Enteropathic Arthropathies Treatment & Management

Updated: Feb 16, 2021
  • Author: Pierre Minerva, MD; Chief Editor: Herbert S Diamond, MD  more...
  • Print

Approach Considerations

Treatment of inflammatory bowel disease (IBD), including surgery, should always be the initial strategy to induce remission of peripheral arthritis.

Although nonsteroidal anti-inflammatory drugs (NSAIDs) are usually recommended as first-line therapy for spondyloarthropathies, in patients with IBD, these agents may exacerbate gastrointestinal (GI) symptoms. [12] Selection of more cyclooxygenase-2 (COX-2)–selective NSAIDs may reduce the risk of bowel flares. [13, 14] Corticosteroids may be used systemically or by local injection.

Whipple disease is treated with long-term tetracycline antibiotics. Celiac disease is treated with a gluten-free diet, although response is not always complete.

Conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) 

Sulfasalazine (2-3g/day) has been shown to be effective for treatment of the peripheral arthropathy associated with IBD, but not axial disease. [15] While methotrexate can be useful to treat bowel activity in Crohn disease (CD), its effect on joint disease with IBD is less certain.

Biologic disease-modifying antirheumatic drugs (bDMARDs)

Although not specifically indicated for an enteropathic arthropathy, the tumor necrosis factor (TNF) antagonists infliximab and adalimumab are indicated to treat ankylosing spondylitis (AS) and IBD, and may be effective for IBD spondyloarthropathy (including axial involvement). [16, 17, 18, 19, 20]

In a cohort of 30 patients with enteropathic arthropathy affected by active articular and GI disease, or axial active articular inflammation, adalimumab led to sustained improvement of both articular and GI disease activities. Significant improvement was achieved at the earliest (6-mo) assessment and maintained at the 12-mo follow-up. [21]  

Etanercept and golimumab are indicated to treat AS, [22] but neither has been shown to be helpful with bowel disease, and there have been reports of new-onset IBD with these 2 agents. [23]  

Vedolizumab is approved for treatment of moderate to severe Crohn disease. A systematic review found evidence that it may be effective in preventing the onset of enteropathic anthropathy but there was no strong evidence for the efficacy of vedolizumab for treating existing arthritis. [24]

Surgical care

Total colectomy or removal of affected colon induces remission of the peripheral arthritis in ulcerative colitis (UC), but not in Crohn disease. Surgery provides no benefit for axial involvement in IBD.


Consultations with the following specialists can be beneficial:

  • Gastroenterologist
  • Rheumatologist
  • Ophthalmologist


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


Order physical therapy to maintain flexibility, range of motion, and upright posture, especially with axial involvement. Patients must be counseled to continue exercises at home.


Arrange follow-up care with a rheumatologist and gastroenterologist.