Identifying Spondyloarthritis in Patients With Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is estimated to affect up to 0.5% of the population, and often develops among patients who have other types of inflammatory conditions, including spondyloarthritis (SpA) that may be present in 2% to 46% of patients with IBD.¹

Because SpA creates a significant burden in terms of pain and disability from progressive joint deformation, early identification in patients at higher risk for the disease is important. Gastrointestinal conditions like IBD may offer the opportunity for clinicians to monitor patients for the development of SpA. “The same immune-mediated factors in IBD are often present in SpA and there is an overlap between the 2,” explained Miguel Regueiro, MD, chair of the department of gastroenterology and hepatology, vice chair of Digestive Disease and Surgery Institute, and professor of medicine at the Lerner College of Medicine, Cleveland Clinic, Ohio.

SpA Subtypes in IBD

The primary symptom of axial manifestations of SpA (axSpA) is inflammatory back pain of the sacroiliac joints. Although ankylosing spondylitis (AS) is the most common subtype of axSpA, it is also least frequently seen among patients with IBD, indicating that the rates of overlap vary with different forms of SpA. Pooled analyses of 71 studies of IBD by Karreman et al¹ showed a prevalence of comorbid AS of 3%, compared with prevalence of sacroiliitis and arthritis of 10% and 13%, respectively. The broad heterogeneity of these findings was attributed to the geographic spread of the studies and variations in study enrollment criteria, but the patterns may be relevant.

“Additionally, for the axial arthritides, such as AS or sacroiliitis, there is often a haplotype overlap,” Dr Regueiro said, pointing to the human leukocyte antigen (HLA)-B27-positive correlation between IBD and axial arthritis. Studies conducted in 2 European cohorts found that both these conditions were associated with the HLA-B27 and indicated a higher risk of developing axSpA.² In addition, the Assessment of SpondyloArthritis international Society (ASAS) identified a group of inflammatory conditions, including AS and IBD, as well as acute anterior uveitis, reactive arthritis, and/or psoriasis, in first- or second-degree relatives with a diagnosis of SpA.³

Dr Regueiro also noted that, given the high overlap with IBD, patients with uveitis and/or AS who are [tested as] HLA-B27-positive merit a workup for IBD. “Usually we don’t screen patients [with] IBD for SpA, as they will have obvious symptoms of SpA,” he noted. “However, there are certain [types of] SpA that would warrant a workup for IBD. For example, patients with AS or sacroiliitis or with many migratory arthritis symptoms, including inflammation to other organs such as the eye, are often referred to a gastroenterologist for a workup of ulcerative colitis (UC) or [Crohn disease] (CD).”

Karreman and colleagues¹ also pointed out that while rheumatologists generally follow overlap criteria defined by the ASAS, which make a distinction between axial and peripheral manifestations, gastroenterologists may apply different standards that reflect 2 types of arthritis.³ The first, type 1 arthritis, runs a course that directly correlates with IBD activity, while type 2 does not; type 1 is self-limiting, whereas type 2 applies to diffuse disease that affects >5 joints. While these definitions have helped identify a comorbid connection, the ASAS criteria have more recently been used to assess specific patterns across the subtypes of both IBD and SpA.¹

Prevalence Data in IBD Subtypes

In a large-scale meta-analysis, Karreman and colleagues¹ evaluated the prevalence of sacroiliitis, AS, arthritis, enthesitis, and dactylitis across 71 studies, where certain patterns were observed. 

• CD vs UC was generally associated with higher rates of axSpA. The prevalence of AS, sacroiliitis, and peripheral arthritis was also higher in CD vs UC. 
• The prevalence reported from 43 of the studies were lowest for the presence of AS (3%), with a slightly higher prevalence in CD than UC.
• Estimates of peripheral SpA in IBD were about 13%, as reported in 40 studies.  Prevalence estimates for enthesitis ranged from 1% to 54%, and the range for dactylis was ≤5%.

Because of the broad heterogeneity of the studies used, the authors have cautioned about relying on the specifics of the data; however, they suggested that patients with IBD should be monitored for potential SpA manifestations.

Quality of Life

Patients from the IBSEN study⁴ who reported current joint symptoms up to 20 years after their initial diagnosis of IBD had a poorer health-related quality of life (HRQoL), which was indicated by higher levels of fatigue and chronic fatigue; however, SpA did not correspond to negative effects on HRQoL or fatigue.⁴ “These patients have a high inflammatory burden on the body with consequent poorer quality of life, because the bowel symptoms or the joint symptoms alone can lead to a poor quality of life. When you combine the 2 in [a patient], this often leads to a poorer quality of life,” Dr Regueiro said.

Treatments

Without suitable treatment, severe joint deformations can occur in patients with SpA, in both the peripheral joints and the spine. Quality of life for these patients is mitigated by prompt identification and treatment of SpA to prevent future disability.¹

Dr Regueiro explained that treatments for IBD may also be used to manage symptoms of SpA. “Often the same anti-inflammatory medications work to reduce inflammation and control in symptoms of both IBD and SpA. Specific therapies include sulfasalazine, methotrexate, and antitumor necrosis factor therapies (eg, infliximab, adalimumab, ustekimumab, and tofacitinib).”

However, when clinicians do not recognize the possible overlaps between IBD and SpA, the 2 conditions may end up being treated separately by different providers. “That’s why it is important that the rheumatologist and gastroenterologist coordinate care of these patients. While fortunately, most of the patients with an overlap of SpA and IBD will respond to the same medication, there needs to be coordination between specialists,” Dr Regueiro concluded.

References

1. Karreman MC, Luime JJ, Hazes JMW, Weel AEAM. The prevalence and incidence of axial and peripheral spondyloarthritis in inflammatory bowel disease: a systematic review and meta-analysis. J Crohns Colitis. 2017;11:631-642.

2. van Lunteren M, Sepriano A, Landewé R, et al. Do ethnicity, degree of family relationship, and the spondyloarthritis subtype in affected relatives influence the association between a positive family history for spondyloarthritis and HLA-B27 carriership? Results from the worldwide ASAS cohort. Arthritis Res Ther. 2018;20:166. 

3. Rudwaleit M, van der Heijde D, Landewé R, et al. The Assessment of Spondylo-Arthritis International Society classification criteria for peripheral spondyloarthritis and for spondyloarthritis in general. Ann Rheum Dis. 2011;70:25-31.

4. Ossum AM, Palm Ø, Cvancarova M et al. The impact of spondyloarthritis and joint symptoms on health-related quality of life and fatigue in IBD patients. Results from a population-based inception cohort (20-year follow-up in the IBSEN study).Inflamm Bowel Dis. 2020;26:114-124.