Ulcerative colitis

Answer: A Man With Ulcerative Colitis and Axial Spondyloarthritis

05/31/2022

Correct Answer: A. Infliximab or D. Tofacitinib.

Patients with inflammatory bowel disease (IBD) often have concurrent extra-intestinal manifestations (EIMs), with reported prevalence rates ranging from 6% to 47% depending on the studied population.1,2 Approximately 75% of EIMs occur within the first 5 years after diagnosis of IBD.1,2 Specifically, axial spondyloarthritis (ax-SpA), which includes the subtypes of ankylosing spondylitis and non-radiographic ankylosing spondylitis, occurs in up to 15% of patients with IBD and can have a substantial impact on quality of life and physical functioning.2

In general, when patients with IBD have an active concurrent EIM, it is preferable to select a therapeutic agent that is effective for both conditions, if possible. In regards to UC and ax-SpA, both TNFα-antagonists (infliximab, adalimumab and golimumab) and JAK inhibitors (tofacitinib, upadacitinib) are effective in treating and inducing remission of gut and joint symptoms.3 On the other hand, more gut-selective agents—such as vedolizumab which blocks leukocyte trafficking into the intestinal tract—does not appear to have a benefit on joint symptoms.4 In the interleukin class, IL-12/23 blockers (ustekinumab) was effective for the treatment of UC, but not ax-SpA in registry trials, whereas IL-17 blockers (secukinumab, ixekizumab) improve ax-SpA but paradoxically worsen IBD.5,6 Given the substantial burden of overlap rheumatologic EIMs in IBD, timely identification of symptoms, obtaining a definitive diagnosis, and personalizing treatment algorithms are of utmost importance.
 

References

  1. Rogler G, Singh A, Kavanaugh A, Rubin DT. Extraintestinal manifestations of inflammatory bowel disease: current concepts, treatment, and implications for disease management. Gastroenterology. 2021;161(4):1118-1132.
  2. Greuter T, Rieder F, Kucharzik T, Peyrin-Biroulet L, Schoepfer AM, Rubin DT, et al. Emerging treatment options for extraintestinal manifestations in IBD. Gut. 2021;70(4):796-802.
  3. Deodhar A, Chakravarty SD, Cameron C, et al. A systematic review and network meta-analysis of current and investigational treatments for active ankylosing spondylitis. Clin Rheumatol. 2020;39(8):2307-2315.
  4. Ramos GP, Dimopoulos C, McDonald NM, et al. The impact of vedolizumab on pre-existing extraintestinal manifestations of inflammatory bowel disease: a multicenter study. Inflamm Bowel Dis. 2021;27(8):1270-1276.
  5. Gracey E, Vereecke L, McGovern D, et al. Revisiting the gut-joint axis: links between gut inflammation and spondyloarthritis. Nat Rev Rheumatol. 2020 Aug;16(8):415-33.
  6. Fauny M, Moulin D, D'Amico F, et al. Paradoxical gastrointestinal effects of interleukin-17 blockers. Ann Rheum Dis. 2020;79(9):1132-1138.