Expert consensus: practical algorithms for management of inflammatory bowel disease patients presenting with back pain or peripheral arthropathies

Abstract

Summary Background Spondyloarthritis is the most frequent extra‐intestinal manifestation of IBD. Aim To present simple strategies to identify and differentiate inflammatory joint pain in IBD patients. Methods A panel of Belgian gastroenterologists and rheumatologists developed seven algorithms for IBD patients with joint symptoms based on a Delphi exercise conducted between April and December 2016. Here, we focus on referral strategies for patients with chronic back pain (evidence‐based strategy), large joint monoarthritis, oligo‐ or polyarticular arthritis or arthralgia (based on expert opinion). We also present management tools for IBD patients with acute back pain and small joint monoarthritis (Supplementary file). Results The reported algorithm for IBD patients with chronic back pain uses basic clinical criteria to identify which patients should be referred to the emergency room (spondylodiscitis), physical medicine and rehabilitation (mechanical back pain) or rheumatologist (spondyloarthritis). IBD patients with large joint monoarthritis should be referred to emergency room if septic arthritis is suspected; in other patients, blood analyses and referral to a rheumatologist for articular puncture with evacuation of synovial fluid are recommended. The analysis of synovial fluid allows for identification of non‐inflammatory (e.g., osteoarthritis) and inflammatory (e.g., [pseudo]‐gout, peripheral spondyloarthritis and Borrelia burgdorferi arthritis) conditions. In patients with inflammatory oligoarticular or polyarticular arthralgia, erythrocyte sedimentation rate, concomitant therapies, anti‐nuclear factor and anti‐double‐stranded DNA antibody levels should be evaluated; in anti‐tumour necrosis factor‐treated patients, a drug‐induced lupus‐like syndrome should be considered. Conclusion We propose straightforward strategies for IBD patients with joint symptoms, which are specific enough to select initial treatment and referral pattern.

Clinical management of the most common extra‐intestinal manifestations in patients with inflammatory bowel disease focused on the joints, skin and eyes

“…Arthropathies, an over-arching term for all types of joint disorders, can be classified according to the predominant localisation of symptoms (axial or peripheral) and according to the presence or absence of clinical joint inflammation, called inflammatory arthritis. [21][22][23] Moreover, it is important to place arthropathies in the context of active or quiescent IBD, as this determinates the (treatment) approach. 24 Of note, in Anglo-Saxon countries, the term 'arthritis' is also often used to cover non-inflammatory joint issues, hence the redundant term 'inflammatory arthritis'.…”

“…21,25,26 Inflammatory arthritis usually presents with signs of host response, including synovial swelling, thickening and/or hydrops, with symptoms such as pain, stiffness, warmth and sometimes redness. 21 Inflammatory joint complaints (also known as clinically suspect arthralgia) are defined as patient-reported joint pain during the previous year, with stiffness of an hour or longer in the morning or after rest, improving upon on exercise, without the presence of arthritis yet. [21][22][23] More specific criteria exist if for example rheumatoid arthritis has been suspected as an underlying disease for clinically suspected arthralgia.…”

Corrigendum

“…In the paper, “Expert consensus: practical algorithms for management of inflammatory bowel disease patients presenting with back pain or peripheral arthropathies” published in Volume 50, issue 11‐12 (Dec 2019), there is an error in Figure 1. A correct copy of Figure 1 is shown below:…”

Editorial: establishing a joint approach to a common problem for gastroenterologists

“…It is within this context that the paper by Varkas et al should be commended for two main reasons. First, it is authored by an appropriate mix of IBD and rheumatology experts.…”

“…In a multi‐system disorder such as IBD, a multidisciplinary, cross‐specialty approach is to the benefit of patients with extraintestinal manifestations. The guidelines presented by Varkas et al will enhance our ability to manage rheumatological complaints in patients with IBD efficiently and appropriately, and are a model to follow for other crossover presentations in IBD and beyond.…”