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Sheth T, Pitchumoni CS, Das KM. Management of Musculoskeletal Manifestations in Inflammatory Bowel Disease. Gastroenterol Res Pract 2015; 2015:387891. [PMID: 26170832 PMCID: PMC4478299 DOI: 10.1155/2015/387891] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Accepted: 04/21/2015] [Indexed: 02/08/2023] Open
Abstract
Musculoskeletal manifestations are the most common extraintestinal manifestations in inflammatory bowel diseases. Some appendicular manifestations are independent of gut inflammation and are treated with standard anti-inflammatory strategies. On the other hand, axial involvement is linked to gut inflammatory activity; hence, there is a considerable amount of treatment overlap. Biological therapies have revolutionized management of inflammatory bowel diseases as well as of associated articular manifestations. Newer mechanisms driving gut associated arthropathy have surfaced in the past decade and have enhanced our interests in novel treatment targets. Introduction of biosimilar molecules is expected in the US market in the near future and will provide an opportunity for considerable cost savings on healthcare. A multidisciplinary approach involving a gastroenterologist, rheumatologist, and physical therapist is ideal for these patients.
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Affiliation(s)
- Tejas Sheth
- Department of Rheumatology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - C. S. Pitchumoni
- Department of Gastroenterology, Rutgers-St. Peter's University Hospital, New Brunswick, NJ, USA
| | - Kiron M. Das
- Division of Gastroenterology and Hepatology, Crohn's and Colitis Center of NJ, Rutgers-Robert Wood Johnson Medical School, Clinical Academic Building, 125 Paterson Street, Suite 5100B, New Brunswick, NJ 08901-1962, USA
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Peluso R, Manguso F, Vitiello M, Iervolino S, Di Minno MND. Management of arthropathy in inflammatory bowel diseases. Ther Adv Chronic Dis 2015; 6:65-77. [PMID: 25729557 DOI: 10.1177/2040622314563929] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The most common extra-intestinal manifestation in patients with inflammatory bowel disease (IBD) is articular involvement, with a prevalence ranging between 17% and 39%. It is frequently characterized by an involvement of the axial joints but may also be associated with peripheral arthritis. The target of therapy in the management of arthritis associated with IBD is to reduce the inflammation and prevent any disability and/or deformity. This requires active cooperation between gastroenterologist and rheumatologist. The treatment of axial involvement has focused on the combination of exercise with nonsteroidal anti-inflammatory drugs. Immunomodulators have been efficacious in patients with peripheral arthritis and other extra-intestinal manifestations, but they are not effective for the treatment of axial symptoms of spondylitis. Tumor necrosis factor (TNF) α inhibitors have been proven to be highly effective in the treatment of IBD patients which are steroid-dependent or refractory to conventional therapy and in patients with associated articular manifestations. The treatment of peripheral involvement and/or enthesitis and/or dactylitis is based on local steroid injections, while sulfasalazine and/or low doses of systemic steroids may be useful in case of inadequate response to intra-articular steroids. Sulfasalazine induces only a little improvement in peripheral arthritis. Immunomodulators such as methotrexate, azathioprine, cyclosporine and leflunomide show their efficacy in some patients with peripheral arthritis and other extra-intestinal components. TNF-α inhibitors should be considered the first-line therapeutic approach when moderate-to-severe luminal Crohn's disease or ulcerative colitis is associated with polyarthritis. The aim of this review is to provide a fair summary of current treatment options for the arthritis associated with IBD.
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Affiliation(s)
- Rosario Peluso
- Rheumatology Research Unit, Department of Clinical Medicine and Surgery, University Federico II, Via Sergio Pansini 5, 80131 Naples, Italy
| | - Francesco Manguso
- Complex Operating Unit of Gastroenterology, AORN 'A. Cardarelli', Naples, Italy
| | - Maria Vitiello
- Rheumatology Research Unit and Department of Clinical Medicine and Surgery, University Federico II, Naples, Italy
| | - Salvatore Iervolino
- Rheumatology and Rehabilitation Research Unit 'Salvatore Maugeri' Foundation, Telese Terme (BN), Italy
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Peluso R, Di Minno MND, Iervolino S, Manguso F, Tramontano G, Ambrosino P, Esposito C, Scalera A, Castiglione F, Scarpa R. Enteropathic spondyloarthritis: from diagnosis to treatment. Clin Dev Immunol 2013; 2013:631408. [PMID: 23690825 PMCID: PMC3649644 DOI: 10.1155/2013/631408] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Accepted: 03/25/2013] [Indexed: 02/08/2023]
Abstract
Enteropathic arthritis (EA) is a spondyloarthritis (SpA) which occurs in patients with inflammatory bowel diseases (IBDs) and other gastrointestinal diseases. Diagnosis is generally established on the medical history and physical examination. It was, generally, made according to the European Spondyloarthropathy Study Group (ESSG) criteria. Rheumatic manifestations are the most frequent extraintestinal findings of IBD with a prevalence between 17% and 39%, and IBD is associated, less frequently, with other rheumatic disease such as rheumatoid arthritis, Sjogren syndrome, Takayasu arteritis, and fibromyalgia. Although the pathogenesis of EA has not been plainly clarified, the most popular theory supposes that joint inflammation occurs in genetically predisposed subjects with bacterial gut infections, provided an important evidence for a possible relationship between inflammation of the gut mucosa and arthritis. The management of patients with EA requires an active cooperation between the gastroenterologist and rheumatologist.
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Affiliation(s)
- Rosario Peluso
- Rheumatology Research Unit, University Federico II, 80131 Naples, Italy.
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Ergül B, Koçak E, Köklü S. Arthritis as a presenting symptom of subclinical Crohn's disease. J Crohns Colitis 2012; 6:634-5. [PMID: 22410347 DOI: 10.1016/j.crohns.2012.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Accepted: 02/03/2012] [Indexed: 02/08/2023]
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Rodríguez-Reyna TS, Martínez-Reyes C, Yamamoto-Furusho JK. Rheumatic manifestations of inflammatory bowel disease. World J Gastroenterol 2009; 15:5517-24. [PMID: 19938189 PMCID: PMC2785053 DOI: 10.3748/wjg.15.5517] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
This article reviews the literature concerning rheumatic manifestations of inflammatory bowel disease (IBD), including common immune-mediated pathways, frequency, clinical course and therapy. Musculoskeletal complications are frequent and well-recognized manifestations in IBD, and affect up to 33% of patients with IBD. The strong link between the bowel and the osteo-articular system is suggested by many clinical and experimental observations, notably in HLA-B27 transgenic rats. The autoimmune pathogenic mechanisms shared by IBD and spondyloarthropathies include genetic susceptibility to abnormal antigen presentation, aberrant recognition of self, the presence of autoantibodies against specific antigens shared by the colon and other extra-colonic tissues, and increased intestinal permeability. The response against microorganisms may have an important role through molecular mimicry and other mechanisms. Rheumatic manifestations of IBD have been divided into peripheral arthritis, and axial involvement, including sacroiliitis, with or without spondylitis, similar to idiopathic ankylosing spondylitis. Other periarticular features can occur, including enthesopathy, tendonitis, clubbing, periostitis, and granulomatous lesions of joints and bones. Osteoporosis and osteomalacia secondary to IBD and iatrogenic complications can also occur. The management of the rheumatic manifestations of IBD consists of physical therapy in combination with local injection of corticosteroids and nonsteroidal anti-inflammatory drugs; caution is in order however, because of their possible harmful effects on intestinal integrity, permeability, and even on gut inflammation. Sulfasalazine, methotrexate, azathioprine, cyclosporine and leflunomide should be used for selected indications. In some cases, tumor necrosis factor-α blocking agents should be considered as first-line therapy.
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Orlando A, Renna S, Perricone G, Cottone M. Gastrointestinal lesions associated with spondyloarthropathies. World J Gastroenterol 2009; 15:2443-8. [PMID: 19468992 PMCID: PMC2686900 DOI: 10.3748/wjg.15.2443] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Subclinical gut inflammation has been described in up to two-thirds of patients with spondyloarthropathies (SpA). Arthritis represents an extra-intestinal manifestation of several gastrointestinal diseases, including inflammatory bowel disease (IBD), Whipple’s disease, Behcet’s disease, celiac disease, intestinal bypass surgery, parasitic infections of the gut and pseudomembranous colitis. Moreover about two-thirds of nonsteroidal anti-inflammatory drug users demonstrate intestinal inflammation. Arthritis may manifest as a peripheral or axial arthritis. The spondyloarthropathy family consists of the following entities: ankylosing spondylitis, undifferentiated spondyloarthritis, reactive arthritis, psoriatic arthritis, spondyloarthritis associated with IBD, juvenile onset spondyloarthritis. This topic reviews the major gastrointestinal manifestations that can occur in patients with SpA and in nonsteroidal anti-inflammatory drugs users.
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Padovan M, Castellino G, Govoni M, Trotta F. The treatment of the rheumatological manifestations of the inflammatory bowel diseases. Rheumatol Int 2006; 26:953-8. [PMID: 16799777 DOI: 10.1007/s00296-006-0148-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2005] [Accepted: 05/26/2006] [Indexed: 12/18/2022]
Abstract
The strong link between the bowel and the osteo-articular system is suggested by many clinical and experimental observations. However, the therapeutic approach is still empirical. For symptomatic therapy it is better to favour the use of steroids and avoid non-steroidal anti-inflammatory drugs because they may induce intestinal ulcerations and can activate inflammatory bowel disease. Second line drugs (sulfasalazine, methotrexate, azathioprine, cyclosporine and leflunomide) should be used for selected indications. In some cases (severe spondylitis, severe and persistent enthesopathy) anti-TNF-alpha agents (infliximab) should be considered as first line therapy. In all cases it is mandatory to select the best therapeutic option for each individual patient, considering that the optimal treatment of bowel inflammation may induce "per se" a remission of the musculo-skeletal manifestations.
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Affiliation(s)
- Melissa Padovan
- Unit of Rheumatology, Department of Clinical and Experimental Medicine, University of Ferrara, Corso Giovecca 203 44100, Ferrara, Italy.
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De Keyser F, Baeten D, Van den Bosch F, De Vos M, Cuvelier C, Mielants H, Veys E. Gut inflammation and spondyloarthropathies. Curr Rheumatol Rep 2002; 4:525-32. [PMID: 12427369 DOI: 10.1007/s11926-002-0061-6] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Spondyloarthropathies (SpA) are a group of related disorders with common clinical and genetic characteristics. The prototype disease in this group is ankylosing spondylitis; other entities include reactive arthritis, psoriatic arthritis, and arthritis in patients with inflammatory bowel disease. Over recent years, there has been a special interest in the relation between spondylitis/synovitis and gut inflammation in patients with SpA. Two thirds of patients with undifferentiated SpA show histologic signs of gut inflammation, and a fraction of these patients go on to develop clinically overt Crohn's disease. In this review, the authors will focus on 1) the growing evidence that has been provided that gut inflammation in SpA is immunologically related to Crohn's disease, based on the molecular characterization of the inflammation (lymphocyte homing markers and ligands, T cell cytokines, macrophage markers, and serology); and 2) on the therapeutic implications resulting from this concept. The recent introduction and positioning of anti-tumor necrosis factor-alpha therapy in patients with ankylosing spondylitis and other types of SpA is, in large part, based on this concept.
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Affiliation(s)
- Filip De Keyser
- Department of Rheumatology, Ghent University Hospital, De Pintelaan 185, Ghent B-9000, Belgium.
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Abstract
Enteropathic arthritis is a label for conditions in which gut pathology is believed to be of pathogenic importance for the developing joint disease. Impaired barrier function, as well as immunogenetic mechanism, are implicated. Recent publications have highlighted strong new support for the homing of lymphocytes from the gut mucosa to joint tissue, persistence of antigen- and cytokine-based immune deficiency. A convincing argument was made for the interesting observation that two distinct types of joint involvement with different class II HLA backgrounds occur in patients with inflammatory bowel disease. A new mechanism implicating dimeric HLA-B27 heavy chains in the pathogenesis of enteropathic arthritis is also presented. Despite evidence for persisting antigen presence, antimicrobial therapy seems ineffective in reactive arthritis.
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Affiliation(s)
- F A Wollheim
- Department of Rheumatology, Lund University Hospital, University of Lund, Lund, Sweden.
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Baeten D, Kruithof E, Van den Bosch F, Demetter P, Van Damme N, Cuvelier C, De Vos M, Mielants H, Veys EM, De Keyser F. Immunomodulatory effects of anti-tumor necrosis factor alpha therapy on synovium in spondylarthropathy: histologic findings in eight patients from an open-label pilot study. ARTHRITIS AND RHEUMATISM 2001; 44:186-95. [PMID: 11212159 DOI: 10.1002/1529-0131(200101)44:1<186::aid-anr25>3.0.co;2-b] [Citation(s) in RCA: 143] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To assess the effects of treatment with anti-tumor necrosis factor alpha (anti-TNFalpha) on synovial histology in patients with spondylarthropathy (SpA) in order to confirm the effect on peripheral synovitis and to investigate the immunologic mechanisms involved in anti-TNFalpha therapy. METHODS Patients with treatment-resistant SpA were treated with infliximab (5 mg/kg) at weeks 0, 2, and 6 in an open-label pilot study. In 8 patients, synovial biopsy tissues obtained at baseline, week 2, and week 12 were used for histologic and immunohistochemical evaluation. RESULTS In all 8 patients (3 with ankylosing spondylitis, 1 with undifferentiated SpA, and 4 with psoriatic arthritis), there was a clear clinical improvement in the peripheral arthritis after anti-TNFalpha therapy. Histologic analysis of the synovial biopsy tissues indicated that the synovial lining layer thickness tended to decrease, with a significant reduction of CD55+ synoviocytes, at week 12. In the sublining layer, vascularity was reduced at week 12, with a decreased endothelial expression of vascular cell adhesion molecule 1 but not intercellular adhesion molecule 1, platelet endothelial cell adhesion molecule 1, and E-selectin. Although at week 2 and week 12, the number of neutrophils and CD68+ macrophages in the sublining layer was decreased, the overall degree of inflammatory infiltration remained unchanged. This could be related to the lymphocyte infiltration since at week 12, only CD4+ cells (but not CD3+, CD45RO+, and CD8+ cells) tended to decrease, while CD20+ lymphocytes and plasma cells were clearly increased. CONCLUSION The reduction in lining layer thickness, vascularity, and infiltration with neutrophils and macrophages paralleled the beneficial effect of anti-TNFalpha therapy on peripheral synovitis in 8 patients with different subtypes of SpA. The adhesion molecule expression, T cell infiltration, and, most important, B cell infiltration seemed to contrast with previous observations in RA. Although these preliminary data need to be confirmed in a larger cohort, they suggest distinct immunomodulatory mechanisms of anti-TNFalpha in SpA.
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Affiliation(s)
- D Baeten
- Department of Rheumatology, Ghent University, Belgium
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Van den Bosch F, Kruithof E, Baeten D, De Keyser F, Mielants H, Veys EM. Effects of a loading dose regimen of three infusions of chimeric monoclonal antibody to tumour necrosis factor alpha (infliximab) in spondyloarthropathy: an open pilot study. Ann Rheum Dis 2000; 59:428-33. [PMID: 10834859 PMCID: PMC1753171 DOI: 10.1136/ard.59.6.428] [Citation(s) in RCA: 226] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To evaluate the efficacy and safety of a loading dose regimen of three intravenous infusions with infliximab in patients with active spondyloarthropathy. METHODS A monocentre, open-label pilot study of 21 patients with different subtypes of spondyloarthropathy was conducted. Treatment resistant patients with active disease (fulfilling inclusion criteria) received three infusions of 5 mg/kg infliximab (at weeks 0, 2, and 6). Standard clinical assessments were performed at baseline, and on days 3, 7, and 14, and from then on every two weeks. In patients who fulfilled criteria for ankylosing spondylitis, axial assessment was performed at baseline and on days 14, 42, and 84. RESULTS In all global assessments (visual analogue scale of patient global assessment, patient pain assessment, doctor global assessment), erythrocyte sedimentation rate, and C reactive protein, a highly significant decrease could be seen already at day 3 (compared with baseline), which was maintained up to day 84. In patients with peripheral disease (n=18), tender and swollen joint count significantly decreased. In patients with axial disease (n=11), functional and disease activity indices significantly improved. Moreover in eight patients with psoriatic arthritis a significant decrease of the psoriasis area and severity index was observed. The treatment was well tolerated in all patients; no significant adverse events were seen. CONCLUSION In this open-label pilot study of a loading dose regimen of three infusions of chimeric monoclonal antibody to tumour necrosis factor alpha in patients with active spondyloarthropathy, there was a fast and significant improvement of axial and peripheral articular manifestations, without major adverse experiences.
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Affiliation(s)
- F Van den Bosch
- Ghent University Hospital, Department of Rheumatology, Belgium
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