Management of enteropathic arthritis
When starting therapy for enteropathic arthritis consider the potential impact of a new drug on the person’s underlying inflammatory bowel disease (IBD), as well as the effects of the therapy used to manage IBD on the person’s arthritis. Whenever possible, a drug that is effective for both indications should be used, to avoid polypharmacy. For guidance on the management of IBD, see the Gastrointestinal guidelines.
All people with spondylitis or peripheral arthritis should be advised to exercise (see Physical activity for axial spondyloarthritis), stop smoking tobacco if applicable and, if tolerated, use nonsteroidal anti-inflammatory drugs (NSAIDs) for symptom relief (see NSAIDs for axial spondyloarthritis). There is a theoretical risk that NSAIDs may aggravate IBD, therefore the potential benefits should be weighed against this and other risks.
Intra-articular corticosteroid injections may be used for peripheral arthritis if a small number of accessible joints are involved. Radiologically guided corticosteroid injections into sacroiliac joints may be beneficial for sacroiliitis. Peritendinous corticosteroid injections may be beneficial for enthesitis. They should be used with caution in enthesitis involving major weightbearing tendons such as the Achilles tendons; consider seeking specialist advice and avoid multiple injections. For principles of use and example doses of local corticosteroid injections, see Principles of local corticosteroid injection use for musculoskeletal pain.
When treatment with exercise and an NSAID is inadequate to control symptoms, or disease is severe, immunomodulatory therapy is added. Drug choice depends on the site of disease activity. For people with peripheral arthritis, conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) may be considered by specialists—sulfasalazine, azathioprine and methotrexate are preferred because they are also used to treat IBD. Biological or targeted-synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) may be effective in the treatment of enteropathic arthritis; however, there is no direct evidence to support their use. In most cases, specialists favour b/tsDMARDS that are effective for both musculoskeletal and intestinal disease—such drugs include tumour necrosis factor (TNF) inhibitors (adalimumab, certolizumab pegol, golimumab, infliximab), interleukin-23 (IL-23) antagonists, and Janus kinase (JAK) inhibitors.