Medscape is available in 5 Language Editions – Choose your Edition here.


Enteropathic Arthropathies Medication

  • Author: Pierre Minerva, MD; Chief Editor: Herbert S Diamond, MD  more...
Updated: Dec 30, 2014

Medication Summary

If both bowel and joint disease are active, then agents that target both should be preferred choices. Medications used to manage the enteropathic arthropathies include nonsteroidal anti-inflammatory drugs (NSAIDs), cyclooxygenase-2 (COX-2) inhibitors, corticosteroids, second-line agents such as sulfasalazine, and tumor necrosis factor (TNF) antagonists.

The selection of a second-line agents should be left to an experienced rheumatologist or gastroenterologist who is familiar with these agents and the required monitoring.

Corticosteroids may be given orally, intravenously, intramuscularly, or intra-articularly to patients for whom NSAIDs alone are not adequate. Consult with a specialist who is familiar with corticosteroids before prescribing them for specific uses.


Nonsteroidal Anti-inflammatory Drugs, Oral

Class Summary

Nonsteroidal anti-inflammatory drugs (NSAIDs) are the initial choice of medication to control pain and inflammation related to enteropathic arthropathies. The potential benefits of this class of drugs must be weighed against the possibility that they may exacerbate the underlying GI disease. Several NSAIDs effectively treat this condition, and administration of any one of them is appropriate. Newer cyclooxygenase-2 (COX-2) inhibitors may be less toxic to the GI tract.[8, 9]

Celecoxib (Celebrex)


Celecoxib primarily inhibits COX-2. COX-2 is considered an inducible isoenzyme, being induced by pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited; thus, incidence of GI toxicity, such as endoscopic peptic ulcers, bleeding ulcers, perforations, and obstructions, may be decreased when compared with nonselective NSAIDs.

Seek the lowest dose for each patient. Celecoxib has a sulfonamide chain and depends primarily on cytochrome P450 enzymes (which are hepatic enzymes) for metabolism.

Meloxicam (Mobic)


Meloxicam decreases the activity of COX, which, in turn, inhibits prostaglandin synthesis. These effects decrease the formation of inflammatory mediators.


5-aminosalicylic Acid Derivative

Class Summary

A second-line agent may be considered for articular disease inadequately controlled by nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids or it may be considered as a steroid-sparing agent. Because of their complex toxicities, second-line agents require administration and monitoring by an experienced medical specialist.

Sulfasalazine (Azulfidine)


Sulfasalazine has been shown to reduce inflammatory symptoms of ankylosing spondylitis (AS) in controlled studies. The most common toxicities include nausea, dyspepsia, vomiting, diarrhea, and hypersensitivity reactions (rash).


DMARDs, TNF Inhibitors

Class Summary

After nonsteroidal anti-inflammatory drugs (NSAIDs) and physical therapy, tumor necrosis factor (TNF) inhibitors are uniquely recommended as the next line of treatment for inflammatory spinal disease and enthesopathy, although they can be effective for all aspects of articular disease.[14] Specific agents may vary in their effectiveness against bowel disease activity; furthermore, new-onset inflammatory bowel disease (IBD) has been described in patients with ankylosing spondylitis (AS) who were treated with TNF antagonists.[13, 15]

Infliximab (Remicade)


Infliximab is a chimeric monoclonal antibody. It neutralizes the cytokine TNF-alpha and inhibits its binding to the TNF-alpha receptor. Infliximab has GI indications for fistulous Crohn disease (CD) and ulcerative colitis (UC) and rheumatologic indications for rheumatoid arthritis, psoriatic arthritis (and psoriasis), and AS. It has been shown to be effective for extra-articular manifestations, such as refractory uveitis and pyoderma gangrenosum.

Etanercept (Enbrel)


Etanercept is a fusion receptor protein that blocks TNF activity. It inhibits the binding of TNF to cell surface receptors, decreasing inflammatory and immune responses. Etanercept is indicated for AS, psoriatic arthritis, psoriasis, rheumatoid arthritis, and juvenile rheumatoid arthritis.

Adalimumab (Humira)


Adalimumab is a recombinant human immunoglobulin-G1 (IgG1) monoclonal antibody specific for human TNF. It is indicated for moderate to severe rheumatoid arthritis, psoriatic arthritis, AS, and CD.

Golimumab (Simponi)


Golimumab is a TNF-alpha inhibitor. It decreases inflammation caused by the overproduction of TNF associated with chronic inflammatory diseases. Golimumab is indicated for moderate to severe rheumatoid arthritis, active psoriatic arthritis, and active AS. It is available as the 50 mg/0.5 mL, single-dose Simponi SmartJect (Autoinjector) or as a prefilled syringe.

Contributor Information and Disclosures

Pierre Minerva, MD Consulting Staff, Department of Rheumatology, Bryn Mawr Medical Specialists Association; Consulting Staff, Department of Rheumatology, Bryn Mawr Hospital, Lankenau Hospital, Paoli Hospital

Pierre Minerva, MD is a member of the following medical societies: American College of Rheumatology

Disclosure: Nothing to disclose.

Chief Editor

Herbert S Diamond, MD Visiting Professor of Medicine, Division of Rheumatology, State University of New York Downstate Medical Center; Chairman Emeritus, Department of Internal Medicine, Western Pennsylvania Hospital

Herbert S Diamond, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American College of Rheumatology, American Medical Association, Phi Beta Kappa

Disclosure: Nothing to disclose.


Lawrence H Brent, MD Associate Professor of Medicine, Jefferson Medical College of Thomas Jefferson University; Chair, Program Director, Department of Medicine, Division of Rheumatology, Albert Einstein Medical Center

Lawrence H Brent, MD is a member of the following medical societies: American Association for the Advancement of Science, American Association of Immunologists, American College of Physicians, and American College of Rheumatology

Disclosure: Abbott Honoraria Speaking and teaching; Centocor Consulting fee Consulting; Genentech Grant/research funds Other; HGS/GSK Honoraria Speaking and teaching; Omnicare Consulting fee Consulting; Pfizer Honoraria Speaking and teaching; Roche Speaking and teaching; Savient Honoraria Speaking and teaching; UCB Honoraria Speaking and teaching

Kristine M Lohr, MD, MS Professor, Department of Internal Medicine, Center for the Advancement of Women's Health and Division of Rheumatology, Director, Rheumatology Training Program, University of Kentucky College of Medicine

Kristine M Lohr, MD, MS is a member of the following medical societies: American College of Physicians and American College of Rheumatology

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

  1. Ajene AN, Fischer Walker CL, Black RE. Enteric pathogens and reactive arthritis: a systematic review of Campylobacter, salmonella and Shigella-associated reactive arthritis. J Health Popul Nutr. 2013 Sep. 31(3):299-307. [Medline]. [Full Text].

  2. Bourikas LA, Papadakis KA. Musculoskeletal Manifestations of Inflammatory Bowel Disease. Inflamm Bowel Dis. 2009 Dec. 15(12):1915-24. [Medline].

  3. Sofia MA, Rubin DT, Hou N, Pekow J. Clinical presentation and disease course of inflammatory bowel disease differs by race in a large tertiary care hospital. Dig Dis Sci. 2014 Sep. 59(9):2228-35. [Medline]. [Full Text].

  4. Orchard TR, Wordsworth BP, Jewell DP. Peripheral arthropathies in inflammatory bowel disease: their articular distribution and natural history. Gut. 1998 Mar. 42(3):387-91. [Medline]. [Full Text].

  5. Hoffman IE, Demetter P, Peeters M, et al. Anti-saccharomyces cerevisiae IgA antibodies are raised in ankylosing spondylitis and undifferentiated spondyloarthropathy. Ann Rheum Dis. 2003 May. 62(5):455-9. [Medline].

  6. Taddio A, Simonini G, Lionetti P, Lepore L, Martelossi S, Ventura A, et al. Usefulness of wireless capsule endoscopy for detecting inflammatory bowel disease in children presenting with arthropathy. Eur J Pediatr. 2011 Oct. 170(10):1343-7. [Medline].

  7. Takeuchi K, Smale S, Premchand P, Maiden L, Sherwood R, Thjodleifsson B. Prevalence and mechanism of nonsteroidal anti-inflammatory drug-induced clinical relapse in patients with inflammatory bowel disease. Clin Gastroenterol Hepatol. 2006 Feb. 4(2):196-202. [Medline].

  8. Sandborn WJ, Stenson WF, Brynskov J, Lorenz RG, Steidle GM, Robbins JL. Safety of celecoxib in patients with ulcerative colitis in remission: a randomized, placebo-controlled, pilot study. Clin Gastroenterol Hepatol. 2006 Feb. 4(2):203-11. [Medline].

  9. Mahadevan U, Loftus EV Jr, Tremaine WJ, Sandborn WJ. Safety of selective cyclooxygenase-2 inhibitors in inflammatory bowel disease. Am J Gastroenterol. 2002 Apr. 97(4):910-4. [Medline].

  10. Clegg DO, Reda DJ, Abdellatif M. Comparison of sulfasalazine and placebo for the treatment of axial and peripheral articular manifestations of the seronegative spondylarthropathies: a Department of Veterans Affairs cooperative study. Arthritis Rheum. 1999 Nov. 42(11):2325-9. [Medline].

  11. 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 Dec. 63(12):1664-9. [Medline].

  12. Van Den Bosch F, Kruithof E, Baeten D, et al. Randomized double-blind comparison of chimeric monoclonal antibody to tumor necrosis factor alpha (infliximab) versus placebo in active spondylarthropathy. Arthritis Rheum. 2002 Mar. 46(3):755-65. [Medline].

  13. Fiehn C, Vay S. Induction of inflammatory bowel disease flares by golimumab: report of three patients with enteropathic spondylarthritis or ankylosing spondylitis and comorbid colitis. Arthritis Rheum. 2011 Nov. 63(11):3640-1. [Medline].

  14. Barrie A, Regueiro M. Biologic therapy in the management of extraintestinal manifestations of inflammatory bowel disease. Inflamm Bowel Dis. 2007 Nov. 13(11):1424-9. [Medline].

  15. Braun J, Baraliakos X, Listing J, Davis J, van der Heijde D, Haibel H, et al. Differences in the incidence of flares or new onset of inflammatory bowel diseases in patients with ankylosing spondylitis exposed to therapy with anti-tumor necrosis factor alpha agents. Arthritis Rheum. 2007 May 15. 57(4):639-47. [Medline].

  16. Brophy S, Pavy S, Lewis P, et al. Inflammatory eye, skin, and bowel disease in spondyloarthritis: genetic, phenotypic, and environmental factors. J Rheumatol. 2001 Dec. 28(12):2667-73. [Medline].

  17. Colombo E, Latiano A, Palmieri O, Bossa F, Andriulli A, Annese V. Enteropathic spondyloarthropathy: a common genetic background with inflammatory bowel disease?. World J Gastroenterol. 2009 May 28. 15(20):2456-62. [Medline]. [Full Text].

  18. De Keyser F, Elewaut D, De Vos M, et al. Bowel inflammation and the spondyloarthropathies. Rheum Dis Clin North Am. 1998 Nov. 24(4):785-813, ix-x. [Medline].

  19. Ellman MH, Hanauer S, Sitrin M, Cohen R. Crohn's disease arthritis treated with infliximab: an open trial in four patients. J Clin Rheumatol. 2001 Apr. 7(2):67-71. [Medline].

  20. Fomberstein B, Yerra N, Pitchumoni CS. Rheumatological complications of GI disorders. Am J Gastroenterol. 1996 Jun. 91(6):1090-103. [Medline].

  21. Grigoryan M, Roemer FW, Mohr A, et al. Imaging in spondyloarthropathies. Curr Rheumatol Rep. 2004 Apr. 6(2):102-9. [Medline].

  22. Guignard S, Gossec L, Salliot C, et al. Efficacy of tumour necrosis factor blockers in reducing uveitis flares in patients with spondylarthropathy: a retrospective study. Ann Rheum Dis. 2006 Dec. 65(12):1631-4. [Medline].

  23. Herfarth H, Obermeier F, Andus T, Rogler G, Nikolaus S, Kuehbacher 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 Oct. 97(10):2688-90. [Medline].

  24. Holden W, Orchard T, Wordsworth P. Enteropathic arthritis. Rheum Dis Clin North Am. 2003 Aug. 29(3):513-30, viii. [Medline].

  25. Karimi O, Pena AS. Indications and challenges of probiotics, prebiotics, and synbiotics in the management of arthralgias and spondyloarthropathies in inflammatory bowel disease. J Clin Gastroenterol. 2008 Sep. 42 Suppl 3 Pt 1:S136-41. [Medline].

  26. Katz JP, Lichtenstein GR. Rheumatologic manifestations of gastrointestinal diseases. Gastroenterol Clin North Am. 1998 Sep. 27(3):533-62, v. [Medline].

  27. Kaufman I, Caspi D, Yeshurun D, Dotan I, Yaron M, Elkayam O. The effect of infliximab on extraintestinal manifestations of Crohn's disease. Rheumatol Int. 2005 Aug. 25(6):406-10. [Medline].

  28. Levine JS, Burakoff R. Extraintestinal manifestations of inflammatory bowel disease. Gastroenterol Hepatol (N Y). 2011 Apr. 7(4):235-41. [Medline].

  29. Mielants H, Veys EM. Enteropathic arthropathis. Hochberg MC, Silman AJ, Smolen JS, Weinblatt ME, Weisman MH. Rheumatology. 4th. Mosby Elsevier; 2008. 1189-1195 / 113.

  30. Palm O, Moum B, Jahnsen J, et al. The prevalence and incidence of peripheral arthritis in patients with inflammatory bowel disease, a prospective population-based sudy (the IBSEN study). Rheumatology. 2001. 40:1256-1261.

  31. Reveille JD. Epidemiology of spondyloarthritis in North America. Am J Med Sci. 2011 Apr. 341(4):284-6. [Medline]. [Full Text].

  32. Reveille JD, Arnett FC. Spondyloarthritis: update on pathogenesis and management. Am J Med. 2005 Jun. 118(6):592-603. [Medline].

  33. Szpalski M, Gunzburg R. What are the advances for surgical therapy of inflammatory diseases of the spine?. Best Pract Res Clin Rheumatol. 2002 Jan. 16(1):141-54. [Medline].

  34. Wollheim FA. Enteropathic arthritis: how do the joints talk with the gut?. Curr Opin Rheumatol. 2001 Jul. 13(4):305-9. [Medline].

  35. Wright V. Enteropathic arthritis. Cleve Clin J Med. 1994 Jan-Feb. 61(1):14-6; quiz 80-2. [Medline].

All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.