From the Guidelines
Patients with Systemic Lupus Erythematosus (SLE) and Rheumatoid Arthritis (RA) are at an increased risk for developing esophageal dysfunction, including dysphagia, due to esophageal involvement of extra-esophageal autoimmune disease, as reported in a recent study published in Clinical Gastroenterology and Hepatology 1.
Gastrointestinal Disorders Associated with SLE and RA
The following gastrointestinal disorders are more likely to occur in patients with SLE and RA:
- Esophageal dysfunction due to disordered immunity and infection
- Dysphagia, which is common in patients with SLE and RA, with a variable and unclear mechanism
- Esophageal involvement of dermatologic disease, such as pemphigus vulgaris and lichen planus
- Eosinophilic esophagitis (EoE), which has been associated with achalasia and may occur in patients with SLE and RA
- Autoimmune esophagitis, which can manifest as ulcerations, dilation with reflux changes, or nonspecific edema and crepe paper appearing tissue
Diagnostic Considerations
When evaluating patients with SLE and RA for gastrointestinal disorders, the following diagnostic considerations should be taken into account:
- Upper endoscopy with biopsies to rule out other diagnoses, such as candidal esophagitis or medication-induced ulceration
- High-resolution esophageal manometry to assess esophageal motility
- Timed barium esophagram with pill to evaluate esophageal function
- Direct immunofluorescence (DIF) staining to diagnose pemphigus vulgaris or other autoimmune esophagitis
Management and Prevention
To manage and prevent gastrointestinal disorders in patients with SLE and RA, the following strategies should be employed:
- Regular monitoring of gastrointestinal symptoms and liver function tests
- Appropriate gastroprotection with proton pump inhibitors, such as omeprazole 20mg daily, for patients on NSAIDs or corticosteroids
- Consideration of eradication of eosinophilic infiltration of the esophagus in patients with clinical suspicion of comorbid EoE
- Avoidance of medications that can exacerbate gastrointestinal disorders, such as NSAIDs and corticosteroids, when possible.
From the Research
Gastrointestinal Disorders in SLE and RA
- Patients with Systemic Lupus Erythematosus (SLE) are more likely to experience functional gastrointestinal disorders (FGIDs) such as nausea and vomiting disorders, belching disorders, globus, anorectal pain, functional heartburn, and functional bloating 2
- The presence of at least one FGID is higher in SLE patients (73.4%) compared to controls (54.1%) 2
- In Rheumatoid Arthritis (RA) patients, the risk of gastrointestinal perforation is higher, particularly in the lower GI tract, with a rate of 1.70 per 1,000 person years 3
- Age and diverticulitis are among the strongest risk factors for perforation in RA patients, with a hazard ratio of 14.5 for diverticulitis 3
Medication-Related Risks
- Nonsteroidal anti-inflammatory drugs (NSAIDs) and glucocorticoids are associated with an increased risk of gastrointestinal events in RA patients 4, 3
- COX-2 specific inhibitors may be a more cost-effective strategy for preventing GI toxicity in RA patients, with a lower risk of gastrointestinal events compared to NSAIDs 4, 5
- In SLE patients, glucocorticoids and NSAIDs are potential risk factors for FGIDs, with an odds ratio of 5.2 and 3.0, respectively 2
Comparison of Gastrointestinal Disorders in SLE and RA
- While both SLE and RA patients are at risk for gastrointestinal disorders, the specific disorders and risk factors may differ between the two conditions 3, 2
- Further research is needed to fully understand the relationship between SLE, RA, and gastrointestinal disorders, and to develop effective strategies for prevention and treatment 4, 2