eMedicine Specialties > Rheumatology > Spondyloarthropathies

Enteropathic Arthropathies

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

Updated: Dec 5, 2008

Introduction

Background

Enteropathic arthropathies comprise a collection of rheumatologic conditions that share a link to GI pathology. These conditions include reactive (ie, infection-related) arthritis caused by bacteria (eg, Shigella, Salmonella, Campylobacter, Yersinia species, Clostridium difficile), parasitic infections (eg, Strongyloides stercoralis, Giardia lamblia, Ascaris lumbricoides, Cryptosporidium species), and spondyloarthropathies associated with inflammatory bowel disease (IBD), Crohn disease, and ulcerative colitis.

Other associated conditions and disorders include intestinal bypass (jejunoileal) arthritis, celiac disease, Whipple disease, and collagenous colitis.

Pathophysiology

The precise causes of enteropathic arthropathies are unknown. Inflammation of the GI tract may increase permeability, resulting in absorption of antigenic material, including bacterial antigens. These arthrogenic antigens may then localize in musculoskeletal tissues (including entheses and synovium), thus eliciting an inflammatory response. Alternatively, an autoimmune response may be induced through molecular mimicry, in which the host's immune response to these antigens cross-reacts with self-antigens in synovium and other target organs.

Of particular interest is the strong association between reactive arthritis and HLA-B27, an HLA class I molecule. A potentially arthrogenic, bacterially derived antigen peptide could fit in the antigen-presenting groove of the B27 molecule, resulting in a CD8+ T-cell response. HLA-B27 transgenic rats develop features of enteropathic arthropathy with arthritis and gut inflammation.

Frequency

United States

Arthritis is the most common extraintestinal manifestation of IBD, with approximately 10%-20% of individuals with IBD developing peripheral arthritis and/or sacroiliitis/spondylitis. The incidence of ulcerative colitis is 6-8 cases per 100,000 population per year, and the prevalence is 70-150 cases per 100,000 population. The incidence of Crohn disease is 2 cases per 100,000 population per year, and the prevalence is 20-40 cases per 100,000 population. The incidence of IBD and, particularly, Crohn disease is increasing.

International

The incidence and prevalence rates of ulcerative colitis and Crohn disease in northern and Western Europe are similar to those in the United States, but rates are lower in other regions of the world.

Race

• The incidence of IBD is higher in whites, especially those of Jewish descent, than in other racial groups.

Sex

• The peripheral arthritis of ulcerative colitis or Crohn disease does not have a sexual predilection.
• Spondylitis is more common in males than in females.
• Whipple disease is more common in men, with a male-to-female ratio of 9:1.

Age

• IBD is most common in persons aged 15-35 years.

Clinical

History

• Axial arthritis (sacroiliitis and spondylitis) in inflammatory bowel disease (IBD)
  • Insidious onset of low back pain, especially in younger persons
  • Morning stiffness
  • Exacerbated by prolonged sitting or standing
  • Improved by moderate activity
  • Independent of GI symptoms
• Peripheral arthritis in IBD (colitic arthritis)
  • Oligoarticular
  • Asymmetric, predominantly involving the lower extremities
  • Associated with GI symptoms
  • Frequently transient and migratory, occasionally additive
  • More common in Crohn disease than ulcerative colitis
  • May precede intestinal involvement, but usually concomitant or subsequent to bowel disease
• Enthesitis
  • Heel - Insertion of Achilles tendon and plantar fascia
  • Knee - Tibial tuberosity, patella
  • Others - Buttocks, foot
• Extra-articular IBD
  • Intestinal - Abdominal pain, weight loss, diarrhea, and hematochezia
  • Skin -Pyoderma gangrenosum (ulcerative colitis), erythema nodosum (Crohn disease)
  • Oral -Aphthous ulcers (ulcerative colitis, Crohn disease)
  • Ocular - Acute anterior uveitis
  • Systemic low-grade fever, secondary amyloidosis (Crohn disease)
• Reactive arthritis
  • Typically an acute asymmetric oligoarthritis
  • Knees and/or ankles
  • Appears up to several weeks after the initial enteric infection (certain species of Yersinia, Salmonella, Shigella, Campylobacter, among others)
• Intestinal bypass arthritis
  • This is a procedure introduced for morbid obesity (jejunocolostomy or jejunoileostomy).
  • Arthritis develops in 20-80% of patients 2-30 months after surgery and is chronic in 25% of cases.
  • Polyarthritis may occur.
  • Dermatitis is associated in 66-80% of cases.
  • The proposed mechanism is bacterial overgrowth in the bypassed bowel, which causes inflammation and synthesis of immune complexes.
  • Reversal of procedure produces permanent remission of symptoms.
• Celiac disease
  • Gluten-sensitive enteropathy
  • Arthritis uncommon
  • May precede diagnosis of celiac disease
  • Lumbar spine, hips, knees, shoulders
  • Usually symmetrical
  • Improves with gluten-free diet
• Collagenous colitis
  • Unknown cause
  • Linear deposition of collagen in the subepithelial layer of the colon
  • Watery diarrhea and colicky abdominal pain
  • Peripheral arthritis of hands and wrists, which may precede GI symptoms by years (10% of cases)
  • Arthritis improved by nonsteroidal anti-inflammatory drugs (NSAIDs)
• Whipple disease
  • Rare, multisystemic
  • Caused by infection with Tropheryma whippleii
  • Most common in middle-aged men
  • Diarrhea, weight loss, and malabsorption
  • Migratory polyarthritis in as many as 90% of cases, which may precede GI symptoms by years
  • Sacroiliitis (occasional)
  • Diagnosis via small-bowel biopsy
  • Symptoms improved by prolonged courses of antibiotics (eg, penicillin, tetracycline, erythromycin)

Physical

• Articular
  • Examine the joints for signs of inflammation and note the pattern and symmetry of involvement.
  • Test the spine for range of motion, flexibility, and sacroiliac tenderness.
  • Look for periarticular soft-tissue swelling and/or tenderness, especially at the heel (eg, enthesitis).
• Skin - Look for pyoderma gangrenosum (ulcerative colitis) and erythema nodosum (Crohn disease).
• Eyes - Look for acute anterior uveitis or conjunctivitis.

Causes

• Causes are unknown but are probably related to immune-mediated inflammation (see Pathophysiology).
• Sacroiliitis is associated with HLA-B27 (40%).
• Spondylitis associated is with HLA-B27 (60%).
• HLA-B27 is not associated with peripheral arthritis with the exception of reactive arthritis (80%).

Differential Diagnoses

Other Problems to Be Considered

Synovitis-acne-pustulosis-hyperostosis osteomyelitis (SAPHO) syndrome

Workup

Laboratory Studies

• Complete blood cell (CBC) count may reveal iron deficiency anemia, leukocytosis, and thrombocytosis.
• The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) concentration are usually elevated.
• Rheumatoid factor (RF) is absent.
• Anti-Saccharomyces cerevisiae antibodies (ASCA) may be helpful in the diagnosis of inflammatory bowel disease (IBD).¹
• Anti-endomysial and anti-tTG (transglutaminase) antibodies are usually elevated in celiac disease.
• Synovial fluid analysis shows mild-to-moderate inflammatory fluid, mononuclear cell predominance (often), negative cultures, and no crystals.

Imaging Studies

• Radiography
  • Anteroposterior pelvis or sacroiliac joints shows bilateral sacroiliitis, usually symmetric when associated with IBD.
  • The spine shows syndesmophytes and apophyseal joint involvement. Bamboo spine is uncommon.
  • Erosive disease is uncommon in the peripheral joints, but bony spurs at the heel (enthesitis) may be observed.
• MRI: This study is useful for early detection of spinal and sacroiliac lesions characteristic of the spondyloarthropathies.
• Bone scintigraphy: This study may show increased uptake in a typical pauciarticular asymmetric joint pattern.
• Ultrasonography: This may be useful in identifying early soft-tissue pathology such as tenosynovitis.

Procedures

• Consider arthrocentesis if joint swelling or effusion is present, especially if concern about infection or crystal disease exists.
• Consider small-bowel biopsy upon clinical suspicion for Whipple disease or for celiac disease when serology findings are equivocal.
• Endoscopy and biopsy may reveal subclinical bowel inflammation in patients with spondyloarthropathy.

Treatment

Medical Care

• Treatment of inflammatory bowel disease (IBD), including surgery, alleviates the pain of peripheral arthritis.
• Exercise caution when administering NSAIDs to patients with IBD because these agents may exacerbate GI symptoms.
• With peripheral symptoms, administer corticosteroids for intra-articular and systemic use. These agents are not effective for axial involvement.
• Sulfasalazine is most widely used.
• Methotrexate and azathioprine are not as well studied. Check HIV status before initiation of either drug.
• Tumor necrosis factor (TNF) antagonists adalimumab and infliximab may be effective for both IBD and arthritis (including axial involvement).^2,3 Etanercept is indicated to treat ankylosing spondylitis but has not been shown to be helpful with bowel disease.
• Whipple disease is treated with long-term tetracycline antibiotics.
• Celiac disease is treated with a gluten-free diet.

Surgical Care

Treatment of IBD, including surgery, alleviates the pain of peripheral arthritis.

Consultations

• Gastroenterologist
• Rheumatologist
• Ophthalmologist

Diet

A gluten-free diet is used to treat celiac disease.

Activity

Order physical therapy to maintain flexibility, range of motion, and upright posture, especially with axial involvement.

Medication

Medications used to manage the enteropathic arthropathies include NSAIDs, corticosteroids, and second-line agents such as sulfasalazine, azathioprine, and methotrexate. TNF antagonists may also be used.

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

Corticosteroid agents may be given orally, intravenously, intramuscularly, or intra-articularly in patients in 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

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.

Indomethacin (Indocin, Indochron)

Traditionally used for the spondyloarthropathy and peripheral arthritis associated with ankylosing spondylitis but has not been proven to be superior in efficacy or safety profile compared to other NSAIDs.

Dosing

Adult

50-75 mg PO bid

Pediatric

1.5-3.0 mg/kg/d PO divided bid/tid

Interactions

Coadministration with ACE inhibitors, angiotensin II receptor blockers, and potassium-sparing diuretics may result in hyperkalemia; coadministration with warfarin may increase PT because of displacement of warfarin from plasma proteins and may aggravate bleeding tendency because of antiplatelet effect of NSAIDs; may decrease the effect of diuretics

Contraindications

Documented hypersensitivity to NSAIDs or aspirin; peptic ulcer disease, recent GI bleed or perforation; renal insufficiency, anticoagulation, coagulopathy

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

The most common toxicities include GI manifestations such as nausea, abdominal pain, peptic ulcer disease and renal insufficiency; may cause increased blood pressure in patients with hypertension because of blunting effects of antihypertensive medications; patients with congestive heart failure may have exacerbations due to fluid and sodium retention; closely monitor renal function in patients with diabetes mellitus

Celecoxib (Celebrex)

Primarily inhibits COX-2. COX-2 is considered an inducible isoenzyme, 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 lowest dose for each patient. Has a sulfonamide chain and depends primarily on cytochrome P450 enzymes (a hepatic enzyme) for metabolism.

Dosing

Adult

100-200 mg PO qd

Pediatric

Not established

Interactions

Coadministration with fluconazole may cause increase in celecoxib plasma concentrations because of inhibition of celecoxib metabolism; coadministration of celecoxib with rifampin may decrease celecoxib plasma concentrations

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

May cause increased blood pressure in patients with hypertension because of blunting effects of antihypertensive medications; patients with congestive heart failure may have exacerbations due to fluid and sodium retention; closely monitor renal function in patients with diabetes mellitus

Immunosuppressants

These are second-line agents generally used for more aggressive disease inadequately controlled by NSAIDs and corticosteroids or as steroid-sparing agents. Because of their complex toxicities, second-line agents require administration and monitoring by an experienced physician/specialist.

Sulfasalazine (Azulfidine, EN-tabs)

Shown to reduce the peripheral inflammatory symptoms of spondyloarthropathies. Relatively safe, but toxicities (eg, GI, hypersensitivity) are common.

Dosing

Adult

500 mg PO bid (with food) initially for 1 wk; increase dose by 500 mg/d each wk until a dose of 1500-3000 mg/d divided bid/tid or clinical improvement is reached

Pediatric

40-60 mg/kg/d PO divided bid/tid doses

Interactions

Sulfasalazine absorption may be reduced by coadministration of oral iron

Contraindications

Documented hypersensitivity to sulfasalazine, sulfonamides, or salicylates; porphyria (may precipitate acute exacerbations)

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

May cause nausea, dyspepsia, vomiting; avoid in G-6-PD deficiency; may rarely cause blood dyscrasias or liver problems; caution in renal or hepatic impairment; may cause yellow/orange discoloration of skin/sweat/urine; warn about potential severe skin rash

Methotrexate (Rheumatrex, Folex PFS)

Unknown mechanism of action in treatment of inflammatory reactions; may affect immune function. Ameliorates symptoms of inflammation with peripheral disease.

Dosing

Adult

7.5-25 mg PO/SC qwk; gradually adjust dose to attain satisfactory response

Pediatric

5-15 mg/m²/wk PO/SC qwk

Interactions

Oral aminoglycosides may decrease absorption and blood levels of concurrent oral methotrexate; charcoal lowers levels; coadministration with etretinate may increase hepatotoxicity; indomethacin and phenylbutazone can increase methotrexate plasma levels; may decrease phenytoin serum levels; probenecid, salicylates, procarbazine, and sulfonamides, including TMP-SMZ, may increase effects and toxicity of methotrexate; may increase plasma levels of thiopurine

Contraindications

Documented hypersensitivity; alcoholism; hepatic disease; documented immunodeficiency syndrome; preexisting blood dyscrasias (eg, bone marrow hypoplasia, leukopenia, thrombocytopenia, significant anemia)

Precautions

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

Toxic effects on hematologic, GI, pulmonary, and neurological systems; caution in active infection, bone marrow suppression, underlying parenchymal lung disease; monitor CBC counts and liver and renal function q1-3mo during therapy (monitor more frequently during initial dosing, dose adjustments, or with risk of elevated methotrexate levels, eg, dehydration); concomitant aspirin, NSAIDs, or low-dose steroids may be safely administered with methotrexate

Tumor necrosis factor antagonists

After NSAIDs and physical therapy, TNF inhibitors are uniquely recommended as the next line of treatment for inflammatory spinal disease in ankylosing spondylitis and the associated spondyloarthropathies. As with the second-line medications, these agents also reduce inflammatory signs and symptoms of peripheral disease.

Infliximab (Remicade)

Chimeric monoclonal antibody. Neutralizes cytokine TNF-alpha and inhibits its binding to TNF-alpha receptor. Has GI indications for fistulous Crohn disease and ulcerative colitis and rheumatologic indications for rheumatoid arthritis, psoriatic arthritis (and psoriasis), and ankylosing spondylitis. Shown to be effective for extra-articular manifestations such as refractory uveitis and pyoderma gangrenosum.

Dosing

Adult

5 mg/kg as single IV infusion administered at weeks 0, 2, 6, then q6wk

Pediatric

Not established

Interactions

None reported

Contraindications

Documented hypersensitivity; active infection; history of demyelinating disease (MS); noncompensated CHF; SLE

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

TNF-alpha modulates cellular immune responses; anti-TNF therapies, such as infliximab, may adversely affect normal immune responses and allow development of superinfections; patients should be screened for previous TB exposure and treated appropriately; caution advised in patients with history of malignancy

Etanercept (Enbrel)

A fusion receptor protein that blocks TNF activity. Inhibits TNF binding to cell surface receptors, decreasing inflammatory and immune responses. Indicated for ankylosing spondylitis, psoriatic arthritis, psoriasis, RA, and JRA.

Dosing

Adult

50 mg SC qwk or 25 mg twice weekly

Pediatric

<4 years: Not established
>4 years with active polyarticular-course JRA: 0.8 mg/kg/wk SC (up to a maximum of 50 mg/wk)

Alternatively:<31 kg (68 lb): Single 0.8 mg/kg/wk SC injection
31-62 kg (68-136 lb): 0.8 mg/kg SC 2 times/wk either on same day or 3-4 d apart
>63 kg (138 lb): Weekly dose of 50 mg SC

Interactions

None reported

Contraindications

Documented hypersensitivity; sepsis; concurrent live vaccination; active infection; history of demyelinating disease (MS); noncompensated CHF; SLE

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Serious infections may develop and the therapy should be discontinued if they occur; possible adverse effects include injection-site pain, redness and swelling at injection site, and headaches; rare cases of lupuslike symptoms and heart failure have been reported (discontinue treatment if symptoms develop); caution advised in patients with history of malignancy

Adalimumab (Humira)

Recombinant human IgG1 monoclonal antibody specific for human TNF. Indicated to reduce inflammation and inhibit progression of structural damage in moderate-to-severe rheumatoid arthritis.

Dosing

Adult

40 mg SC q2wk; may be increased to qwk if clinical response inadequate
Recommended HUMIRA dose regimen for adult patients with Crohn disease: 160 mg initially on day 1 (given as four 40-mg injections in one day or as two 40-mg injections/d for 2 consecutive days), followed by 80 mg 2 wk later (day 15); 2 weeks later (day 29), begin a maintenance dose of 40 mg qowk

Pediatric

Not established

Interactions

None reported

Contraindications

Documented hypersensitivity; active infection; history of demyelinating disease (MS); noncompensated CHF; SLE

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

TNF-alpha modulates cellular immune responses; anti-TNF therapies, such as infliximab, may adversely affect normal immune responses and allow development of superinfections; patients should be screened for previous TB exposure and treated appropriately; caution advised in patients with history of malignancy

Follow-up

Further Outpatient Care

• Arrange follow-up care with a rheumatologist and gastroenterologist.

Complications

• Mainly related to inflammatory bowel disease (IBD)
• Chronic arthritis, occasionally extra-articular involvement (uveitis)
• Secondary amyloidosis (mainly with Crohn disease)
• Toxicity of therapy

Prognosis

• Depends mainly on prognosis of underlying GI disease
• Severe spinal inflammatory disease (rare)

Patient Education

• Patients must be counseled to continue exercises at home.
• eMedicine has excellent patient education resources regarding inflammatory bowel disease available at http://www.emedicinehealth.com/articles/40954-1.asp.
• eMedicine has excellent patient education resources regarding Crohn disease available at http://www.emedicinehealth.com/collections/crohn.asp.

Miscellaneous

Medicolegal Pitfalls

• The main pitfall is administering medications without proper monitoring for potential toxicities.

References

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

2. 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. Dec 2004;63(12):1664-9. [Medline].

3. 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. Mar 2002;46(3):755-65. [Medline].

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

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

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

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

8. 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. Dec 2006;65(12):1631-4. [Medline].

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

10. 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. Sep 2008;42 Suppl 3 Pt 1:S136-41. [Medline].

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

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

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

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

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

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

Keywords

enteropathic arthropathy, enteropathic arthropathies, reactive arthritis, Shigella, Salmonella, Campylobacter, Yersinia, Clostridium difficile, C difficile, intestinal parasites, Strongyloides stercoralis, S stercoralis, Taenia saginata, T saginata, Giardia lamblia, G lamblia, Ascaris lumbricoides, A lumbricoides, Cryptosporidium, inflammatory bowel disease, Crohn disease, Crohn’s disease, IBD, jejunoileal intestinal bypass, celiac disease, Whipple disease, Whipple’s disease, collagenous colitis, HLA-B27, sacroiliitis, spondylitis, peripheral arthritis, colitic arthritis, axial arthritis, sacroiliitis, spondylitis

Contributor Information and Disclosures

Author

Pierre Minerva, MD, Consulting Staff, Department of Rheumatology, Bryn Mawr Medical Specialists Association; Consulting Staff, Department of Rheumatology, Bryn Mawr Hospital, Lankenay Hospital, Paoli Hospital
Pierre Minerva, MD is a member of the following medical societies: American College of Rheumatology
Disclosure: Nothing to disclose.

Medical Editor

Kristine M Lohr, MD, MS, Program Director, Professor, Department of Internal Medicine, Division of Rheumatology and Women's Health, University of Kentucky School of Medicine
Kristine M Lohr, MD, MS is a member of the following medical societies: American College of Physicians, American College of Rheumatology, and American Medical Women's Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Lawrence H Brent, MD, Associate Professor of Medicine, 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 of Immunologists, American College of Physicians, and American College of Rheumatology
Disclosure: Genentech Honoraria Speaking and teaching; Genentech Grant/research funds Other; Amgen Honoraria Speaking and teaching; Wyeth Honoraria Speaking and teaching; Abbott Immunology Honoraria Speaking and teaching

CME Editor

Alex J Mechaber, MD, FACP, Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Herbert S Diamond, MD, Professor of Medicine, Temple University School of Medicine; 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, and Phi Beta Kappa
Disclosure: medifocus Honoraria Review panel membership; health dialogs Honoraria Consulting; Merck, Amgen, Biogen, Zimmer, Wyeth, Johnson&Johnson, Stryker, Medtronic, Zimmer.Abbott,  Ownership interest Other; West Penn Allegheny Health System Consulting fee Consulting; Alpharma Honoraria Consulting; Proctor&Gamble Grant/research funds Independent contractor

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