obvious, but do GLP ones have effects beyond weight loss?

Sarah: 24:18

Absolutely. I think there's so much more to GLP ones than just weight loss. Obviously diabetic component as well, but I think there's so much more that it can help so many other patients, not just with diabetes or for weight management. And it's exciting to be on the verge of science to see all of this and hopefully see those improvements that GLP ones can do.

Kerry: 24:40

Yeah, I feel like there's probably lots of these little studies going on with a small sample size and figuring out what else can these, amazing drugs be helpful for. It's pretty exciting. I think, as I have a patient who has mast cell activation syndrome, and there's been a guy who wrote I don't know he had a similar case study approach and that is a very inflammatory condition. And honestly, our one patient that's on it right now is off all of her mcass meds. It's amazing. Yeah. So if we can find out, sometimes an FDA approved comorbidity, if you will, which is just another problem the patient has to get it prescribed, I guess through the brand medicine, I think, it's a nice extra way to help them with the other problem that they're probably more worried about. Yeah.'cause of quality of life. Very cool. So anything else that you left out on your pretty awesome study here?

Sarah: 25:36

No I can't think of anything. I was just really happy that the microdosing had such an impact that it did. I was, that was probably my favorite part, that you don't need such high dosing to have certain impacts, like the smaller dosing microdosing.'cause a lot of times people are like, I need to go up. I need to go up. But smaller dosing was having a good impact. Again, it's very patient dependent, but it was cool to see.

Kerry: 26:00

Yeah. I know a lot of people hate on that microdosing term, but after you do like studies like this, we know that there's real benefit in this.

Sarah: 26:08

Absolutely.

Kerry: 26:09

In these medicines. So I think that's important. So what you think you're gonna do another study or

Sarah: 26:17

I'm gonna hopefully get this one published.

Kerry: 26:19

Okay, that's, yeah.

Sarah: 26:21

Maybe after that it's a pretty rigorous, the publishing process. I was not aware of how much feedback they give you each time, but yes, ideally I would love to do another one maybe on GLP ones and hone in on certain things that I didn't exactly do on this one, differently

Kerry: 26:39

Cool. Give me one anti-inflammatory habit. Everyone should start.

Sarah: 26:46

one and. Do something probably for your diet. Do it consistently. Not necessarily always a hundred percent, but just do it every single day. It doesn't have to be such a huge change, but do it consistently daily.

Kerry: 27:03

Consistency, I think is a really big part of everything. I've definitely had other podcasts, guests, and myself focus on consistency. That's awesome. What is your favorite Texas food

Sarah: 27:15

My favorite Texas food. Oh, barbecue.

Kerry: 27:17

Barbecue. Very good. Awesome.

Sarah: 27:20

Always.

Kerry: 27:21

I don't know if I've had Texas barbecue. We've had North Carolina Barbecue, Missouri Barbecue.

Sarah: 27:26

to my parents' ranch.

Kerry: 27:28

Nice. All right. Do you have any other advice or anything else for our listeners today?

Sarah: 27:34

No, I'm all set.

Kerry: 27:36

All right. This was

Sarah: 27:37

to be here. Thank you.

Kerry: 27:38

Yes. Thank you so much for coming on the podcast and telling us about your research and good luck on getting it published. And we'd love to have you back someday. I'm sure I'll make you get on this podcast again.

Sarah: 27:49

Of course.

Kerry: 27:50

Bye everybody. Have a good day. Okay, take care.