Here’s What You May Not Know about IBD and Arthritis

Inflammatory bowel disease (IBD) has long been associated with the development of arthritis. Research suggests there could be a genetic component or the connection could be associated with an inflamed gut.

While rheumatoid arthritis patients can develop IBD, the type of arthritis typically associated with IBD is entirely different and is one that primarily affects the large joints but without long-term damage as seen in RA.

In this article, we feature a Q&A by Timothy R. Orchard, M.D., a gastroenterologist with St. Mary's Hospital of Imperial College in London, that was published in 2012 in Gastroenterology and Hepatology. Dr. Orchard shares his expertise and insights on arthritis after an IBD diagnosis.

Types of arthritis in IBD

There are some joint problems that are unique to patients who suffer from inflammatory bowel disease (IBD):  inflammatory arthritis and arthralgia (or, joint pain without inflammation) with the latter occurring in 40-50 percent of IBD patients. Of these, 15-20 percent have Crohn's disease and 10 percent have ulcerative colitis.

Most IBD patients - 60-70 percent - experience peripheral arthritis affecting fewer than five large joints most commonly being knees, ankles, wrists, elbows and hips. Peripheral arthritis often presents as acute, hot, swollen large joints with pain that radiates from joint to joint. It can last for years consistently affecting the same joints.

A smaller number of IBD patients have symmetrical polyarthritis which is typically seen in rheumatoid arthritis patients who develop inflammation in any joint, but most often smaller joints in the hands.

And, 1-6 percent of all IBD patients develop ankylosing spondylitis, a progressive inflammatory arthropathy of the sacroiliac joints and spine.

Misdiagnosis

Sometimes physicians mistake large joint arthritis for reactive arthritis, which usually develops as a result of an infection, such as Shigella or Yersinia infections in the gut or chlamydial infections of the genitourinary system. Achieving an accurate diagnosis can be difficult because it can mimic arthritis that is associated with IBD. “In patients known to have IBD, a presentation with diarrhea and arthritis could be due to reactive arthritis secondary to a gut infection, or it could be a flare of the IBD associated with arthritis. For patients not known to have IBD, this clinical presentation can be the first presentation of IBD, as joint problems are the first symptom of the disease in some IBD patients,” Dr. Orchard wrote.

Arthritis in Crohn’s disease and ulcerative colitis:

Arthritic symptoms in CD and UC are similar, but arthritis is more common in CD patients, particularly in patients with CD of the large bowel.

Causes of arthritis in IBD:

Dr. Orchard states there is probably a genetic component to arthritis in IBD patients. This type of arthritis is classified as a seronegative spondyloarthropathy. And while it does not include the presence of autoantibodies, it is associated with an increased risk of ankylosing spondylitis.

Peripheral arthritis in IBD patients has a strong association with HLA-DR103, which is present in 35% of patients with large joint arthritis (but in only 1-3% of the general population).

“How this genetic association results in arthritis among IBD patients is largely speculation. My hypothesis is that episodic bouts of arthritis are triggered by the combination of a leaky, inflamed gut, which is found in IBD, plus a genetic susceptibility to certain bacteria that patients may encounter. This susceptibility is determined by the HLA genes (and possibly other genes) that patients have inherited, and it allows an uncontrolled inflammatory response to develop, specifically targeting the joints,” Dr. Orchard wrote.

Both ankylosing spondylitis and peripheral arthritis in IBD patients are associated with HLA-B27, a gene that controls the immune response.

A leaky gut can trigger an arthritic flare:  “If they have gut inflammation, which makes the gut very leaky, then their immune system is exposed to many antigens they would not otherwise encounter, and IBD can trigger ankylosing spondylitis in the absence of HLA-B27. If patients have the combination of both HLA-B27 and a leaky gut, then their chances of developing axial arthritis are very high.”

Treatment

For persistent inflammatory arthritis with IBD, anti-TNF therapies such as infliximab, adalimumab and certolizumab pegol have been shown to be most effective. Corticosteroids are not generally effective for ankylosing spondylitis and immunomodulators may help in peripheral arthritis, he wrote.

Dr. Orchard cautions against the use of nonsteroidal anti-inflammatory drugs (NSAIDs) to treat arthritis in patients with active IBD as research suggests it can trigger an IBD flare-up.

References:

Timothy R. Orchard, M.D. “Management of Arthritis in Patients with Inflammatory Bowel Disease,” Gastroenterology and Hepatology. May 2012. PMCID: PMC3424429