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Arthritis And Inflammatory Bowel Disease

A Common Complication Of IBD, Arthritis Affects An Estimated 25% Of Patients.

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Updated August 29, 2012

Written or reviewed by a board-certified physician. See About.com's Medical Review Board.

Inflammatory bowel disease (IBD) is associated with several other conditions, including the liver disorder primary sclerosing cholangitis, fissures, fistulas, and arthritis. Arthritis is the most common extraintestinal complication, affecting an estimated 25% of all IBD patients. The two most common forms of arthritis experienced by IBD patients are peripheral and axial arthritis.

Peripheral Arthritis

Peripheral arthritis is most common in people with ulcerative colitis or Crohn's disease of the colon. Typically, the course of the arthritis follows that of the IBD, with flare-ups and remission coinciding.

There is no single test that can diagnose peripheral arthritis. Instead, several tests, such as blood tests, joint fluid analysis, and x-rays, are used to exclude other conditions that could be causing the symptoms.

Symptoms of peripheral arthritis include:

  • Joint pain
  • Swelling of the joints
  • Stiffness in one or more joints
  • Symptoms that migrate between joints

Peripheral arthritis tends to affect the elbow, wrist, knee, and ankle. When pain from peripheral arthritis is left untreated, it may last from several days to weeks; however, permanent damage to the joints is not usually found.

Treating peripheral arthritis often involves resting painful joints along with splints and occasional moist heat. Exercises prescribed by a physical therapist are used to improve range of motion. Non-steroidal anti-inflammatory drugs (NSAIDs) are sometimes used to decrease the redness, swelling, and pain of inflamed joints -- but NSAIDs may aggravate the symptoms of IBD.

Another method of treating this form of arthritis is to gain control over the inflammation in the colon due to IBD. The arthritis symptoms will usually lessen when the IBD is quiescent, and several drugs used to treat IBD may also be helpful for peripheral arthritis. IBD patients being treated with prednisone often get a bonus side effect of relief from joint pain. Patients receiving anti-tumor necrosis factor-alpha (anti-TNF) drugs, such as Remicade (infliximab) or Humira (adalimumab), to treat their IBD may also experience improvement in arthritis symptoms. Azulfadine (sulfasalzine), a 5-Aminosalicylate drug that has long been used to treat IBD, may also provide symptom relief, although there is not much evidence to support its use. Another drug that is prescribed to treat IBD, methotrexate, may also be an effective treatment for peripheral arthritis.

Axial Arthritis (Spondyloarthropathy)

In cases of axial arthritis, symptoms could appear months or years before the onset of IBD. Symptoms include pain and stiffness in the joints of the spinal column that is at its worst in the morning, but will improve with physical activity. Active axial arthritis typically affects younger people and rarely continues in patients who are over 40.

Axial arthritis can lead to fusion of the bones of the vertebral column. This permanent complication can lead to a decrease in range of motion in the back and a limitation of rib motion that impairs the ability to take deep breaths.

The goal of treatment for axial arthritis is to maximize range of motion of the spine. Physical therapy, using postural and stretching exercises and the application of moist heat to the back, are two common forms of treatment. Some patients benefit from treatment with NSAIDs.

Treating the IBD usually has no effect on this type of arthritis; however, anti-TNF medications and Azulfadine may be of some benefit in reducing symptoms.

Ankylosing Spondylitis

Ankylosing spondylitis (AS) is a form of arthritis where the joints in the spine and the pelvis become inflamed. AS tends to affect those who have Crohn's disease more often than those who have ulcerative colitis, and men more often than women. AS is considered rare because it only affects about 2 to 3% of those with IBD. There could also be a genetic component to AS, but what causes this form of arthritis is still unknown.

The onset of AS is usually accompanied by a loss of flexibility in the lower spine. Treatment includes pain management and rehabilitation to maintain spine flexibility. Remicade and Humira are approved for the treatment of both IBD and AS, and may be effective in treating both conditions at the same time. Azulfadine may be helpful in reducing symptoms, especially morning stiffness. Some studies have shown methotrexate to be helpful for AS, while others show no benefit; methotrexate is often used to treat AS in combination with other drugs. However, even with therapy some people with AS are still symptomatic, and the bones of the spine may fuse together.

Sources:

Bourikas LA, Papadakis KA. "Musculoskeletal Manifestations of Inflammatory Bowel Disease." Inflamm Bowel Dis 2009; 1915–1924. 27 Aug 2012.

Chen J, Liu C. "Sulfasalazine for ankylosing spondylitis." Cochrane Database of Systematic Reviews 2005: CD004800. 18 Aug 2010.

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 Aug 2005;25:406-10. Epub 2004 Aug 12. 18 Aug 2010.

Peluso R, Atteno M, Iervolino S, et al. "Methotrexate in the treatment of peripheral arthritis in ulcerative colitis." Rheumatismo 2009 Jan-Mar;61:15-20. 18 Aug 2010.

van der Heijde D, Dijkmans B, Geusens P, et al. "Efficacy and safety of infliximab in patients with ankylosing spondylitis: Results of a randomized, placebo-controlled trial (ASSERT)." Arthritis & Rheumatism Feb 2005;52:582–591. 18 Aug 2010.

Yüksel I, Ataseven H, Başar O, Köklü S, et al. "Peripheral Arthritis in the Course of Inflammatory Bowel Diseases." Dig Dis Sci 11 May 2010. [Epub ahead of print] 11 Aug 2010.

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