Achieving remission of IBD: Why proactive treatment is crucial
It is difficult to imagine a more significant development in the treatment of inflammatory bowel disease (IBD) than the introduction of biologic medications, says Tauseef Ali, MD, FACP, FACG, AGAF, Medical Executive Director, SSM Health Digestive Institute and SSM Health Crohn’s and Colitis Center, Oklahoma City. The main reason: Unlike systemic drugs such as methotrexate, which act on the entire immune system, biologics target only specific immune proteins known to be involved in the inflammatory process. What’s more, says Dr. Ali, biologic medications (as well as one small-molecule therapy) offer a range of benefits:
- Long-term control of moderate-to-severe IBD symptoms
- Healing of damaged mucosal tissue
- Reduced use of corticosteroids
- Lower rates of surgery
- Reduced risk of colon cancer
The key to getting the most from biologic therapy: Set aggressive treatment goals and consider patient needs and preferences. To accomplish this, experts advise the following:
Take a treat-to-target approach
Dr. Ali notes that the first step is to define a target and then continue to monitor the patient’s response and adjust therapy accordingly to achieve it. “The reason to define and then go after a target is to achieve better clinical outcomes,” he explains. In patients with IBD, targets are set to improve symptoms and prevent complications such as surgery, hospitalization and cancer. There are three types, says Dr. Ali: 1) Short-term targets, defined as resolution of diarrhea, abdominal pain and rectal bleeding, are to improve quality of life and enable patients to conduct their daily activities; 2) Intermediate targets, defined as improving markers of inflammation such as the blood marker CRP or the stool marker calprotectin, indirectly help to assess control of inflammation; and 3) Long-term targets, defined as improving endoscopic findings of inflammation (such as the resolution of ulcers) and controlling the microscopic level of inflammation, are crucial for preventing complications such as cancer development or the need for surgery.
Consider history and comorbidities
Selection of IBD therapy should be based on shared decision-making with the patient, taking into consideration their medical history and personal preferences, says Kelly Colleen Cushing, MD, a gastroenterologist at the Brighton Center for Specialty Care in Michigan and a clinical lecturer in gastroenterology at the University of Michigan. When deciding on a treatment plan, keep these considerations in mind:
- Comorbidities that may contraindicate or raise a caution on the use of selected biologics (e.g., heart failure, renal disease)
- Vulnerability to infection
- History of malignancy
- Pregnancy
- Presence of extraintestinal manifestations (e.g., joint pain, skin disorders)
- Co-existing inflammatory disease (e.g., rheumatoid arthritis, psoriasis)
Also important: Consider frailty, as frail patients are vulnerable to serious infections. TNF inhibitors induce systemic immune suppression and are associated with an increased risk for infection, which may make non-TNF inhibitors preferable for frail patients. In one study, vedolizumab (which only targets inflammation in the gut) was associated with a 46% lower risk for serious infections among patients with ulcerative colitis compared with other patients given TNF inhibitors.1 (There was no difference in infection risk among patients with Crohn’s disease.) Dr. Cushing notes that this rule may not apply to seniors who are in good health, and that patient frailty may be a better determinant than age when electing to avoid systemic immune suppression with a TNF inhibitor.
Still, if you determine that a patient is a candidate for a particular biologic therapy, choice may be dictated by their insurance plan’s formulary. For example, some insurers will mandate a specific TNF inhibitor as the first-choice biologic therapy. “However, more insurers are becoming open to alternative first-line therapies besides anti-TNFs,” notes Dr. Cushing. Moreover, she says, insurers can be receptive to appeals for prior authorization when a non-TNF inhibitor is the best choice for a patient. “For example, if you have a patient undergoing cancer treatment, you may want a more gut-selective therapy rather than a systemic immune suppressive due to the latter’s increased risk for infection,” she says. “In that case, we could go to the insurer and outline the reasons why we think a non-TNF inhibitor would be a better first-line approach.” Another tip: Take advantage of resources at the Crohn’s & Colitis Foundation (crohnscolitisfoundation.org), which has customizable appeal letters for downloading as well as links to various programs for patients who need financial support to pay for IBD medications.
Be proactive if patients are not responding
“We used to treat active IBD more as an acute illness, but such reactive management is outdated,” says David T. Rubin, MD, Chief, Section of Gastroenterology, Hepatology and Nutrition, and Codirector, Digestive Diseases Center, University of Chicago Medicine. “Now, it’s appropriate to be proactive. This is a disease that needs a chronic management strategy.” Indeed, the Selecting Therapeutic Targets in IBD (STRIDE-II) initiative, produced by the International Organization for the Study of IBD, encourages clinicians to consider changing treatments when targets are not achieved.2 Time to response to a new agent varies depending on the patient and the medication, but after taking a baseline measurement, Dr. Rubin often repeats stool or blood tests in 6 weeks and repeats scoping in 6 months (for more on assessing response, see box).
Keep in mind, however, that some patients may respond to the initial biologic therapy at subtherapeutic levels as a result of pharmacokinetics or the presence of antidrug antibodies; in such cases, the patient may respond to drug optimization (a higher dose of drug or a shorter interval between doses). If dosage adjustment does not work, Drs. Rubin and Cushing suggest the following:
- Try another biologic within the same class. However, if a patient previously achieved therapeutic levels of a biologic with no or inadequate response, it’s unlikely that an alternative biologic within the same class will be effective. “In that case, we would likely go to a different class of medications,” says Dr. Cushing.
- Combine a biologic with an immunomodulator (thiopurines or methotrexate), which has produced superior outcomes when compared with monotherapy in clinical trials.3,4
- Investigate other reasons for nonremission, such as postinflammatory hypersensitivity, which can result in symptoms despite healing of the bowel; scar tissue that is causing obstructive symptoms; an infection such as Clostridioides difficile; or an undiagnosed comorbidity such as celiac disease.
Educate patients on biologic therapy
Some patients may be reluctant to start a biologic or may not follow their regimen as prescribed. In such cases, Dr. Rubin finds that a little knowledge can ease the minds of patients who are put off by the term “biologic” or who are frightened by the prospect of an infused or injected medication. “I always make sure people understand that ‘biologic’ simply refers to the fact that the protein is made by living cells,” says Dr. Rubin. “And I explain that biological therapies are proteins that are too big to get absorbed through the lining of your small intestine, so they have to be delivered through an injection or infusion.”
Dr. Cushing also stresses that selection of therapy should be based on shared decision-making with the patient, taking into consideration their medical history and preferences. “My approach is to have a very open, back-and-forth conversation with the patient,” says Dr. Cushing. “What’s really important is to not only talk about the risks and benefits of the medication but also what will happen if we don’t do anything. That helps patients understand that the risks are quite negligible compared with the risk of not treating the disease.”
—by Timothy Gower
Assessing treatment response
Setting specific goals for both symptom improvement and reduction in objective measures of inflammation increases a patient’s odds for achieving deep remission, says David T. Rubin, MD, Chief, Section of Gastroenterology, Hepatology and Nutrition, and Codirector, Digestive Diseases Center, University of Chicago Medicine, who coauthored the 2021 Selecting Therapeutic Targets in IBD (STRIDE-II) initiative produced by the International Organization for the Study of IBD. Start by making a baseline assessment of patient symptoms and objective targets, then routinely monitor them, says Dr. Rubin. “Not everyone can hit their targets, but with this strategy you don’t waste time on therapies that aren’t working,” he notes. “It also helps strengthen the relationship with patients.” In addition to patient-reported symptoms, these objective measures are most commonly used:
- Fecal calprotectin: STRIDE-II suggests a cut-off value of 150 µg/g to identify endoscopic healing. However, lower thresholds (<100 µg/g) may reflect deeper mucosal healing.
- C-reactive protein: Normalization (<0.5 mg/dL) is the goal, though the upper limit of normal (<0.8 mg/dL) is acceptable; however, bear in mind that 20% of the population does not form this inflammatory marker.
- Scoping. Biochemical assessment may be adequate but you might also consider colonoscopy or sigmoidoscopy to measure endoscopic healing. Various indices are available depending on the diagnosis: For Crohn’s disease, endoscopic remission is indicated by a Simple Endoscopic Score for Crohn’s Disease of ≤2 or Crohn’s Disease Endoscopic Index of Severity of <3 with lack of any ulceration. For ulcerative colitis, complete remission is associated with resolution of symptoms and a Mayo Endoscopic Subscore of 0 or 1.
References
1. Singh S, et al. Comparative risk of serious infections with biologic and/or immunosuppressive therapy in patients with inflammatory bowel diseases. Clin Gastroenterol Hepatol. 2020;18(1):69-81.e3.
2. Turner D, et al. STRIDE-II: An Update on the Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) Initiative of the International Organization for the Study of IBD (IOIBD): Determining therapeutic goals for treat-to-target strategies in IBD. Gastroenterology. 2021;160(5):1570-1583.
3. Feurstein JD, et al. AGA Clinical Practice Guidelines on the Management of Moderate to Severe Ulcerative Colitis. Gastroenterology. 2020;158(5):1450-1461.
4. Lichtenstein GR, et al. ACG Clinical Guideline: Management of Crohn’s Disease in Adults. Am J Gastroenterol. 2018;113(4):481-517.
Overcoming
barriers to effective communication
One of the biggest hurdles in a clinical setting—particularly when it comes to gastrointestinal disease—is patients’ reluctance to talk about bodily functions because they’ve been taught that it isn’t polite. What’s more, lack of an open dialogue may affect disease management by contributing to treatment nonadherence and patient dissatisfaction.1,2
“While doctors talk to many people throughout the day about bowel activities, many people still consider this to be private or embarrassing to talk about,” says Cedrek McFadden, MD, FACS, FASCRS, a colorectal surgeon and Clinical Associate Professor at the University of South Carolina School of Medicine, Greenville, and staff physician at the Greenville Health System. Other issues include inadequate verbiage to discuss symptoms, confusion about what’s “normal,” worries about being judged and fear of cancer. Understanding these common barriers and taking steps to address them are important for optimizing management of inflammatory bowel disease (IBD). Here’s how to help patients feel comfortable discussing their symptoms and concerns.
Barrier: Lack of trust
This is a challenge for every medical specialty but can be even more so with a condition like IBD. Patients who don’t completely trust their gastroenterologists may hesitate to share potentially embarrassing information with them.
How to overcome it:
Establish a partnership from the start.
“I make patients feel that this is a safe environment,” says Dr. McFadden. Two things he likes to say: “What can I do to help you today?” and “I understand the challenges you’re having.” And then he listens carefully. “There may be clues in the patient’s history that could lead to improvements in the treatment plan,” he says. “Once patients recognize the physician as an ally and advocate, they will feel more comfortable opening up.”
Barrier: Embarrassment
In general, people have been taught it’s impolite to discuss bodily functions. A recent survey suggests this extends to the gastroenterologist’s office: A questionnaire given to U.S. adults with ulcerative colitis revealed that about one-third did not report symptoms such as bowel urgency because of embarrassment, although the majority said they would like to discuss it with their GI specialist.3
How to overcome it: Be relaxed and straightforward.
“Don’t make it seem hush-hush or awkward,” says Lisa Ganjhu, DO, gastroenterologist and Clinical Associate Professor of Medicine at NYU Langone Health. “Talk about it matter-of-factly so they feel at ease.” She tells her patients, “This is a normal bodily function and we all do it. We all want to be comfortable, and I can help make you feel better.”
It’s also important to adopt a nonjudgmental attitude, says Dr. McFadden: “I could assume something about a patient that could interfere with my treatment of them. So I approach every encounter with no assumptions and no judgment.”
Barrier: Inability to describe symptoms
Research suggests that because patients are not used to talking about their bowel problems, they may not offer the information that’s necessary for an accurate diagnosis and treatment.2,3
How to overcome it: Ask for specific details.
“If your questions aren’t specific, the answers may not be,” says Dr. McFadden. An unhelpful question: “How are your bowel movements?” Better: “How many bowel movements do you have per day?” “How often do you feel a sense of urgency to have a bowel movement?” “Is there blood in your stool?” Dr. Ganjhu agrees: “I tell my patients that the more information they give me, the better I’m able to discern what the problem is.”
Barrier: Fear
A change in bowel habits can be a sign of colorectal cancer—and the fear of cancer can keep people from being honest about their symptoms. “They figure if they don’t mention it, it won’t happen to them,” says Dr. Ganjhu.
How to overcome it: Ease their mind.
“I tell my patients that a cough can be a sign of lung cancer or it can be a sign of pneumonia or it can just be a cough,” Dr. Ganjhu says. “It’s the same with a bowel problem. It’s a symptom, not necessarily cancer. I tell them it’s better to have a colonoscopy to see whether there is a problem rather than continuing to worry about a problem that may not exist.”
—by Andrea Barbalich
References
1. Karimi N, et al. Clinical communication in inflammatory bowel disease: a systematic review of the study of clinician–patient dialogue to inform research and practice. BMJ Open. 2021;11(8):e051053.
2. Chelvanayagam S. Stigma, taboos, and altered bowel function. Gastrointest Nurs. 2014 Feb;12(1).
3. Travis S, et al. The Communicating Needs and Features of IBD Experiences (CONFIDE) Study: US and European patient and health care professional perceptions of the experience and impact of symptoms of moderate-to-severe ulcerative colitis. Inflamm Bowel Dis. August 21, 2023; doi.org/10.1093/ibd/izad142 (epub ahead of print).
Strategies to help patients build coping skills
It’s not surprising that inflammatory bowel disease (IBD) can feel overwhelming for patients, from the embarrassment of needing to use the bathroom to worrying about when a flare will hit to handling awkward social situations. Yet research suggests these and other emotional stressors are not being fully addressed by clinicians: A survey in the Journal of Crohn’s and Colitis that compared patient versus physician perceptions of care found that healthcare providers underestimated the burden of patients’ suffering.1 Another survey of patients with ulcerative colitis found that only half of them felt comfortable discussing emotional concerns with their gastroenterologist.2
The implications of these findings: Addressing the emotional aspects of living with IBD is key to improving patient outcomes and quality of life. It’s something Mariana Middelhof, MD, a Florida-based gastroenterologist for Gastro Health, has experienced firsthand. “Over the years, I’ve learned the psychological burden that chronic disease can have on patients because there’s no cure, so it’s never ending. It’s a heavy load for them,” she says.“Being able to give them peace of mind that we’re doing the best we can, we care about how they feel and we want to find answers is really important.” The following strategies can help you boost patients’ resilience and guide them on how to live well with IBD.
Validate their feelings
Acknowledging what patients are going through emotionally is the first step to helping them cope, explains Bryan Curtin, MD, MHSc, director of neurogastroenterology at Mercy Medical Center in Baltimore. During visits, he allows a few extra minutes to ask how a patient has been feeling from an emotional standpoint. “Whether or not I have a great answer for their concerns, most patients are grateful for having been heard,” he says.
Doing this is especially crucial after a diagnosis of IBD, when a patient is processing what it means to have this chronic condition, notes Mark C. Mattar, MD, FACG, AGAF, Director of the IBD Center at MedStar Georgetown University Hospital in Washington, DC. “Up front, I validate what the patient is expected to go through with the roller coaster of emotions and thoughts when first diagnosed—the stages of grief and coping. These include denial, anger, bargaining, depression and, finally, acceptance and ownership.” Acknowledging these feelings not only prepares patients for what to expect, but also assures them you understand the stress that comes with a diagnosis of IBD.
Brainstorm solutions to everyday concerns
Since the symptoms of IBD can make a patient feel helpless, providing a sense of control is key, says Dr. Middelhof. She finds it’s important to go through all possible scenarios and give her patients clear, actionable instructions. “The first step is always to breathe and think, What warning signs do I have?” she says. Then, for each symptom, she discusses what the first course of action is so they know when to treat symptoms on their own and when to call her. She also advises them on how to stay prepared, such as keeping antidiarrheal medications and baby wipes in a bag in case they have an accident and making sure to locate the nearest bathroom when they go somewhere new. And she always has patients take part in the process, giving them options and allowing them to decide what tactics they want to use. “So they’ve decided on these steps, too—it’s not just my way or the highway,” says Dr. Middelhof. “With a plan in place that they helped create, patients feel more empowered.”
Dr. Curtin agrees, adding that a common patient concern is how to deal with certain social settings—for example, a birthday party where an offer for a potential trigger like ice cream may feel harder to turn down. Planning mentally for these events by going over triggers to avoid before leaving home can strengthen their ability to say no, says Dr. Curtin. To ease their self-consciousness no matter the occasion, he gives patients this piece of advice: “Social events are designed to be social, not just to eat. If you skip certain items, it’s likely that only you are going to notice.”
Help them create a support network
Dr. Middelhof urges her patients to think of managing their IBD as a group effort. To start, she asks patients who their other healthcare providers are. “This allows me to see how I can work with their other specialists to form a plan.” It also allows her to suggest additional care team members to add, such as a nutritionist.
One specialist in particular that patients often find helpful, says Dr. Mattar, is a therapist. “These patients are usually diagnosed as generally healthy young adults. All of a sudden, having to worry about medications, office visits, labs and procedures can be difficult to acclimate to and takes time.” Referring patients to a mental health professional can help them better cope with the emotional exhaustion and depression that can occur when trying to manage their IBD.
In addition, Dr. Mattar says an online or in-person support group can help patients feel less alone and overcome the stigma of having a bowel disease, including negative attitudes about people with IBD and patients’ belief that such stereotypes are true (e.g., their symptoms are psychosomatic or caused by their lifestyle choices). This is crucial, as research shows destigmatizing IBD can have a positive impact on quality of life, psychological functioning and adherence to treatment.3,4 Dr. Mattar recommends support groups such as those found at the Crohn’s & Colitis Foundation (crohnscolitisfoundation.org) and thegreatbowelmovement.org.
Address issues at school and work
Whether it’s dealing with bowel symptoms or the stigma attached to them, IBD can affect a patient’s work and school life, notes Dr. Mattar. Research confirms gastrointestinal conditions can negatively impact school attendance.5 When it comes to employment, a survey in Intestinal Research found that nearly half of respondents said they had received unfair comments or experienced discrimination at work because of their IBD, and the same number felt IBD had a negative impact on their income.6
To head off problems, Dr. Mattar says, patients can alert their teacher or employer about their diagnosis, as there may be accommodations they are eligible for based on the Americans with Disabilities Act. If speaking directly with a teacher or work supervisor seems intimidating, patients could go to a school counselor or their employer’s human resources department, notes Dr. Mattar. He also advises patients to offer suggestions of how they could be supported. Some examples while at work: Allowing enough time for bathroom breaks, moving a workstation closer to the bathroom and adjusting work hours to accommodate appointments and infusion schedules. For those in school, suggestions include special permission for frequent bathroom breaks and a “stop the clock” option to pause an exam when symptoms flare so they aren’t punished for missing class time.
—by Beth Shapouri
References
1. Subrata G, et al. A global, prospective, observational study measuring disease burden and suffering in patients with ulcerative colitis, using the pictorial representation of illness and self-measure tool. J Crohn’s Colitis. 2021;15(2):228-237.
2. Rubin DT, et al. Ulcerative Colitis Narrative Global Survey findings: communication gaps and agreements between patients and physicians. Inflamm Bowel Dis. 2021;27(7):1096-1106.
3. Lawrence R, et al. Barriers to psychosocial support and quality of life for patients with inflammatory bowel disease: a survey study. Crohn’s Colitis 360. 2020;2(4):otaa068.
4. Taft TH, et al. A systematic review of disease-related stigmatization in patients living with inflammatory bowel disease. Clin Exp Gastroenterol. 2016;9:49-58.
5. Assa A, et al. School attendance in children with functional abdominal pain and inflammatory bowel diseases. J Pediatr Gastroenterol Nutr. 2015;61(5):553-557.
6. Kim YS, et al. Impact of inflammatory bowel disease on daily life: an online survey by the Korean Association for the Study of Intestinal Diseases. Intest Res. 2017;15(3):338-344.
Case Study
PATIENT: KENDRA, 44, HAD A 16-YEAR HISTORY OF CROHN’S DISEASE THAT HAD BECOME INCREASINGLY DIFFICULT TO CONTROL.
“Kendra’s severe IBD was ruining her quality of life”
PHYSICIAN:
Tauseef Ali, MD, FACP, FACG, AGAF, Medical Executive Director, SSM Health Digestive Institute and SSM Health Crohn’s and Colitis Center, Oklahoma City
History:
Kendra, a mother of three, began experiencing diarrhea, abdominal pain and nausea in 2007, which were interfering with her job as a phone operator due to frequent (and often lengthy) bathroom trips. She first came to see me in 2009 after struggling with and self-managing her symptoms for 2 years, when I diagnosed her with Crohn’s disease of the large intestine. Initially, Kendra did very well on mercaptopurine, but a year later she began losing response to the drug and was started on a TNF blocker. Eventually, this agent failed her as well, so I prescribed another type of TNF blocker.
Things were going fine until the past year or so, when Kendra started experiencing symptom flares and multiple urinary tract infections. Her flares increased in intensity and eventually sent her to the ER. It turned out she had developed antibodies to the second TNF blocker, which led to loss of response and severe inflammation. Kendra’s fecal calprotectin score—a biomarker of inflammation—soared to 1,200 µg/g, which was far outside of the normal range.
Initiating treatment:
Keeping Kendra’s prior treatment failures in mind, I decided to start her on a different class of biologic, an integrin receptor antagonist. Kendra was hesitant at first—understandably so, since two other biologics had failed, and it had been a challenge trying to get off work to get her infusions. However, we discussed the potential benefits of switching to another class of biologic. I also explained that this medication may soon be approved for use as a subcutaneous self-injection (this form is already approved for ulcerative colitis), at which time she could transition to a maintenance dose taken at home. Kendra was willing to try this option and started the medication.
As we had hoped, the results were immediate and dramatic: Her symptoms disappeared almost completely, and her fecal calprotectin level dropped to 123 µg/g, which represented a significant improvement. Side effects were minimal (a little nausea, which resolved quickly), and Kendra’s quality of life dramatically improved.
Considerations:
Like other patients dealing with IBD, Kendra found her Crohn’s disease to be isolating. Her gastrointestinal symptoms, coupled with the failure of several treatments, caused her to miss time at work and with her family, which triggered bouts of depression and anxiety. These have largely disappeared, however, thanks to the efficacy of her new biologic. In fact, when I last saw her, Kendra reported no active symptoms and was planning to go on a cruise—something she had dreamed of doing for years but which her Crohn’s disease had put a pause on.
Kendra’s story is a great example of the need to monitor patients closely after starting them on an immunosuppressive drug, as there’s always the risk that the patient will develop antibodies to the medication and lose response to it. In Kendra’s case, the third time was indeed the charm, as we found a biologic that’s effective and fits her lifestyle. Better still, the medication isn’t just managing Kendra’s symptoms; it’s serving to heal the bowel and, most importantly, reduce her risk of colon cancer.
KOL on Demand
Q&A
Insight on managing IBD
Q: Why is it important to tailor education to the patient? How do you accomplish this?
A: The lack of health literacy in IBD contributes to adverse health outcomes, particularly among communities of color. Therefore, improving health literacy by tailoring education is key. This is best accomplished in partnership with individuals and specific patient populations in the community to understand what their perceptions are on how to best educate them about IBD. Of course, as their physician, I always discuss patient concerns at office visits, but it’s helpful to reinforce this information in other ways. For example, some patients may prefer direct engagement with health materials, others may prefer one-on-one education with a care team member and some may prefer attending educational events at, say, a support group. Often, it’s about engaging them to actively participate in their care and empowering them to find the information that best suits their needs and preferences.
—Julius M. Wilder, MD, PhD, Assistant Professor of Medicine at Duke University School of Medicine
Q: Which patients are candidates for a biologic—and how do you counsel them when initiating therapy?
A: In general, patients with moderate to severe Crohn’s disease or ulcerative colitis are candidates for a biologic. Some patients may need to start a biologic early in their disease, while others may try nonbiologic medications first. There are several classes of biologics that focus on different inflammatory pathways. Biologics are given either by intravenous infusion or injection. When discussing biologics, I counsel patients on mode of administration as well as possible side effects and risks of treatment. I also tell them laboratory studies are done before starting biologics to exclude certain asymptomatic infections that might become reactivated when starting these medications, and they will also need periodic laboratory monitoring while on a biologic. Some patients may be advised to take combination therapy, which includes a biologic and an immunomodulator. Combination therapy can increase the effectiveness of IBD treatment but may be associated with increased risk of additional side effects and toxicity, which should also be communicated to the patient.
—Rebecca Matro, MD, gastroenterologist and IBD specialist,
Scripps Clinic, San Diego
Q: What are the most common extraintestinal complications of IBD? Can treating IBD improve these complications?
A: Joint pain is the most common extraintestinal manifestation of IBD. About one-third of patients experience joint pain and stiffness, with some research suggesting the figure is even higher. One example is peripheral arthritis, which typically affects joints in the limbs such as the knees, hips, elbows and shoulders, though the fingers may become symptomatic, too. Severity of joint symptoms generally parallel those of the gastrointestinal tract. Fortunately, no joint destruction occurs and peripheral arthritis usually resolves when the underlying IBD is effectively treated. Another type is axial arthritis, or spondylitis, which causes pain and stiffness in the lower back and pelvis. These joints can become inflamed independently of IBD disease activity, with symptoms occurring before IBD symptoms are reported. We can fix the IBD with treatment, but the joint problems will still progress. Therefore, it’s important to coordinate care with a rheumatologist.
The second most common extraintestinal complication is inflammatory skin disease. People with Crohn’s disease and ulcerative colitis are around 60% more likely to develop psoriasis versus those without IBD. The skin changes of psoriasis are unrelated to disease activity in the gut. In cases where topical therapy is not sufficient to control skin symptoms, certain biologics that are approved for both moderate-to-severe IBD and plaque psoriasis can be considered to help control both diseases.
—David T. Rubin, MD, Chief, Section of Gastroenterology, Hepatology and Nutrition, and Codirector, Digestive Diseases Center, University of Chicago Medicine
Clinical Minute:
Special thanks to our medical reviewer:
Julius M. Wilder, MD, PhD, Assistant Professor of Medicine at Duke University School of Medicine and chair of its Diversity, Equity, Inclusion, and Antiracism Committee
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