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Treatment of arthritis associated with inflammatory bowel disease

Author
Robert D Inman, MD, FRCPC, FACP, FRCP Edin
Section Editor
Joachim Sieper, MD
Deputy Editor
Paul L Romain, MD

INTRODUCTION

Arthritis is a recognized extraintestinal manifestation of several illnesses and conditions, including inflammatory bowel disease (IBD) and other disorders. Management of this condition has similarities to the treatment of other forms of spondyloarthritis; it is complicated by the need to coordinate treatment interventions with those needed for concurrent inflammation of the gut due to the Crohn disease or ulcerative colitis that is also present. Other illnesses also have a propensity for causing inflammation of joints and the gut.

The treatment of arthritis associated with IBD is presented here. The clinical manifestations, diagnosis, and differential diagnosis of IBD-associated arthritis; and the pathogenesis, other clinical manifestations, diagnosis, and management of inflammatory bowel disease, including Crohn disease and ulcerative colitis, are reviewed in detail separately. (See "Clinical manifestations and diagnosis of arthritis associated with inflammatory bowel disease and other gastrointestinal diseases" and "Clinical manifestations and diagnosis of arthritis associated with inflammatory bowel disease and other gastrointestinal diseases", section on 'Other diseases with bowel and joint involvement' and "Immune and microbial mechanisms in the pathogenesis of inflammatory bowel disease" and "Clinical manifestations, diagnosis and prognosis of Crohn disease in adults" and "Clinical manifestations, diagnosis, and prognosis of ulcerative colitis in adults" and "Management of severe ulcerative colitis in adults" and "Overview of the medical management of mild to moderate Crohn disease in adults".)

TREATMENT APPROACH

The approach to the treatment of arthritis associated with inflammatory bowel disease (IBD) (algorithm 1) is very similar to and derived from the treatment of other forms of spondyloarthritis (SpA). Thus, it includes the use of nonsteroidal antiinflammatory drugs (NSAIDs) for initial therapy for peripheral and axial disease; selected conventional nonbiologic disease-modifying antirheumatic drugs (DMARDs) for peripheral arthritis resistant to initial therapy, if biologics are not already required for axial or gastrointestinal disease manifestations; and tumor necrosis factor (TNF) inhibitors for peripheral arthritis resistant to conventional nonbiologic DMARDs and for axial disease resistant to NSAIDs. (See 'Management of peripheral arthritis' below and 'Management of spondylitis and sacroiliitis' below.)

There is relatively limited direct evidence to support the efficacy of these or other treatment options for IBD-related arthritis. Support for this approach is largely indirect, derived from trials and observational studies involving patients with peripheral and axial SpA who have been diagnosed with ankylosing spondylitis, psoriatic arthritis, and other forms of SpA. Our approach is also generally consistent with expert opinion on the management of patients with coexisting SpA and IBD, as expressed by a multidisciplinary panel of specialists [1]. (See "Assessment and treatment of ankylosing spondylitis in adults" and "Treatment of peripheral spondyloarthritis" and "Treatment of psoriatic arthritis".)

Effective treatment of the underlying IBD is often helpful in controlling the peripheral arthritis; in addition, it is not uncommon for the gastroenterologist to initiate glucocorticoids or TNF inhibitor therapy primarily for the IBD, which then also reduces the activity of the musculoskeletal symptoms concurrently. (See "Overview of the medical management of mild to moderate Crohn disease in adults" and "Overview of the medical management of severe or refractory Crohn disease in adults" and "Management of mild to moderate ulcerative colitis in adults" and "Management of severe ulcerative colitis in adults".)

                 
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Literature review current through: Sep 2017. | This topic last updated: Sep 26, 2017.
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