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Current Reviews in Musculoskeletal Medicine

Published in:

01-09-2011

Inflammatory bowel disease associated arthropathy

Authors: Sheila L. Arvikar, Mark C. Fisher

Published in: Current Reviews in Musculoskeletal Medicine | Issue 3/2011

Abstract

Arthritis is the most common extraintestinal manifestation of inflammatory bowel disease (IBD) and can have a significant impact on morbidity and quality of life. IBD-associated arthropathy is considered a subtype of seronegative spondyloarthropathy, with axial, peripheral, or a combination of both joint manifestations. Peripheral arthritis is generally non-erosive and the oligoarticular variant particularly may correlate with intestinal disease activity. Axial arthritis may include inflammatory back pain, sacroiliitis, or ankylosing spondylitis, and is less likely to correlate with gastrointestinal symptoms. While there have been advances in identifying predisposing genetic factors and in elucidating pathophysiology of inflammatory bowel disease, the mechanisms surrounding the development of arthritis in IBD remain unclear. Treatment of inflammatory bowel disease is not always sufficient for control of arthritis. While treatment with biologic agents is promising, there remains a great need for larger, randomized studies to address optimal therapy of IBD associated arthropathy.

Salvarani C, Vlachonikolis IG, van der Heijde DM, et al. Musculoskeletal manifestations in a population-based cohort of inflammatory bowel disease patients. Scand J Gastroenterol. 2001;36:1307–13.PubMedCrossRef

Lanna CC, Ferrari Mde L, Rocha SL, et al. A cross-sectional study of 130 Brazilian patients with Crohn’s disease and ulcerative colitis: analysis of articular and ophthalmologic manifestations. Clin Rheumatol. 2008;27:503–9.PubMedCrossRef

Dougados M, van der Linden S, Juhlin R, et al. The European Spondylarthropathy Study Group preliminary criteria for the classification of spondylarthropathy. Arthritis Rheum. 1991;34:1218–27.PubMedCrossRef

Orchard TR, Wordsworth BP, Jewell DP. Peripheral arthropathies in inflammatory bowel disease: their articular distribution and natural history. Gut. 1998;42:387–91.PubMedCrossRef

Calin A, Porta J, Fries J, Schurman D. Clinical history as a screening test for ankylosing spondylitis. JAMA. 1977;237:2613–4.PubMedCrossRef

Sieper J, van der Heijde D, Landewé R, et al. New criteria for inflammatory back pain in patients with chronic back pain: a real patient exercise by experts from the Assessment of SpondyloArthritis International Society (ASAS). Ann Rheum Dis. 2009;68:784–8.PubMedCrossRef

Van der Linden S, Valkenburg HA, Cats A. Evaluation of diagnostic criteria for ankylosing spondylitis. A proposal for modification of the New York criteria. Arthritis Rheum. 1984;27:361–8.PubMedCrossRef

McEniff N, Eustace S, McCarthy C, et al. Asymptomatic sacroiliitis in inflammatory bowel disease. Assessment by computed tomography. Clin Imaging. 1995;19:258–62.PubMedCrossRef

Wolfe F, Michaud K. Severe rheumatoid arthritis (RA), worse outcomes, comorbid illness, and sociodemographic disadvantage characterize RA patients with fibromyalgia. J Rheumatol. 2004;31:695–700.PubMed

10.

Naranjo A, Ojeda S, Erausquin C, et al. Fibromyalgia in patients with rheumatoid arthritis is associated with higher scores of disability. Ann Rheum Dis. 2002;61:660–1.PubMedCrossRef

11.

Almodóvar R, Carmona L, Zarco P, et al. Fibromyalgia in patients with ankylosing spondylitis: prevalence and utility of the measures of activity, function and radiological damage. Clin Exp Rheumatol. 2010;28:S33–9.PubMed

12.

Palm O, Moum B, Jahnsen J, Gran JT. Fibromyalgia and chronic widespread pain in patients with inflammatory bowel disease: a cross sectional population survey. J Rheum. 2001;28:590–4.PubMed

13.

Buskila D, Odes LR, Neumann L, Odes HS. Fibromyalgia in inflammatory bowel disease. J Rheum. 1999;26:1167–71.PubMed

14.

Loftus EV. Clinical epidemiology of inflammatory bowel disease: incidence, prevalence, and environmental influences. Gastroenterology. 2004;126:1504–17.PubMedCrossRef

15.

Kappelman MD, Rifas-Shiman SL, Kleinman K, et al. The prevalence and geographic distribution of Crohn’s disease and ulcerative colitis in the United States. Clin Gastroenterol Hepatol. 2007;5:1424–9.PubMedCrossRef

16.

Acheson ED. An association between ulcerative colitis, regional enteritis, and ankylosing spondylitis. Q J Med. 1960;29:489–99.PubMed

17.

Ansell BM, Wigley RA. Arthritic manifestations in regional enteritis. Ann Rheum Dis. 1964;23:64–72.PubMedCrossRef

18.

Wright V, Watkinson G. Sacro-iliitis and ulcerative colitis. Br Med J. 1965;2:675–80.PubMedCrossRef

19.

Wright V, Watkinson G. The arthritis of ulcerative colitis. Br Med J. 1965;2:670–5.PubMedCrossRef

20.

Haslock I. Arthritis and Crohn’s disease. A family study. Ann Rheum Dis. 1973;32:479–86.PubMedCrossRef

21.

Dekker-Saeys BJ, Meuwissen SG, Van Den Berg-Loonen EM, et al. Ankylosing spondylitis and inflammatory bowel disease. II. Prevalence of peripheral arthritis, sacroiliitis, and ankylosing spondylitis in patients suffering from inflammatory bowel disease. Ann Rheum Dis. 1978;37:33–5.PubMedCrossRef

22.

Maeda K, Okada M, Yao T, et al. Intestinal and extraintestinal complications of Crohn’s disease: predictors and cumulative probability of complications. J Gastroenterol. 1994;29:577–82.PubMedCrossRef

23.

Veloso FT, Carvalho J, Magro F. Immune-related systemic manifestations of inflammatory bowel disease. A prospective study of 792 patients. J Clin Gastroenterol. 1996;23:29–34.PubMedCrossRef

24.

Suh CH, Lee CH, Lee J, et al. Arthritic manifestations of inflammatory bowel disease. J Korean Med Sci. 1998;13:39–43.PubMed

25.

Triantafillidis JK, Emmanouilidis A, Manousos O, Nicolakis D, Kogevinas M. Clinical patterns of Crohn’s disease in Greece: a follow-up study of 155 cases. Digestion. 2000;61:121–8.PubMedCrossRef

26.

de Vlam K, Mielants H, Cuvelier C, et al. Spondyloarthropathy is underestimated in inflammatory bowel disease: prevalence and HLA association. J Rheumatol. 2000;27:2860–5.PubMed

27.

Queiro R, Maiz O, Intxausti J, et al. Subclinical sacroiliitis in inflammatory bowel disease: a clinical and follow-up study. Clin Rheumatol. 2000;19:445–9.PubMedCrossRef

28.

Christodoulou DK, Katsanos KH, Kitsanou M, et al. Frequency of extraintestinal manifestations in patients with inflammatory bowel disease in Northwest Greece and review of the literature. Dig Liver Dis. 2002;34:781–6.PubMedCrossRef

29.

Palm Ø, Moum B, Jahnsen J, Gran JT. The prevalence and incidence of peripheral arthritis in patients with inflammatory bowel disease, a prospective population-based study (the IBSEN study). Rheumatology (Oxford). 2001;40:1256–61.CrossRef

30.

Palm O, Moum B, Ongre A, Gran JT. Prevalence of ankylosing spondylitis and other spondyloarthropathies among patients with inflammatory bowel disease: a population study (the IBSEN study). J Rheumatol. 2002;29:511–5.PubMed

31.

Al-Shamali MA, Kalaoui M, Patty I, et al. Ulcerative colitis in Kuwait: a review of 90 cases. Digestion. 2003;67:218–24.PubMedCrossRef

32.

Steer S, Jones H, Hibbert J, et al. Low back pain, sacroiliitis, and the relationship with HLA-B27 in Crohn’s disease. J Rheumatol. 2003;30:518–22.PubMed

33.

Turkcapar N, Toruner M, Soykan I, et al. The prevalence of extraintestinal manifestations and HLA association in patients with inflammatory bowel disease. Rheumatol Int. 2006;26:663–8.PubMedCrossRef

34.

Peeters H, Vander Cruyssen B, Mielants H, et al. Clinical and genetic factors associated with sacroiliitis in Crohn’s disease. J Gastroenterol Hepatol. 2008;23:132–7.PubMed

35.

Orchard TR, Holt H, Bradbury L, et al. The prevalence, clinical features and association of HLA-B27 in sacroiliitis associated with established Crohn’s disease. Aliment Pharmacol Ther. 2008;29:193–7.PubMedCrossRef

36.

D’Incà R, Podswiadek M, Ferronato A, et al. Articular manifestations in inflammatory bowel disease patients: a prospective study. Dig Liver Dis. 2009;41:565–9.PubMedCrossRef

37.

Yüksel I, Ataseven H, Başar O, et al. Peripheral arthritis in the course of inflammatory bowel disease. Dig Dis Sci. 2011;56:183–7.PubMedCrossRef

38.

Hwangbo Y, Kim HJ, Park JS, et al. Sacroiliitis is common in Crohn’s disease patients with perianal or upper gastrointestinal involvement. Gut Liver. 2010;4:338–44.PubMedCrossRef

39.

• Vavricka SR, Brun L, Ballabeni P, et al. Frequency and risk factors for extraintestinal manifestations in the swiss inflammatory bowel disease cohort. Am J Gastroenterol. 2011;106:110–9. This is a recent epidemiologic study examining EIMs in a large cohort of IBD patients. PubMedCrossRef

40.

Mielants H, Veys EM, Cuvelier C, De Vos M. Subclinical involvement of the gut in undifferentiated spondylarthropathies. Clin Exp Rheumatol. 1989;7:499–504.PubMed

41.

De Vos M, Mielants H, Cuvelier C, Elewaut A, Veys E. Long-term evolution of gut inflammation in patients with spondyloarthropathy. Gastroenterology. 1996;110:1696–703.PubMedCrossRef

42.

Jacques P, Elewaut D. Joint expedition: linking gut inflammation to arthritis. Mucosal Immunol. 2008;1:364–71.PubMedCrossRef

43.

Taurog JD, Richardson JA, Croft JT, et al. The germfree state prevents development of gut and joint inflammatory disease in HLA-B27 transgenic rats. J Exp Med. 1994;180:2359–64.PubMedCrossRef

44.

Salmi M, Jalkanen S. Human leukocyte subpopulations from inflamed gut bind to joint vasculature using distinct sets of adhesion molecules. J Immunol. 2001;166:4650–7.PubMed

45.

May E, Märker-Hermann E, Wittig BM, et al. Identical T-cell expansions in the colon mucosa and the synovium of a patient with enterogenic spondyloarthropathy. Gastroenterology. 2000;119:1745–55.PubMedCrossRef

46.

Demetter P, De Vos M, Van Huysse JA, et al. Colon mucosa of patients both with spondyloarthritis and Crohn’s disease is enriched with macrophages expressing the scavenger receptor CD163. Ann Rheum Dis. 2005;64:321–4.PubMedCrossRef

47.

Baeten D, Demetter P, Cuvelier CA, et al. Macrophages expressing the scavenger receptor CD163: a link between immune alterations of the gut and synovial inflammation in spondyloarthropathy. J Pathol. 2002;196:343–50.PubMedCrossRef

48.

Salmi M, Rajala P, Jalkanen S. Homing of mucosal leukocytes to joints. Distinct endothelial ligands in synovium mediate leukocyte-subtype specific adhesion. J Clin Invest. 1997;99:2165–72.PubMedCrossRef

49.

Armaka M, Apostolaki M, Jacques P, et al. Mesenchymal cell targeting by TNF as a common pathogenic principle in chronic inflammatory joint and intestinal diseases. J Exp Med. 2008;205:331–7.PubMedCrossRef

50.

Turner MJ, Soweders DP, DeLay ML, et al. HLA-B27 misfolding in transgenic rats is associated with activation of the unfolded protein response. J Immunol. 2005;175:2438–48.PubMed

51.

•• Reveille JD. The genetic basis of spondyloarthritis. Ann Rheum Dis. 2011;70:i44-50. This is an excellent review of the genetic associations of spondylarthropathies found to date. PubMedCrossRef

52.

Hampe J, Cuthbert A, Croucher PJ, et al. Association between insertion mutation in NOD2 gene and Crohn’s disease in German and British populations. Lancet. 2001;357:1925–8.PubMedCrossRef

53.

Hugot JP, Chamaillard M, Zouali H, et al. Association of NOD2 leucine-rich repeat variants with susceptibility to Crohn’s disease. Nature. 2001;411:599–603.PubMedCrossRef

54.

Ogura Y, Bonen DK, Inohara M, et al. A frameshift mutation in NOD2 associated with susceptibility to Crohn’s disease. Nature. 2001;411:603–6.PubMedCrossRef

55.

Crane AM, Bradbury L, van Heel DA, et al. Role of NOD2 variants in spondylarthritis. Arthritis Rheum. 2003;46:1629–33.CrossRef

56.

Laukens D, Peeters H, Marichal D, et al. CARD15 gene polymorphisms in patients with spondyloarthropathies identify a specific phenotype previously related to Crohn’s disease. Ann Rheum Dis. 2005;64:930–5.PubMedCrossRef

57.

Miceli-Richard C, Zouali H, Lesage S, et al. CARD15/NOD2 analyses in spondylarthropathy. Arthritis Rheum. 2002;46:1405–6.PubMedCrossRef

58.

Duerr RH, Taylor KD, Brant SR, et al. A genome-wide association study identifies IL23R as an inflammatory bowel disease gene. Science. 2006;314:1461–3.PubMedCrossRef

59.

Rahman P, Inman RD, Gladman DD, et al. Association of interleukin-23 receptor variants with ankylosing spondylitis. Arthritis Rheum. 2008;58:1020–5.PubMedCrossRef

60.

• Danoy P, Pryce K, Hadler J, Bradbury LA, Farrar C, Pointon J, et al. Association of variants at 1q32 and STAT3 with ankylosing spondylitis suggests genetic overlap with Crohn’s disease. PLoS Genet. 2010;6:e1001195. This a recent study identifying novel genetic susceptibility loci associated with AS and CD. PubMedCrossRef

61.

Brown M, Pile K, Kennedy L, et al. HLA class I associations of ankylosing spondylitis in the white population in the United Kingdom. Ann Rheum Dis. 1996;55:268–70.PubMedCrossRef

62.

Enlow RW, Bias WB, Arnett FC. The spondylitis of inflammatory bowel disease. Evidence for a non-HLA linked axial arthropathy. Arthritis Rheum. 1980;23:1359–65.PubMedCrossRef

63.

• Braun J, Baraliakos X. Imaging of axial spondyloarthritis including ankylosing spondylitis. Ann Rheum Dis. 2011;70:i97-103. This is an exellent review of imaging in axial SpA. PubMedCrossRef

64.

Baraliakos X, Listing J, Rudwaleit M, et al. Progression of radiographic damage in patients with ankylosing spondylitis: defining the central role of syndesmophytes. Ann Rheum Dis. 2007;66:910–5.PubMedCrossRef

65.

• Rudwaleit M, Jurik AG, Hermann KG, et al. Defining active sacroiliitis on magnetic resonance imaging (MRI) for classification of axial spondyloarthritis: a consensual approach by the ASAS/OMERACT MRI group. Ann Rheum Dis. 2009;68:1520–7. This article defines a new approach for classifying SpA which includes MRI findings.PubMedCrossRef

66.

Abi Karam G, Awada H, Nasr F, Uthman I. Ileal pouchitis and arthritis. Semin Arthritis Rheum. 2003;33:215.PubMedCrossRef

67.

Balbir-Gurman A, Schapira D, Nahir M. Arthritis related to ileal pouchitis following total proctocolectomy for ulcerative colitis. Semin Arthritis Rheum. 2001;30:242–8.PubMedCrossRef

68.

Andreyev HJ, Kamm MA, Forbes A, Nicholls RJ. Joint symptoms after restorative proctocolectomy in ulcerative colitis and familial polyposis coli. J Clin Gastroenterol. 1996;23:35–9.PubMedCrossRef

69.

Sandborn WJ, Stenson WF, Brynskov J, et al. Safety of celecoxib in patients with ulcerative colitis in remission: a randomized, placebo-controlled, pilot study. Clin Gastroenterol Hepatol. 2006;4:203–11.PubMedCrossRef

70.

Carbonnel F. Methotrexate: a drug of the future in ulcerative colitis? Curr Drug Targets. 2011;e-pub, in press.

71.

Present DH, Rutgeerts P, Targan S, Hanauer SB, Mayer L, van Hogezand RA, et al. Infliximab for the treatment of fistulas in patients with Crohn’s disease. N Engl J Med. 1999;340(18):1398–405.PubMedCrossRef

72.

Hanauer SB, Feagan BG, Lichtenstein GR, et al. Maintenance infliximab for Crohn’s disease: The ACCENT I randomised trial. Lancet. 2002;359:1541–9.PubMedCrossRef

73.

Sandborn WJ, Rutgeerts P, Feagan BG, Reinisch W, Olson A, Johanns J, et al. Colectomy rate comparison after treatment of ulcerative colitis with placebo or infliximab. Gastroenterology. 2009;137:1250–60.PubMedCrossRef

74.

Van den Bosch F, Kruithof E, Vos MD, Keyser FD, Mielants H. Crohn’s disease associated with spondyloarthropathy: effect of TNF-α blockade with infliximab on articular symptoms. Lancet. 2000;356:1821–2.PubMedCrossRef

75.

Herfarth H, Obermeier F, Andus T, et al. Improvement of arthritis and arthralgia after treatment with infliximab (Remicade) in a German prospective, open-label, multicenter trial in refractory Crohn’s disease. Am J Gastroenterol. 2002;97:2688–90.PubMedCrossRef

76.

Generini S, Giacomelli R, Fedi R, et al. Infliximab in spondyloarthropathy associated with Crohn’s disease: an open study on the efficacy of inducing and maintaining remission of musculoskeletal and gut manifestations. Ann Rheum Dis. 2004;63:1664–9.PubMedCrossRef

77.

van der Heijde D, Kivitz A, Schiff MH, et al. Efficacy and safety of adalimumab in patients with ankylosing spondylitis: results of a multicenter, randomized, double-blind, placebo-controlled trial. Arthritis Rheum. 2006;54:2136–46.PubMedCrossRef

78.

Sandborn WJ, Hanauer SB, Rutgeerts PJ, et al. Adalimumab for maintenance treatment of Crohn’s disease: results of the CLASSIC II trial. Gut. 2007;56:1232–9.PubMedCrossRef

79.

Colombel JF, Sandborn WJ, Rutgeerts P, et al. Adalimumab for maintenance of clinical response and remission in patients with Crohn’s disease: the CHARM trial. Gastroenterology. 2007;132:52–65.PubMedCrossRef

80.

Lichtiger S, Binion DG, Wolf DC, et al. The CHOICE trial: adalimumab demonstrates safety, fistula healing, improved quality of life and increased work productivity in patients with Crohn’s disease who failed prior infliximab therapy. Aliment Pharmacol Ther. 2010;32:1228–39.PubMedCrossRef

81.

••Lofberg R, Louis EV, Reinisch W, et al. Adalimumab produces clinical remission and reduces extraintestinal manifestations in Crohn’s disease: Results from CARE. Inflamm Bowel Dis. 2011;epub ahead of print, doi: 10.1002/ibd.21663. This is a recent large multicenter open label trial assessing treatment of arthritis in IBD with Adalimumab.

82.

Sandborn WJ, Hanauer SB, Katz S, et al. Etanercept for active Crohn’s disease: a randomized, double-blind, placebo-controlled trial. Gastroenterology. 2001;121:1088–94.PubMedCrossRef

83.

van Dijken TD, Vastert SJ, Gerloni VM, et al. Development of inflammatory bowel disease in patients with juvenile idiopathic arthritis treated with Etanercept. J Rheumatol. 2011;epub ahead of print, doi: 10.3899/jrheum.100809

84.

• Yanai H, Hanauer SB. Assessing response and loss of response to biological therapies in IBD. Am J Gastroenterol. 2011;106:685–98. An important article which highlights the important issue of developing refractoriness to biologic therapies. PubMedCrossRef

85.

Sandborn WJ, Feagan BG, Fedorak RN, et al. A randomized trial of ustekinumab, a human interleukin-12/23 monoclonal antibody, in patients with moderate-to-severe Crohn’s disease. Gastroenterology. 2008;135:1130–41.PubMedCrossRef

86.

Gottlieb A, Menter A, Mendelsohn A, et al. Ustekinumab, a human interleukin 12/23 monoclonal antibody, for psoriatic arthritis: randomised, double-blind, placebo-controlled, crossover trail. Lancet. 2009;373:633–40.PubMedCrossRef

87.

Chen Z, Brant SR, Li C, et al. CTLA4–1661A/G and 3′UTR long repeat polymorphisms are associated with ulcerative colitis and influence CTLA4 mRNA and protein expression. Genes Immun. 2010;11:573–83.PubMedCrossRef

88.

Hradsky O, Dusatkova P, Lenicek M, et al. The CTLA4 variants may interact with the IL23R- and NOD2-conferred risk in development of Crohn’s disease. BMC Med Genet. 2010;11:91.PubMedCrossRef

89.

Ardelean DS, Gonska T, Wires S, et al. Severe ulcerative colitis after rituximab therapy. Pediatrics. 2010;126:e243–6. doi:10.1542/peds.2009–3395.PubMedCrossRef

90.

Goetz M, Atreya R, Ghalibafian M, Galle PR, Neurath MF. Exacerbation of ulcerative colitis after rituximab salvage therapy. Inflamm Bowel Dis. 2007;13:1365–8.PubMedCrossRef

91.

Leiper K, Martin K, Ellis A, et al. Randomised placebo-controlled trial of rituximab (anti-CD20) in active ulcerative colitis. Gut. 2011;epub ahead of print: doi:10.1136/gut.2010.225482

92.

Nishimoto N, Ito K, Takagi N. Safety and efficacy profiles of tocilizumab monotherapy in Japanese patients with rheumatoid arthritis: meta-analysis of six initial trials and five long-term extensions. Mod Rheumatol. 2010;20:222–32.PubMedCrossRef

93.

Tebbutt NC, Giraud AS, Inglese M, et al. Reciprocal regulation of gastrointestinal homeostasis by SHP2 and STAT-mediated trefoil gene activation in gp130 mutant mice. Nat Med. 2002;8:1089–97.PubMedCrossRef

94.

Targan SR, Feagan BG, Fedorak RN, et al. Natalizumab for the treatment of active Crohn’s disease: results of the ENCORE trial. Gastroenterology. 2007;132:1672–83.PubMedCrossRef

95.

• Etzel JP, Larson MF, Anawalt BD, Collins J, Dominitz JA. Assessment and management of low bone density in inflammatory bowel disease and performance of professional society guidelines. Inflamm Bowel Dis. 2011;Jan 13. This is an article highlighting the high prevalence of osteoporosis in IBD patients, and the underutilization of osteoporosis screening and treatment in IBD.

96.

Miele E, Markowitz JE, Mamula P, Baldassano RN. Human antichimeric antibody in children and young adults with inflammatory bowel disease receiving infliximab. J Pediatr Gastroenterol Nutr. 2004;38:502–8.PubMedCrossRef

97.

Elliott MJ, Maini RN, Feldmann M, et al. Repeated therapy with monoclonal antibody to tumour necrosis factor alpha (cA2) in patients with rheumatoid arthritis. Lancet. 1994;344:1125–7.PubMedCrossRef

98.

Radstake TR, Svenson M, Eijsbouts AM, et al. Formation of antibodies against infliximab and adalimumab strongly correlates with functional drug levels and clinical responses in rheumatoid arthritis. Ann Rheum Dis. 2009;68:1739–45.PubMedCrossRef

Title: Inflammatory bowel disease associated arthropathy
Authors: Sheila L. Arvikar
Mark C. Fisher
Publication date: 01-09-2011
Publisher: Current Science Inc.
Published in: Current Reviews in Musculoskeletal Medicine / Issue 3/2011
Electronic ISSN: 1935-9748
DOI: https://doi.org/10.1007/s12178-011-9085-8

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Inflammatory bowel disease associated arthropathy

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Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

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