Sections

Treatment

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

Consultations with the following specialists can be beneficial:

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. Patients must be counseled to continue exercises at home.

Follow-up

Arrange follow-up care with a rheumatologist and gastroenterologist.

Medication

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Generali E, Bose T, Selmi C, Voncken JW, Damoiseaux JGMC. Nature versus nurture in the spectrum of rheumatic diseases: Classification of spondyloarthritis as autoimmune or autoinflammatory. Autoimmun Rev. 2018 Sep. 17 (9):935-941. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link]. [Full Text].
Conigliaro P, Chimenti MS, Ascolani M, Triggianese P, Novelli L, Onali S, et al. Impact of a multidisciplinary approach in enteropathic spondyloarthritis patients. Autoimmun Rev. 2016 Feb. 15 (2):184-90. [QxMD MEDLINE Link].
Bourikas LA, Papadakis KA. Musculoskeletal Manifestations of Inflammatory Bowel Disease. Inflamm Bowel Dis. 2009 Dec. 15(12):1915-24. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link]. [Full Text].
Generali E, Ceribelli A, Massarotti M, Cantarini L, Selmi C. Seronegative reactive spondyloarthritis and the skin. Clin Dermatol. 2015 Sep-Oct. 33 (5):531-7. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Grigoryan M, Roemer FW, Mohr A, et al. Imaging in spondyloarthropathies. Curr Rheumatol Rep. 2004 Apr. 6(2):102-9. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Luchetti MM, Benfaremo D, Ciccia F, Bolognini L, Ciferri M, Farinelli A, et al. Adalimumab efficacy in enteropathic spondyloarthritis: A 12-mo observational multidisciplinary study. World J Gastroenterol. 2017 Oct 21. 23 (39):7139-7149. [QxMD MEDLINE Link]. [Full Text].
Dougados M, van der Heijde D, Sieper J, Braun J, Citera G, Lenaerts J, et al. Effects of Long-Term Etanercept Treatment on Clinical Outcomes and Objective Signs of Inflammation in Early Nonradiographic Axial Spondyloarthritis: 104-Week Results From a Randomized, Placebo-Controlled Study. Arthritis Care Res (Hoboken). 2017 Oct. 69 (10):1590-1598. [QxMD MEDLINE Link]. [Full Text].
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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. [QxMD MEDLINE Link].
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Author

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.

Acknowledgements

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

Enteropathic Arthropathies Treatment & Management

Approach Considerations

Conventional synthetic disease-modifying antirheumatic drugs (csDMARDs)

Biologic disease-modifying antirheumatic drugs (bDMARDs)

Surgical care

Consultations

Diet

Activity

Follow-up

References

Tables

Contributor Information and Disclosures

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