eMedicine Specialties > Rheumatology > Spondyloarthropathies
Enteropathic Arthropathies: Treatment & Medication
Updated: Dec 5, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
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.
Adult
50-75 mg PO bid
Pediatric
1.5-3.0 mg/kg/d PO divided bid/tid
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
Documented hypersensitivity to NSAIDs or aspirin; peptic ulcer disease, recent GI bleed or perforation; renal insufficiency, anticoagulation, coagulopathy
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.
Adult
100-200 mg PO qd
Pediatric
Not established
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
Documented hypersensitivity
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.
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
Sulfasalazine absorption may be reduced by coadministration of oral iron
Documented hypersensitivity to sulfasalazine, sulfonamides, or salicylates; porphyria (may precipitate acute exacerbations)
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.
Adult
7.5-25 mg PO/SC qwk; gradually adjust dose to attain satisfactory response
Pediatric
5-15 mg/m2/wk PO/SC qwk
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
Documented hypersensitivity; alcoholism; hepatic disease; documented immunodeficiency syndrome; preexisting blood dyscrasias (eg, bone marrow hypoplasia, leukopenia, thrombocytopenia, significant anemia)
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.
Adult
5 mg/kg as single IV infusion administered at weeks 0, 2, 6, then q6wk
Pediatric
Not established
None reported
Documented hypersensitivity; active infection; history of demyelinating disease (MS); noncompensated CHF; SLE
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.
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
None reported
Documented hypersensitivity; sepsis; concurrent live vaccination; active infection; history of demyelinating disease (MS); noncompensated CHF; SLE
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.
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
None reported
Documented hypersensitivity; active infection; history of demyelinating disease (MS); noncompensated CHF; SLE
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
More on Enteropathic Arthropathies |
| Overview: Enteropathic Arthropathies |
| Differential Diagnoses & Workup: Enteropathic Arthropathies |
 Treatment & Medication: Enteropathic Arthropathies |
| Follow-up: Enteropathic Arthropathies |
| References |
| « Previous Page | Next Page » |
References
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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].
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Further Reading
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
