Dr Ritchlin reviews his presentation from the virtual regional meeting March 5 of Advances in Inflammatory Bowel Diseases on the management of joint pain among patients with IBD.

Christopher Ritchlin, MD, is a professor of medicine in the Division of Allergy, Immunology, and Rheumatology at the University of Rochester Medical Center in Rochester, New York.
 

For more content from the Advances in Inflammatory Bowel Disease 2022 Regional Meetings, visit our Meeting Newsroom.

TRANSCRIPT:

Christopher Ritchlin:  Hello, I'm Christopher Ritchlin, Professor of Medicine in the Division of Allergy, Immunology, and Rheumatology at the University of Rochester Medical Center. My presentation is centered on, "My joints hurt, do I need more or less medication?"

This is really an overview of enteropathic arthritis in which I speak about the epidemiology, pathogenesis, diagnostic pearls, and treatment options for patients with inflammatory bowel disease who have musculoskeletal involvement.

Enteropathic arthritis is part of the spondyloarthritis group of diseases. These include axial spondyloarthritis for which I'll define in a moment, which includes ankylosing spondylitis, reactive arthritis, psoriatic arthritis, and of course, enteropathic arthritis. These diseases share several clinical features.

In terms of the pathogenesis, there's accumulating data that the disease in the joints is linked to dysbiosis in the bowel. These studies have been centered primarily in mouse models.

There are additional data coming from humans that really provide some powerful evidence that inflammation begins in the gut with the departure of activated T cells in the gut into the joints and the entheses—the entheses being the ligaments and tendons, where they insert onto the bone and also where joint capsules insert onto the bone.

In terms of diagnosis of musculoskeletal involvement in patients with inflammatory diseases, it can be very challenging. Typically, they can have two forms of arthritis, one that involves the axial skeleton. The axial skeleton includes the sacroiliac joints, the entire spine, shoulders, and hips.

There are two types of peripheral arthritis that are separate from the axial disease, one in which patients have 5 or less joints involved. This tends to be more transient and not debilitating, although certainly there are exceptions.

You can have patients who have polyarthritis, 5 or more joints involved. This tends to be longer‑acting, tends to be independent of the activity of the bowel disease, and can lead to joint damage. I should mention that the axial disease tends to be independent of the bowel inflammation as well.

Imaging has really changed our perception of these diseases because it used to be thought that the disease ankylosing spondylitis was diagnosed by changes in the sacroiliac joints on X‑ray. Indeed, these were advanced changes. It became apparent over time that there were many patients who had the symptom complex of ankylosing spondylitis without the X‑ray changes in the sacroiliac joints.

With MRI imaging, it also became quite apparent that many of these patients that didn't have X‑ray findings had MRI findings in the SI joints, which included bone marrow edema and sometimes some erosions that were subtle. Many of these patients were women.

This led to the renaming of the axial diseases to axial spondyloarthritis, both radiographic— which is ankylosing spondylitis—and nonradiographic. The patients that have involvement of the sacroiliac joints or their spine in a setting of inflammatory bowel disease or otherwise are recognized to have both radiographic and nonradiographic forms.

We now know that with studies looking for bowel involvements, such as the MRE, one can actually see inflammation in the SI joints on MRE. This is another way for the gastroenterologist to pick up disease in the sacroiliac joints.

In terms of symptoms and signs, patients will present with inflammatory back pain if they have axial disease, which is characterized by stiffness and pain in the morning when they wake up that improves with activity or nonsteroidal anti‑inflammatory agents. Again, it tends to be independent of the activity of the bowel disease.

In terms of the peripheral arthritis, it's usually joint pain, often in the large joints, often more likely in the lower extremities, although it can also occur in joints in the upper extremities, often with swelling as well.

In terms of the diagnosis, there are some links to HLA antigens. HLA‑B27 is more highly present in the patients with axial disease. They'll often have elevated sedimentation rate and CRP, although this also may be seen, as you well know, with inflammatory bowel disease.

We now have other features that we know can be present in these patients, which includes dactylitis, which is swelling of a digit and diffuse swelling of a finger or toe, and also enthesitis, most commonly presents as Achilles tendinitis or lateral epicondylitis, areas where joint capsules and tendons insert onto bone.

The therapeutics of these diseases have also advanced considerably over the last decade. These agents that we have available to us to treat the inflammatory bowel disease and the arthritis often overlap, but there are important differences.

For example, NSAIDs can be very effective for the treatment of musculoskeletal pain, but are often not advised in inflammatory bowel disease. Corticosteroids can be effective for peripheral arthritis in IBD, but not axial arthritis. Of course, sulfasalazine has some efficacy in IBD and mild efficacy for peripheral arthritis. Methotrexate is another agent that can be effective for inflammatory bowel disease and peripheral, but not axial arthritis.

The biologics have really changed the outcomes for many of our patients who have these diseases. Of course, anti‑TNF agents, with the exception of etanercept, which is not effective for IBD, can be remarkably effective for bowel and joint disease.

The anti‑IL‑23 agents are effective for peripheral arthritis and bowel disease, but not for axial disease. The agents that block IL‑17 are remarkably effective for arthritis but, of course, we avoid in patients who have inflammatory bowel disease.

Lastly, the JAK‑STAT inhibitors, tofacitinib and upadacitinib, are effective for inflammatory arthritis, both axial and peripheral. Of course, these had been approved in either ulcerative colitis or Crohn's disease, depending on which of the agents we're thinking about. That covers the area that I discussed. I thank you for your attention.