Ulcerative Colitis Clinical Case Review

Sujaata Dwadasi, MD, an IBD Specialist at Carle Foundation Hospital in Illinois, talks about the patient’s results after using the chosen therapy and discusses the case:

“Once we got her started on adalimumab, we wanted to make sure that we were monitoring her per the STRIDE2 guidelines.

We ended up having a follow-up visit around 3 months, and we noticed that her clinical symptoms had greatly improved — she was almost in clinical remission. As far as her objective markers, I could see that her fecal calprotectin improved to 103, and her CRP normalized and she noted that there was resolution of her joint pain.

About 6 months later, after starting adalimumab, she was in complete clinical remission and [underwent] a colonoscopy. As you can see here from these pictures, she was in endoscopic remission as well, and she continued to have no joint pains. Because [of this], we didn’t actually discuss any further workup for her joint pains and felt that this was truly an IBD arthropathy that started at the time that her symptoms were getting worse.

Talking a little bit about IBD-associated arthritis, or IBD arthropathy: it is the most common extraintestinal manifestation. It occurs in about 15% to 30% of IBD patients. It is more common in [patients with] Crohn’s disease than UC, and [there is] a higher likelihood if other extraintestinal manifestations are present as well.

There [are] actually three different types of IBD arthropathies. There is type 1 , which is peripheral. It can be isolated joints, and it usually affects less than five joints, usually larger joints, and this can be self-limiting and parallels luminal inflammation. So, [in] our case, our patient likely had type 1 peripheral arthritis.

There’s also type 2 peripheral — it’s usually symmetric joints that are involved, and usually more than five. They’re usually smaller joints, including MCPs, ankles and knees. It is usually chronic and does not always parallel luminal inflammation.

There’s also axial arthritis, which includes ankylosing spondylitis and sacroiliitis. It is not always associated with serology of HLA-B27, but it can be sometimes, and that can be positive. It can also be seen with peripheral arthritis. It does not always parallel luminal inflammation.

When making the diagnosis of IBD arthropathy, imaging is not needed to diagnosis IBD peripheral arthritis. However, it may be helpful to rule out other causes of joint pain. Imaging can be helpful for IBD axial arthritis. And unfortunately, there’s no lab testing to confirm IBD arthropathy, as we have just discussed. Sometimes, some patients may have a positive HLA-B27 for axial arthritis, but not always, and sometimes patients can have an elevated inflammatory marker such as a CRP. But as you know, those can be nonspecific and can be elevated for other reasons, like luminal inflammation.

So, if you’re starting a therapy on a patient and there is [a] high likelihood of IBD arthropathy, just like the patient in our case, we want to make sure that we start a therapy that could potentially treat both. However, if a patient is already on a therapy, then we really want to make sure before starting a therapy or making a huge change in their therapy plan that we’re ruling out and considering other causes for their joint pain, such as osteoarthritis or rheumatoid arthritis. Have they recently been on steroids and potentially having joint pain from steroid withdrawal? A lot of patients who are on anti-TNF therapies can get joint pains from antibodies to their anti-TNF [therapies] or [develop] a lupus-like reaction due to their anti-TNF therapy. 

[We must consider] all of these causes before making huge changes to their therapy plan. Of course, this can be challenging and can be difficult sometimes to really diagnose, so always [make] sure that if needed, you can always consult your colleague in rheumatology to help with diagnosis.”