What is the management of enteropathic arthritis?

Management of Enteropathic Arthritis

TNF inhibitors (infliximab or adalimumab) are the first-line treatment for enteropathic arthritis with active IBD, as they effectively treat both the joint and intestinal manifestations simultaneously. 1

Initial Assessment and Classification

• Distinguish between peripheral and axial involvement, as treatment strategies differ significantly 1
• Peripheral arthritis is subdivided into Type I (pauciarticular, ≤4 joints) and Type II (polyarticular, ≥5 joints) 2, 3
  • Type I typically correlates with IBD flares and improves with bowel disease control 3
  • Type II runs independently of bowel disease activity and requires more aggressive management 3
• Use ASDAS-CRP for axial disease activity monitoring (cut-offs: ≤1.3 inactive, >3.5 very high activity) 1
• Use DAPSA for peripheral disease activity monitoring 1

Treatment Algorithm for Active Peripheral Arthritis with Active IBD

Mild Disease

• Sulfasalazine 2-3 g/day for mild ulcerative colitis with peripheral arthritis 1
• In Crohn's disease, sulfasalazine can be added as adjunctive therapy for peripheral arthritis only (not effective for intestinal Crohn's) 1
• Local corticosteroid injections for oligoarthritis (≤4 joints), enthesitis, or dactylitis 1

Moderate-to-Severe Disease

• TNF inhibitors (infliximab, adalimumab, or golimumab in UC) as first-line therapy 1
  • This recommendation is based on extensive efficacy data and availability of cost-effective biosimilars 1
• Short-term systemic corticosteroids (2-4 weeks) for rapid symptom control as bridge therapy 1
• JAK inhibitors (tofacitinib, filgotinib, upadacitinib) or ustekinumab as alternative first-line options 1

After Primary TNF Inhibitor Failure

• Switch to ustekinumab or JAK inhibitors (change mechanism of action preferred over switching within TNF inhibitor class) 1

After Secondary TNF Inhibitor Failure or Intolerance

• Consider dose escalation of current TNF inhibitor, switch to another TNF inhibitor, JAK inhibitor, or ustekinumab 1

Treatment Algorithm for Axial Spondyloarthritis with Active IBD

First-Line Treatment

• TNF inhibitors (infliximab or adalimumab) are recommended 1
• Certolizumab pegol is FDA-approved for Crohn's disease and effective for axial SpA 1
• Avoid etanercept as it is ineffective in Crohn's disease and may trigger new-onset disease 1

Medications to Avoid

• Sulfasalazine and methotrexate have no efficacy for axial disease 1

After Primary TNF Inhibitor Failure

• Switch to JAK inhibitors 1

After Secondary TNF Inhibitor Failure or Intolerance

• Consider dose escalation, switch to another TNF inhibitor, or JAK inhibitor 1

Treatment for Arthritis with IBD in Remission

Axial Disease with Quiescent IBD

• Short 2-4 week course of selective COXIBs (celecoxib or etoricoxib) is acceptable 1
• TNF inhibitors (infliximab, adalimumab, or golimumab in UC) if COXIBs insufficient 1
• After primary TNF failure, switch to JAK inhibitors 1
• After secondary TNF failure, consider dose escalation, switch to another TNF inhibitor, or JAK inhibitor 1

Peripheral Disease with Quiescent IBD

• After secondary TNF failure, consider dose escalation, switch to another TNF inhibitor, JAK inhibitor, or ustekinumab 1

Special Considerations and Pitfalls

Vedolizumab

• Avoid vedolizumab for musculoskeletal manifestations as its gut-specific mechanism makes it ineffective for arthritis 1
• Paradoxically, vedolizumab may cause new-onset or worsening arthritis/arthralgias 1
• Only consider vedolizumab after failure of all other therapies in patients with active intestinal disease 1

Anti-IL-17 Agents

• Use anti-IL-17 agents only in axial SpA unresponsive to all other treatments with long-term IBD remission 1
• Monitor closely for IBD exacerbation or new-onset IBD 1

De-escalation Strategy

• In stable remission of both musculoskeletal and intestinal symptoms, consider discontinuing advanced therapy on case-by-case basis 1
• Continue 5-ASA compounds in ulcerative colitis 1
• Consider thiopurines (CD and UC) or methotrexate (CD only) for maintenance 1
• Do not discontinue therapy in axial SpA remission due to high recurrence probability 1

Critical Pitfalls

• Avoid long-term NSAID use in IBD patients as it may exacerbate bowel symptoms 1, 4
• Do not use methotrexate or sulfasalazine for axial disease as they are ineffective 1
• Recognize that Type I peripheral arthritis often improves with IBD treatment alone, while Type II requires independent management 3