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IBD and rheumatic disease can be managed concurrently.

SANTA MONICA, CALIF.--How to treat a patient with concurrent inflammatory bowel disease and rheumatic disease depends on which condition is "hot" and which is quiescent.

Using standard anti-inflammatory agents to treat the rheumatic disease is problematic because it may exacerbate the IBD. Conventional NSAIDs are associated with reversible colitis and ulceration in patients without IBD, and NSAID enteropathy--often subclinical--is present in up to 60% of patients who take these agents, according to Dr. Bennett E. Roth, director of the digestive disease center and chief of clinical gastroenterology at the University of California, Los Angeles.

Data do support the use of available cyclo-oxygenase-2 (COX-2) inhibitors in patients with both active IBD and active joint disease, Dr. Roth said at a meeting sponsored by RHEUMATOLOGY NEWS and Skin Disease Education Foundation.

Why some patients develop both IBD and arthritis is not fully understood, Dr. Roth noted. Possible explanations include the potential relocation of the immune reaction from the intestine to the joints; the activation of immune cells in the gut, draining lymphocytes that localize in the joints; and the overlap of expression of adhesion molecules that have been observed on the surface of intestinal epithelial cells and in synovial fluid. Other possibilities include the potential reactivation of T cells at the articular levels and possible T-helper 17 (Th17) cell-mediated response aided by tumor necrosis factor (TNF).

IBD arthropathy can take two forms: spondyloarthropathy (SpA) and peripheral arthropathy. Each has its own course and relationship to IBD, Dr. Roth said.

The degree of SpA activity in IBD patients is independent of the IBD activity.

Among patients with both conditions, 20%-25% have sacroiliitis on x-ray; 50% of cases of sacroiliitis in IBD are asymptomatic.

Ankylosing spondylitis (AS)--be it HLA-B27 negative or positive--has a prevalence of 3%-10% in this population, according to Dr. Roth.

Rheumatologists may be the first to see signs of IBD in some of these patients. Young patients who present with axial arthropathy may be candidates for a gastrointestinal evaluation, said Dr. Roth, who is also director of the center for esophageal disorders at UCLA.

The treatment regimen for AS includes physiotherapy 5-aminosalicylic acid (5-ASA) or immunomodulatory therapy with agents such as 6-mercaptopurine or azathioprine (6MP/AZA), or methotrexate. Fallback treatments are short courses of steroids. If these are insufficient, biologic anti-TNF antibodies may be effective.

One large study showed that infliximab was efficacious in 61% of a group of IBD patients with peripheral arthritis (Am. J. Gastroenterol. 2002;97:2688-90). Infliximab has been shown to be effective in 53% of patients with AS, regardless of the presence of concurrent IBD (Lancet 2002; 359:1187-93). Findings from randomized controlled trials of patients who had both AS and IBD and were treated with infliximab show a significant drop in BASDAI (Bath Ankylosing Spondylitis Disease Activity Index) scores but not CDAI (Crohn's Disease Activity Index) scores (Ann. Rheum. Dis. 2004; 63:1664-9).

Peripheral arthropathy is divided into types 1 and 2 for classification purposes. Type 1 peripheral arthropathy can involve the large joints, specifically ankles, knees, hips, elbows, and shoulders, in a pauciarticular pattern.

When it comes to the treatment of type 1, Dr. Roth said that as the IBD goes, "so goes the arthritis." In other words, because the joint inflammation corresponds to the activity of the disease in the gut, there is likely to be a concomitant joint response once the bowel disease is placed into remission. Standard approaches to treating the IBD are employed, including anti-inflammatory agents such as 5-ASA and steroids with the additional use of immunosuppressants 6MP/AZA, or anti-TNF agents as needed.

Other options include a local steroid injection when possible and the use of simple analgesics. However, NSAIDs (with the possible exception of celecoxib) should be avoided.

Type 2 peripheral arthropathy involves the small joints of the hands, is persistent and polyarticular, and follows a course that is independent of the IBD course.

Treatment consists of physical therapy, simple analgesics, short courses of steroids with progression to immunosuppressive agents, and/or biologics as needed.

Disclosures: Dr. Roth reported that he has no financial disclosures that are relevant to the topic of his presentation. Skin Disease Education Foundation and RHEUMATOLOGY NEWS are owned by Elsevier.
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Title Annotation:GASTROENTEROLOGY; inflammatory bowel disease
Author:Kubetin, Sally Koch
Publication:Internal Medicine News
Article Type:Report
Geographic Code:1USA
Date:Apr 1, 2010
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