Dr Dulai recaps his presentation from the July 23 Advances in Inflammatory Bowel Diseases regional meeting on managing skin, joint, and ocular extraintestinal manifestations of IBD.

Parambir Dulai, MD, is an associate professor of medicine at Northwestern University in Chicago, Illinois.

TRANSCRIPT:

Hi, I'm Parambir Singh Dulai, an associate professor at Northwestern University here in Chicago, Illinois. I just gave my talk on evidence-based approach to extraintestinal manifestations at our AIBD regional event in Chicago. We want to just highlight a few key learning objectives and points for you to take home from this discussion.

First, extraintestinal manifestations of IBD are very common. They can be seen in a third of patients. And I think the most common ones that you'll often encounter are peripheral arthritis or arthritis or enthesitis. Uveitis is not an uncommon consideration. And asymptomatic axial arthritis can actually be seen in up to 50% of Crohn's disease patients and something we often do not look for. Primary sclerosing cholangitis, although less common, only 5% of patients does come with complications and considerations. And pyoderma gangrenosum has its own special treatment paradigm that needs to be considered.

The most important thing to take away from considering extraintestinal manifestations is you need to involve your consultants. It's very important to work closely with a rheumatologist, dermatologist, ophthalmologist, and hepatologist for the respective EIM that you're treating. The first thing you want to try to make sure you do is treat the underlying intestinal inflammation. Several of these EIMs parallel the disease course. So, the most effective therapy is whatever therapy is most appropriate to control the underlying bowel inflammation. The second thing you want to think about is go through your list of common EIMs and ask yourself a few key points to differentiate the subtypes. So, when you're thinking about musculoskeletal EIMs you want to ask yourself whether this is tendon or ligament insertion pain that would help you differentiate enthesitis or arthritis. You want to think about whether there's any synovitis or morning inflammation to suggest that there's actually active inflammation as opposed to arthritis.

And you want to determine whether there's peripheral or axial involvement, because that really helps change some of the treatments that you might have available for you. So when you think about these arthritis and spondyloarthritis treatments, non-selective NSAIDs, although contraindicated for the treatment of IBD, because they may increase the risk of flares, selective COX-2 inhibitors in short duration can be used as long as you're monitoring the bowel symptoms and ensuring that they don't have complications from it. Systemic steroids are effective when it comes to arthritis and spondyloarthritis, but they're not effective for enthesitis. This is why it's important to understand when somebody says they have joint pain, a good exam and description can help you understand what the source is. And always watch out for emergence of arthritis or spondyloarthritis when tapering steroids or unmasking of the EIM. Sulfasalazine is a good option for UC patients with peripheral arthritis and methotrexate has some consideration for peripheral arthritis in patients with Crohn's disease.

Most importantly, none of those therapies that I just mentioned are effective for axial arthritis or spondyloarthritis, and that requires its own considerations for treatment largely with biologic therapies. The most evidence for treatment of axial spondyloarthropathy is anti-TNF therapy. And I think this is our go to for IBD patients who have axial involvement. There's some emerging data that tofacitinib may have some benefit for axial disease, but it definitely has some involvement and benefit for peripheral arthritis and can be a consideration for patients who have rheumatological conditions alongside their IBD for ulcerative colitis, which is what it's FDA approved for. Ustekinumab has evidence and efficacy for peripheral arthritis, but it actually has negative clinical trials when dealing with axial spondyloarthritis. So it's not a treatment option for axial EIMs, and vedolizumab has no evidence for support for axial and very limited in terms of use for peripheral.

So when you're thinking about arthritis and spondyloarthritis, particularly axial anti-TNF therapies remain your go to treatment strategy. Now thinking about a couple of sort of rare, but really high risk complications or EIMs, pyoderma gangrenosum is often sometimes a consideration. This is pathognomonic with a clinical finding called pathergy. If you scratch it, or if you cut it, the lesion actually extends. So you want to avoid surgical debridement at all costs. And this can be very tricky or difficult to treat at times. The first line treatments for this remains systemic steroids and either consideration for cyclosporine therapy or anti-TNF therapy. Infliximab is the only therapy that has a randomized controlled trial done specifically for pyoderma gangrenosum. And I think it remains our first line of choice. However, there are some recent data that suggests that ustekinumab and tofacitinib may be of some benefit.

Now it's unclear if this is because it was treating the underlying inflammation or directly dealing with the pathology related to the pyoderma gangrenosum. And the last thing I want to leave you with is that one of the most high-risk complications or EIMs that we have to think about is ocular. And this is in large part because scleritis or refractory uveitis can be very threatening to vision, and you should not delay the diagnosis when you're dealing with scleritis in particular, because it can progress to permanent visual loss. Always consult with an ophthalmologist, if you're concerned about this. Mild uveitis you can typically treat it with topical steroids, but you want to introduce high dose steroids early if you're suspecting scleritis or refractory uveitis, typically at 1-1.5 mg/kg per day. So those are some of the key takeaways that I want you to try to think about when you're looking at extraintestinal manifestations and most importantly, assess for them, ask for them, because they're actually quite more common than you would realize, but our patients don't necessarily verbalize that on their own.