50
etanercept is probably less effective than infliximab and adalimumab, although
data regarding this comparison are limited. A study outlining the Danish experi-
ence with infliximab from 1999 to 2005 noted that 80% of patients with CD and
skin or joint symptoms had improvement or remission in symptoms [ 10 ], and
similar overall response rates have been reported for adalimumab [ 11 ]. More
recently, a systematic review of 9 interventional and 13 non-interventional stud-
ies also concluded that infliximab and adalimumab are effective for some
classes of EIM including certain musculoskeletal, dermatologic, and ocular
manifestations [ 12 ]. Consistent with this report, the 2016 ECCO consensus
document on the use of anti-TNF drugs for the management of EIMs in IBD
patients also noted anti-TNFs to be effective for certain EIMs and recommended
considering their use in patients with spondyloarthropathy, arthritis, dermato-
logic manifestations such as pyoderma gangrenosum or erythema nodosum and
uveitis [ 13 ].
Peripheral Arthritis
IBD-associated peripheral arthritis is categorized into 2 distinct subtypes, termed
type 1 and type 2. Type 1 peripheral arthritis often occurs acutely, affects the large
joints (knees most commonly), and typically tracks with luminal disease activity.
On the other hand, type 2 usually occurs independently of intestinal disease, affects
multiple small joints (especially the metacarpophalangeal joints), and is more com-
monly chronic [ 8 , 14 ].
In line with existing data that anti-TNF therapy is effective in the treatment of
rheumatoid and psoriatic arthritis [ 15 ], available evidence suggests that anti-TNFs
are effective in the treatment of IBD-associated peripheral arthritis. A prospective,
open-label study of Crohn’s patients who had failed prior therapy (steroids, azathio-
prine, 6-mercaptopurine, or methotrexate) looked at patients with arthritis or arthral-
gia treated with infliximab (dosed either 5 mg/kg at 0 weeks for luminal disease or
at 0, 2, and 6 weeks for fistulizing disease). The study showed that 61% (36/59) had
improvement in their joint symptoms and 46% (27/59) of patients had symptom
resolution [ 16 ]. In another study, 7 of 11 patients with Crohn’s disease and inflam-
matory arthralgia reported improvement after treatment with a single 5 mg/kg infu-
sion of infliximab [ 17 ].
Although data for adalimumab are more limited, the CARE trial provides evi-
dence for its use for IBD-associated arthritis. Of over 900 patients with CD studied,
20 of 82 patients who had baseline arthritis had resolution of their arthritis at the
conclusion of 20 weeks of treatment with adalimumab [ 18 ].
Generally, anti-TNF therapy should be a leading consideration for treatment of
peripheral arthritis in patients with indications for systemic therapy of luminal dis-
ease. In the absence of a need for luminal-directed systemic therapy, a decision to
undertake anti-TNF therapy for IBD-associated peripheral arthritis should be made
in consultation with a rheumatologist.
D.I. Fudman and S.N. Flier