51Axial Arthritis
Anklylosing spondylitis (AS) and sacroiliitis are associated with IBD, although
they occur less frequently than peripheral arthritis and typically manifest indepen-
dently of intestinal activity [ 8 , 14 ].
The efficacy of anti-TNF therapy for AS in the absence of IBD is well estab-
lished [ 19 – 22 ]. In a multicenter randomized placebo-controlled trial, 53% (18/34)
of patients with AS treated with infliximab (5 mg/kg at 0, 2, and 6 weeks) had symp-
tomatic improvement at 12 weeks, compared to 9% (3/35) in the placebo group
(p < 0.0001) [ 20 ]. An open-label follow-up study of the same cohort after 3 years of
infliximab maintenance suggested that infliximab was effective in maintaining
remission of AS [ 21 ].
The use of anti-TNF therapy for axial arthritis in patients with concomitant IBD
is less well studied. The largest study of patients with both IBD and spondyloar-
thropathy compared 24 patients with Crohn’s (16 of whom had active disease) given
infliximab (5 m/kg at 0, 2, and 6 weeks then 3–5 mg/kg every 5–8 weeks) to 12
patients with active Crohn’s on other treatments. Although there was a similar
improvement in CDAI scores between the groups, the infliximab group had signifi-
cantly better arthritis disease scores [ 23 ]. In a smaller cohort of 11 patients with
Crohn’s-associated inflammatory lower back pain treated with infliximab, 7 saw
benefit [ 17 ].
Adalimumab also appears to be effective in treating IBD-related axial arthritis
[ 11 , 18 ]. In the open-label CARE trial, for example, 15 of 16 patients with AS
treated with adalimumab had resolution of their joint symptoms after 20 weeks of
therapy [ 18 ].
Based on the available data, anti-TNF therapy should be considered for treatment
of axial arthritis in patients in whom systemic therapy for luminal disease is war-
ranted, and in conjunction with a rheumatologist for patients with IBD-associated
axial arthritis who lack an indication for luminal-directed systemic therapy.
Uveitis
Although there are several ocular manifestations of IBD, only for uveitis does there
exist a body of literature supporting treatment with anti-TNF therapy. This typical
chronic condition that presents with eye pain, blurry vision, photophobia, and head-
aches can develop before or after the onset of bowel symptoms and frequently
occurs concurrently with arthritis [ 8 , 9 , 24 ].
Although not considered first-line therapy, anti-TNF agents have an important
role in treating uveitis. They counter the role of TNF in fueling ocular inflammation,
as demonstrated in animal models and analyses of human ocular fluids [ 25 ].
Adalimumab, infliximab, and etanercept have been studied in uveitis; however,
these studies include patients with refractory uveitis and are not limited to patients
4 Anti-TNF Therapy for Treatment of Extraintestinal Manifestations of Inflammatory