Joint pain common EIM in IBD
Joint pain is the most common extraintestinal manifestation (EIM) of inflammatory bowel disease (IBD), according to a presentation during AIBD 2018.
Arthralgias and pauciarticular arthritis are associated with relapsing disease and are self-limiting, while polyarticular arthritis is not associated with relapsing disease and is often chronic, said Dr Raymond Cross, Professor of Medicine at the University of Maryland School of Medicine in Baltimore, Maryland, US. “[Polyarticular arthritis is] more challenging and typically happens when patients are in remission [or] before diagnosis.”
Enteropathic arthritis occurs in 10–20 percent of patients with IBD and is more commonly observed in individuals with Crohn’s disease than ulcerative colitis (28 percent vs 14 percent). Although the pathogenesis remains unknown, some HLA* genotypes have been linked to both pauciarticular (ie, HLA-DRB1*0103 and HLA-B27) and polyarticular arthritis (HLA-B44). [Gastroenterology 2000;118:274-278; J Exp Med 1994;180:2359-2364]
Pauciarticular arthritis typically involves <5 joints, is more common than the polyarticular type and almost always asymmetrical, and lasts a mean of 5 weeks. [Dig Dis Sci 2011;56:183-187; Gut 1998;42:387-391]
On the other hand, polyarticular arthritis affects >5 joints, more commonly the small joints in the hands (ie, metacarpophalangeal joints). [Arch Ophthalmol 1997;115:61-64] This type is usually persistent with a mean duration of symptoms of 3 years, said Cross.
Noninflammatory joint pain usually affects 8–16 percent of patients with IBD and resolves with treatment. “The joint pain should get better upon initiating effective therapy,” said Cross. Lack of response to therapy may signify pseudorheumatism, other drug side effects, or other forms of arthritis. [J Rheumatol 2005;32:1755-1759]
Managing arthritis in IBD
Rest is of primary significance in the management of arthritis in IBD, said Cross, followed by analgesics, particularly Cox II inhibitors, as these do not increase relapse in IBD.
For pauciarticular arthritis, treatment options are intra-articular steroids and sulfasalazine. “[The latter is] more commonly used for patients with concurrent joint pain [and] can be very effective even in low doses,” said Cross.
For polyarticular arthritis, sulfasalazine is the alternative should Cox II inhibitors be insufficient, noted Cross. Other treatment options are low-dose oral steroids, methotrexate, and anti-TNF** agents. [Am J Gastroenterol 2006;101:311-317; Clin Gastroenterol Hepatol 2006;4:203-211]
Drug-induced lupus (DIL)
DIL is rare yet one of the most common forms of paradoxical autoimmune reactions in IBD with a symptom onset at approximately 41 weeks following anti-TNF therapy, noted Cross. However, DIL diagnosis can be difficult, he added.
“[Individuals with DIL typically] present with asthenia, malaise, fever, rash, arthralgias, and/or myalgias [causing] very intense joint pain and stiffness … [A] classic lupus rash [may] drive home the diagnosis,” said Cross.
Symptoms typically resolve after cessation of anti-TNF with or without a course of steroids, and usually do not recur after rechallenge with a different anti-TNF. [Arthritis Res Ther 2005;7:R545-551; Ann Rheum Dis 2006;65:889-894] “Most patients would need a tapering course of prednisone [while some might] need immune suppressants,” said Cross.
Cross recommends referral to a rheumatology specialist to ascertain the presence and type of arthritis or other autoimmune manifestations in patients with IBD.