Enteropathic Arthropathies Medication
- Author: Pierre Minerva, MD; Chief Editor: Herbert S Diamond, MD more...
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
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 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 decreases the activity of COX, which, in turn, inhibits prostaglandin synthesis. These effects decrease the formation of inflammatory mediators.
5-aminosalicylic Acid Derivative
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 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
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. 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 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 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 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 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.
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