Pharmacists Can Promote Patient Care by Identifying Musculoskeletal Manifestations of Inflammatory Bowel Disease
The symptoms of inflammatory bowel disease are already debilitating, yet the suffering doesn’t stop there for those who also develop IBD-related arthritis or osteoporosis. Such extraintestinal manifestations aren’t rare—about half of all patients with IBD can expect musculoskeletal disease—which can be tricky to identify.
The symptoms arising from musculoskeletal manifestations of inflammatory bowel disease are confusing. They may appear before IBD is diagnosed and some run a course parallel to IBD flare-ups, while others come and go without any obvious correlation with IBD activity. Pharmacist counseling is one of the keys to proper diagnosis and treatment.
Inflammatory Bowel Disease and Its Extraintestinal Complications
Inflammatory bowel disease (IBD) is the umbrella name for two major diseases: ulcerative colitis and Crohn’s disease. Both conditions arise from an abnormal immune response that damages the lining of the digestive tract, leading to inflammation and ulceration. Ulcerative colitis primarily affects the colon and rectum. Crohn’s disease can occur anywhere along the digestive tract, but in 35 percent of cases it’s in the ileum and colon, 32 percent of the time it stays in the colon, and in 28 percent of cases it affects the small intestine.1
Experts continue to debate whether the gastrointestinal barrier is damaged due to IBD-related inflammation or if a primary defect in the barrier causes inflammation that leads to IBD.2 While the answer makes a difference for IBD research and treatment, cause versus effect doesn’t matter when it comes to extraintestinal manifestations (EIM). Either way, increased permeability in the barrier allows inflammation to spread through the body, causing EIM in up to 47 percent of patients.3
Patients and health professionals alike may not initially associate EIMs with inflammatory bowel disease because symptoms appear at different times. For instance:
- One-quarter of patients have up to four EIMs before they’re diagnosed with IBD. The median time is 5 months before the diagnosis, but sometimes EIMs appear more than two years ahead of IBD.
- EIMs that initially manifest after IBD is identified occur nearly 8 years following the diagnosis on average, although they’re known to appear between 2.5 to 15 years after diagnosis.
- Thirty years after the diagnosis, half of all patients have experienced at least one EIM.
Musculoskeletal Extraintestinal Manifestations of IBD
Extraintestinal manifestations of IBD may affect the joints, skin, eyes, mouth, lungs and hepatobiliary system, but in 40 percent of patients they occur in the musculoskeletal system. Here’s a rundown of the musculoskeletal manifestations you’ll encounter in patients:
- Peripheral arthritis – This type of EIM affects 5 to 10 percent of patients with ulcerative colitis and 10 to 20 percent of those with Crohn’s disease. It’s divided into two categories:
- Type I pauciarticular arthritis – Impacts five or less large weight-bearing joints but causes little to no deterioration. It worsens in conjunction with IBD activity and is self-limiting, usually lasting no longer than 10 weeks. The knee is most commonly involved.
- Type II polyarticular arthritis – Develops in more than five small joints. This type is progressive and erosive. It’s not related to IBD symptoms and can persist for months to years, lasting for three years on average. The metacarpophalangeal joint is commonly involved. These patients also have a higher risk for IBD-related uveitis.
- Axial arthritis – Occurs less frequently than type I and type II. Most often appears as ankylosing spondylitis and sacroiliitis. Symptoms are independent of IBD activity. The disease is progressive and may result in permanent skeletal damage.
- Osteoporosis – Patients with IBD have a 40 percent greater risk of fractures than the general population due to low bone mineral density.4 It’s often asymptomatic until diagnosis or a fracture occurs. Inflammatory factors cause increased bone resorption. Other risk factors for osteoporosis include corticosteroid use, vitamin malabsorption from intestinal damage, and lack of weight-bearing physical activity.
- Arthralgia without arthritis – Up to 16 percent of patients with musculoskeletal EIMs experience joint pain without swelling or erythema.5
Summary of Treatment Options
As you can tell from the diverse manifestations, treatment is highly individualized. Treating the underlying bowel disease improves some arthritis symptoms, but disease that occurs independently of IBD activity, or that doesn’t respond to care, needs other anti-inflammatory and disease-modifying agents. Patients who have osteoporosis undergo standard treatment with bisphosphonate, calcium and vitamin D. Patients taking long-term corticosteroids should undergo bone density screening, consider prophylaxis with calcium and vitamin D, and make appropriate lifestyle changes such as adding weight-bearing exercises to their regimen.
Medications that may be considered include:6
- Corticosteroids – oral or topical
- Immunomodulators – limited use in active disease due to slow onset of action – often used as steroid-sparing agents
- Sulfasalazine or other aminosalicylates
- COX-2 inhibitors
- Biologic agents – adalimumab, infliximab and vedolizumab are approved for ulcerative colitis and Crohn’s disease
Pharmacist Outreach Can Promote Treatment
Pharmacists can significantly help patients with musculoskeletal EIMs by doing what they do best—counseling about medications used to treat their IBD. They must ensure that questions about joint pain and patient education about osteoporosis become an integral part of medication reviews. These patients need to know they’re at extreme risk for osteoporosis, which usually doesn’t have symptoms until they fracture a bone. Also remember that awareness and treatment of EIMs may depend on the type of physician treating the IBD. This is such a complex disease that referral to a gastroenterologist may be in order. The bottom line is to reach out as an advocate for IBD patients to ensure timely treatment of musculoskeletal EIMs.
Pharmaceutica North America provides prescription drug products and high-quality unit-dose and bulk active pharmaceutical ingredients to treat patients with IBD-related arthritis and arthralgia. Contact us today to talk about how we can help meet your pharmaceutical needs.
- “Inflammatory Bowel Disease,” June 2016, http://emedicine.medscape.com/article/179037-overview ↩
- “Intestinal Permeability in Inflammatory Bowel Disease: Pathogenesis, Clinical Evaluation, and Therapy of Leaky Gut,” October 2015, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4637104/ ↩
- “Extraintestinal Manifestations of Inflammatory Bowel Disease,” August 2015, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4511685/ ↩
- “The Role of Specialty Pharmacists in the Management of Extraintestinal Manifestations in Inflammatory Bowel Disease, August 2016, http://www.specialtypharmacytimes.com/publications/specialty-pharmacy-times/2016/july-2016/the-role-of-specialty-pharmacists-in-the-management-of-extraintestinal-manifestations-in-inflammatory-bowel-disease ↩
- “Management of Musculoskeletal Manifestations in Inflammatory Bowel Disease,” 2015, https://www.hindawi.com/journals/grp/2015/387891/ ↩
- “Management of Inflammatory Bowel Disease,” July 2014, http://www.pharmacytimes.com/publications/health-system-edition/2014/july2014/management-of-inflammatory-bowel-disease ↩