Initial treatment of inflammatory bowel disease (IBD)-related arthritis

COX: cyclooxygenase; IA: intraarticular; IBD: inflammatory bowel disease; JAK: Janus kinase; NSAID: nonsteroidal antiinflammatory drug; TNF: tumor necrosis factor.

* Patients with IBD should only be treated for IBD-related arthritis if septic arthritis has been excluded. For more information on the clinical manifestations and diagnosis of septic arthritis, refer to UpToDate content on septic arthritis.

¶ For patients with peripheral arthritis affecting a limited number of joints that are amenable to injection, add IA glucocorticoid injections. We generally inject up to a maximum of 3 to 4 joints. For information on the procedure and drug dosing for IA glucocorticoids, refer to UpToDate content on joint aspiration and injection in adults and children.

Δ We define active IBD based on symptoms (eg, weight loss, bloody stool) or evidence of active subclinical disease activity on laboratory tests (eg, elevated fecal calprotectin), imaging, and/or endoscopy.

◊ An NSAID trial should only be done in coordination with the patient's gastroenterologist.

§ Agents that have been used to treat both IBD and IBD-related arthritis include glucocorticoids, sulfasalazine, methotrexate, azathioprine, 6-mercaptopurine (6-MP), TNF inhibitors, and JAK inhibitors. For more information on choosing a therapy, refer to UpToDate content on the treatment of IBD and IBD-related arthritis.

¥ Treatments for one disease manifestation that may exacerbate another include NSAIDs (treats IBD-related arthritis, may cause a flare of IBD) and vedolizumab (treats IBD, may cause a flare of arthritis). When an NSAID is required, we choose a COX-2 selective NSAID (eg, celecoxib) instead of a nonselective NSAID (eg, ibuprofen).