Treatment of arthritis associated with inflammatory bowel disease
- Robert D Inman, MD, FRCPC, FACP, FRCP Edin
Robert D Inman, MD, FRCPC, FACP, FRCP Edin
- Professor of Medicine and Immunology
- University of Toronto
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".)
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 . (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".)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Olivieri I, Cantini F, Castiglione F, et al. Italian Expert Panel on the management of patients with coexisting spondyloarthritis and inflammatory bowel disease. Autoimmun Rev 2014; 13:822.
- Lakatos PL, Lakatos L, Kiss LS, et al. Treatment of extraintestinal manifestations in inflammatory bowel disease. Digestion 2012; 86 Suppl 1:28.
- De Keyser F, Van Damme N, De Vos M, et al. Opportunities for immune modulation in the spondyloarthropathies with special reference to gut inflammation. Inflamm Res 2000; 49:47.
- Rispo A, Scarpa R, Di Girolamo E, et al. Infliximab in the treatment of extra-intestinal manifestations of Crohn's disease. Scand J Rheumatol 2005; 34:387.
- Caprilli R, Gassull MA, Escher JC, et al. European evidence based consensus on the diagnosis and management of Crohn's disease: special situations. Gut 2006; 55 Suppl 1:i36.
- Fornaciari G, Salvarani C, Beltrami M, et al. Muscoloskeletal manifestations in inflammatory bowel disease. Can J Gastroenterol 2001; 15:399.
- Herfarth H, Obermeier F, Andus T, et al. Improvement of arthritis and arthralgia after treatment with infliximab (Remicade) in a German prospective, open-label, multicenter trial in refractory Crohn's disease. Am J Gastroenterol 2002; 97:2688.
- Van Bodegraven AA, Peña AS. Treatment of Extraintestinal Manifestations in Inflammatory Bowel Disease. Curr Treat Options Gastroenterol 2003; 6:201.
- Leirisalo-Repo M, Turunen U, Stenman S, et al. High frequency of silent inflammatory bowel disease in spondylarthropathy. Arthritis Rheum 1994; 37:23.
- Smale S, Natt RS, Orchard TR, et al. Inflammatory bowel disease and spondylarthropathy. Arthritis Rheum 2001; 44:2728.
- Takeuchi K, Smale S, Premchand P, et al. Prevalence and mechanism of nonsteroidal anti-inflammatory drug-induced clinical relapse in patients with inflammatory bowel disease. Clin Gastroenterol Hepatol 2006; 4:196.
- Biancone L, Tosti C, Geremia A, et al. Rofecoxib and early relapse of inflammatory bowel disease: an open-label trial. Aliment Pharmacol Ther 2004; 19:755.
- O'Brien J. Nonsteroidal anti-inflammatory drugs in patients with inflammatory bowel disease. Am J Gastroenterol 2000; 95:1859.
- Miao XP, Li JS, Ouyang Q, et al. Tolerability of selective cyclooxygenase 2 inhibitors used for the treatment of rheumatological manifestations of inflammatory bowel disease. Cochrane Database Syst Rev 2014; :CD007744.
- Sandborn WJ, Stenson WF, Brynskov J, et al. Safety of celecoxib in patients with ulcerative colitis in remission: a randomized, placebo-controlled, pilot study. Clin Gastroenterol Hepatol 2006; 4:203.
- El Miedany Y, Youssef S, Ahmed I, El Gaafary M. The gastrointestinal safety and effect on disease activity of etoricoxib, a selective cox-2 inhibitor in inflammatory bowel diseases. Am J Gastroenterol 2006; 101:311.
- Kirsner JB, Shorter RG. Recent developments in "nonspecific" inflammatory bowel disease (first of two parts). N Engl J Med 1982; 306:775.
- Moshkowitz M, Oren R, Tishler M, et al. The absorption of low-dose methotrexate in patients with inflammatory bowel disease. Aliment Pharmacol Ther 1997; 11:569.
- Varkas G, Thevissen K, De Brabanter G, et al. An induction or flare of arthritis and/or sacroiliitis by vedolizumab in inflammatory bowel disease: a case series. Ann Rheum Dis 2017; 76:878.
- Van den Bosch F, Kruithof E, De Vos M, et al. Crohn's disease associated with spondyloarthropathy: effect of TNF-alpha blockade with infliximab on articular symptoms. Lancet 2000; 356:1821.
- Generini S, Giacomelli R, Fedi R, et al. Infliximab in spondyloarthropathy associated with Crohn's disease: an open study on the efficacy of inducing and maintaining remission of musculoskeletal and gut manifestations. Ann Rheum Dis 2004; 63:1664.
- Marzo-Ortega H, McGonagle D, O'Connor P, Emery P. Efficacy of etanercept for treatment of Crohn's related spondyloarthritis but not colitis. Ann Rheum Dis 2003; 62:74.
- Sandborn WJ, Hanauer SB, Katz S, et al. Etanercept for active Crohn's disease: a randomized, double-blind, placebo-controlled trial. Gastroenterology 2001; 121:1088.
- TREATMENT APPROACH
- MANAGEMENT OF PERIPHERAL ARTHRITIS
- Initial peripheral arthritis therapy/NSAIDs
- Inadequate response to NSAIDs
- - Sulfasalazine
- - Alternatives to SSZ
- Use of TNF inhibitors in patients resistant to conventional DMARDs
- Resistant to initial TNF inhibitor
- Role of glucocorticoids
- MANAGEMENT OF SPONDYLITIS AND SACROILIITIS
- Initial treatment of axial disease
- Resistant to initial therapy for axial symptoms
- MANAGEMENT OF ENTHESITIS AND DACTYLITIS
- MONITORING AND DURATION OF THERAPY
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS