Spring 2017 (Volume 27, Number 1)
Top Ten Things Rheumatologists Should Know About the Inflammatory Bowel Diseases
By Heba M. Al-Farhan, MD, MRCP; and Gilaad G. Kaplan, MD, MPH, FRCPC
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Joint diseases are the most common extra-intestinal manifestations of the inflammatory bowel diseases (IBD), occurring in 13% of patients with Crohn’s disease (CD) or ulcerative colitis (UC).1 This article reviews considerations for patients with arthritis and a co-existing IBD diagnosis.
1. Peripheral arthritis associated with IBD.
Two different types of arthritis can be identified. Type 1 is non-erosive, asymmetrical, and affects less than five large joints. The arthritis is related to activity of the underlying bowel disease, potentially occurring prior to onset of bowel symptoms. The arthritis is managed by treating the acute flare of CD or UC. 2 Type 2 is polyarticular and symmetrical, and is less often correlated with bowel disease activity.
2. Axial arthropathy and IBD.
The risk of sacroiliitis and ankylosing spondylitis in IBD patients is 10% and 3%, respectively.1 Similarly, 4.1% of patients with ankylosing spondylitis will have a co-existing diagnosis of IBD.3 Treating the IBD does not influence the natural history of the axial arthritis.2
3. Investigating a new diagnosis of IBD.
Patients with spondyloarthritis may present with active gastrointestinal symptoms (e.g., abdominal pain, diarrhea, rectal bleeding). Non-IBD considerations include non-steroidal anti-inflammatory drug (NSAID) enteropathy, gastrointestinal infections including Clostridium difficile, and celiac disease.4
4. Diagnosing IBD.
Colonoscopy with biopsies is necessary for an IBD diagnosis. Modalities for imaging the small bowel include contrast-enhanced ultrasound, magnetic resonance (MR) enterography, and computed tomography (CT) enterography. General CT scans of the abdomen for IBD should be avoided unless ruling out an intestinal complication (e.g., perforation or obstruction).
5. Pain Management.
NSAIDs are associated with an increased risk of triggering a flare of IBD. Acetaminophen is safe for managing joint pain in IBD patients.5
6. Treating an acute flare with steroids.
Prednisone is prescribed at 40 mg daily for one week followed by dose tapering by 5 mg per week. Patients with CD limited to the ileum or right colon can use oral budesonide, which has fewer systemic side effects. Budesonide multi-matrix (MMX) is a formulation of budesonide that extends budesonide release throughout the colon using MMX system technology and can treat a UC flare.6
7. Treating IBD with sulfasalazine and 5-aminosalicylates (5-ASA).
Sulfasalazine and 5-ASA (mesalamine) are effective in treating UC with weaker evidence for Crohn’s colitis. Five-aminosalicylate medications are available as oral tablets, rectal enemas and suppositories. Each medication has a slightly different formulation and coating that allow it to reach different parts of the bowel. 7
8. Immunomodulators.
Methotrexate, azathioprine, and 6-mercaptopurine are ineffective in inducing remission in IBD. They are used following induction (e.g., with steroids) or in combination with an anti-tumor necrosis factor (anti-TNF) agent to reduce immunogenicity. Patients with a genetic mutation affecting the thiopurine methyltransferase (TMPT) enzyme need dose reduction (heterozygote) or avoidance (homozygote) of azathioprine or 6-mercaptopurine.8
9. Anti-TNF Therapies.
Infliximab is used in CD and UC: 5 mg/kg at weeks 0, 2, 6, followed by maintenance dosing every 8 weeks. Adalimumab is used in CD and UC: week 0, 160 mg; week 2, 80 mg; then 40 mg every 2 weeks. Golimumab is used in UC: week 0, 200 mg; week 2, 100 mg; then 100 mg every 4 weeks. Certolizumab is not approved in Canada for IBD. Etanercept is not effective in IBD.8,9
10. New biologics in IBD.
Vedolizumab is an antibody against α4β7 integrin for CD and UC. Vedolizumab is the first gut selective biologic.8,9 Its role in managing co-existing spondyloarthritis is unknown.
References
1. Karreman MC, Luime JJ, Hazes JM, et al. The prevalence and incidence of axial and peripheral spondyloarthritis in inflammatory bowel disease: a systematic review and meta-analysis. J Crohns Colitis 2016.
2. Harbord M, Annese V, Vavricka SR, et al. The first European evidence-based consensus on extra-intestinal manifestations in inflammatory bowel disease. J Crohns Colitis 2016;10(3):239-254.
3. de Winter JJ, van Mens LJ, van der Heijde D, et al. Prevalence of peripheral and extra-articular disease in ankylosing spondylitis versus non-radiographic axial spondyloarthritis: a meta-analysis. Arthritis Res Ther 2016; 18:196.
4. Danese S, Fiorino G, Mary JY, et al. Development of red flags index for early referral of adults with symptoms and signs suggestive of Crohn's disease: an IOIBD initiative. J Crohns Colitis 2015; 9(8):601-606.
5. Takeuchi K, Smale S, Premchand P, et al. Prevalence and mechanism of nonsteroidal anti-inflammatory drug-induced clinical relapse in patients with inflammatory bowel disease. Clin Gastroenterol Hepatol 2006; 4(2):196-202.
6. Rezaie A, Kuenzig ME, Benchimol EI, et al. Budesonide for induction of remission in Crohn's disease. Cochrane Database Syst Rev 2015(6):CD000296.
7. Wang Y, Parker CE, Feagan BG, et al. Oral 5-aminosalicylic acid for maintenance of remission in ulcerative colitis. Cochrane Database Syst Rev 2016(5):CD000544.
8. Hazlewood GS, Rezaie A, Borman M, et al. Comparative effectiveness of immunosuppressants and biologics for inducing and maintaining remission in Crohn's disease: a network meta-analysis. Gastroenterology 2015; 148(2):344-354 e345; quiz e314-345.
9. Vickers AD, Ainsworth C, Mody R, et al. Systematic review with network meta-analysis: comparative efficacy of biologics in the treatment of moderately to severely active ulcerative colitis. PLoS One 2016; 11(10):e0165435.
Heba Al-Farhan, MD, MRCP
Advanced IBD Fellow,
University of Calgary
Gastroenterologist,
Foothills Medical Center
Calgary, Alberta
Amiri Hospital,
Kuwait
Gilaad G. Kaplan, MD, MPH, FRCPC
Associate Professor,
University of Calgary
Gastroenterologist,
Foothills Medical Center
Calgary, Alberta
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