REVIEW URRENT C OPINION Sacroiliitis in inflammatory bowel disease Fardina Malik a and Michael H. Weisman b Purpose of review This review summarizes the recent evidence regarding the epidemiology of inflammatory bowel disease (IBD) associated sacroiliitis, including the prevalence, pathogenesis, role of imaging, and therapeutic challenges. Recent findings Sacroiliitis is an underappreciated musculoskeletal manifestation of IBD, a chronic inflammatory condition of the gut affecting the younger population. Untreated sacroiliitis can lead to joint destruction and chronic pain, further adding to morbidity in IBD patients. Recent publications suggest sacroiliitis can be detected on abdominal imaging obtained in IBD patients to study bowel disease, but only a small fraction of these patients were seen by rheumatologists. Early detection of IBD-associated sacroiliitis could be achieved by utilization of clinical screening tools in IBD clinics, careful examination of existing computed tomography and MRI studies, and timely referral to rheumatologist for further evaluation and treatment. Current treatment approaches for IBD and sacroiliitis include several targeted biologic therapies, but IBD-associated sacroiliitis has limited options, as these therapies may not overlap in both conditions. Summary With the advances in imaging, sacroiliitis is an increasingly recognized comorbidity in IBD patients. Future studies focusing on this unique patient population will expand our understanding of complex pathophysiology of IBD-associated sacroiliitis and lead to identification of novel targeted therapies for this condition. Keywords inflammatory bowel disease, MRI, sacroiliitis, spondyloarthritis INTRODUCTION Inflammatory bowel disease (IBD) is a chronic relapsing inflammatory disease of the gut with Crohn’s disease and ulcerative colitis being the major subtypes. Sacroiliitis, a hallmark of axial spondyloarthritis (axSpA), could impact up to 40% patients with IBD. A seminal publication by Moll and Wright in 1974 described IBD-associated arthritis (including ankylosing spondylitis, AS) as one of the subtypes of seronegative SpA, based on their shared clinical and immunological presentations [1]. AxSpA has been subdivided into nonradiographic (nr-axSpA) and radiographic (AS) diseases based on regulatory considerations, but most rheumatologists consider them as a single disease. Even though the most common extra-intestinal manifestation (EIM) of IBD patients is musculoskeletal, sacroiliitis is often underdiagnosed in this population. Similar to prototypical axSpA, the diagnosis of sacroiliitis is often delayed and untreated sacroiliitis can negatively impact quality of life of patients with IBD [2–4,5 ]. IBD-associated sacroiliitis presents clinically in a spectrum, ranging from nonradiographic axSpA to radiographic stages [6] and a small & www.co-rheumatology.com fraction of patients presenting without any back pain, making it harder to diagnose. Furthermore, the correlation between IBD activity and sacroiliitis is poor, making the therapeutic decision challenging for physicians. Advances in targeted therapies over the recent decades revolutionized disease outcomes in both IBD and sacroiliitis; however, approved therapies for both diseases do not always overlap. In this contemporary review, we summarize prevalence, pathophysiology, clinical presentation, diagnostic modalities, and treatment options of IBD-associated sacroiliitis. a Division of Rheumatology, New York University Grossman School of Medicine, New York, New York and bDivision of Rheumatology, Stanford University School of Medicine, Stanford, California, USA Correspondence to Fardina Malik, MBBS, MS, Assistant Professor of Medicine, Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA. Tel: +1 646 501 7400; fax: +1 646 754 9607; e-mail: [email protected] Curr Opin Rheumatol 2024, 36:274–281 DOI:10.1097/BOR.0000000000001017 Volume 36 Number 4 July 2024 Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved. Sacroiliitis in inflammatory bowel disease Malik and Weisman KEY POINTS Sacroiliitis is an under recognized comorbidity in patients with inflammatory bowel disease (IBD). Proper screening of patients in IBD clinics and utilizing existing abdominal imaging to detect sacroiliitis could ensure early diagnosis and timely referral. Implementation of artificial intelligence based imaging tools, diagnostic or prognostic biomarkers, and development of novel therapeutic targets might improve patient outcomes in this disease. Prevalence of inflammatory bowel disease associated sacroiliitis IBD affects 0.7% of United States population (approximately 2.4 million) with incidence peaking in early adulthood [7]. Reported prevalence of sacroiliitis in IBD, however, varies widely. A systematic review and meta-analysis in 2017 reported pooled prevalence of AS and sacroiliitis as 3 and 10%, respectively, with higher prevalence in European countries, compared to North or South America. IBD patients at tertiary care centers were also more likely to have diagnosis of sacroiliitis than other centers [8]. A more recent systematic review of axSpA imaging study in IBD patients reported prevalence between 2.2 and 68%. This unusually wide margin likely stems from heterogeneity of study population across studies, differences in methodology and definitions of sacroiliitis, that is, modified New York (mNY) criteria or MRI-based definitions [9]. Prospectively enrolled IBD patients without any back pain were noted to have occult sacroiliitis in 24–27.1% on radiographs [10,11]; however, it is unclear whether these radiographs met mNY criteria. On follow-up studies, these IBD cohorts showed an association of occult sacroiliitis with peripheral arthritis and erythema nodosum and 18% developed back pain, and hence ax-SpA diagnosis in 3 years [10,11]. McEniff et al. [12] showed prevalence of sacroiliitis meeting mNY criteria was slightly higher (32%) when computed tomography (CT) was utilized. Assessment of SpondyloArthritis International Society (ASAS) classification criteria was utilized in some studies to determine prevalence of sacroiliitis in IBD patients with back pain. It should be noted that specificity of clinical arm of ASAS criteria [13,14] in IBD patients can be low, as it does not require imaging confirmation of sacroiliitis. For example, an HLA-B27 positive IBD patient with chronic back pain that started before 45 years of age with only one other SpA feature (e.g. enthesitis, inflammatory back pain, uveitis, etc.) will automatically meet clinical arm criteria of axSpA without confirmation on imaging. A population-based retrospective cohort study using Rochester Epidemiology project reported incidence of axSpA (meeting clinical arm of ASAS criteria) as 13.9 and 18.6% at 20 and 30 years after Crohn’s disease diagnosis and only 0.5% with AS (mNY) [15]. But incidence of axSpA and AS was reported as 7.7% and 4.5%, respectively, among a prospective IBD cohort from Norway at 20 years of follow up [16]. Incidence of Ax-SpA may be quite different in the latter study owing to utilization of imaging arm of ASAS criteria. Cross-sectional studies of abdominopelvic CT or CT enterography (CTE) obtained from IBD patients as standard of care were retrospectively reviewed by radiologists to determine presence of sacroiliitis using standardized scoring system [17– 22]. Sacroiliitis was noted in 15–20% of IBD patients and there was no difference between ulcerative colitis and Crohn’s disease patients. Chan et al. [18] showed prevalence of sacroiliitis was three-fold higher in IBD patients compared to patients without IBD. A temporal relationship with back pain was not established as these were retrospective studies. Only 10% of these patients were ever assessed by rheumatologists, suggesting an underdiagnosis. Kelly et al. [17] reported association of sacroiliitis with male sex, history of peripheral arthritis and Crohn’s disease inflammatory phenotype [17]. Standardized MRI of sacroiliac joint (SIJ) showed sacroiliitis in 12–39% of patients with IBD [23–26] and this wide range was again due to differences in MRI interpretations in these studies (e.g. ASAS definition of MRI positivity vs. inclusion/exclusion of structural lesions). Magnetic resonance enterography (MRE) is a contrastenhanced imaging modality invariably used to assess luminal disease activity in Crohn’s disease patients, but it allows visualization of SIJ. MRE images include T1-weighted and short tau inversion recovery (STIR) sequences that are required to detect SIJ structural lesions and bone marrow edema (BME), respectively. Retrospective studies where musculoskeletal radiologists reviewed previously obtained MRE images for clinical care, reported sacroiliitis was present in 15–16.7% of patients, with up to two-thirds showing evidence of BME meeting ASAS criteria of MRI positivity [27–29]. We showed that structural lesions noted on MRE correlated with rheumatologist diagnosis of ax-SpA in a follow-up study [30]. Older age and female sex were associated with MRE-based sacroiliitis, but there was no correlation between Crohn’s disease activity and ASASpositive cases. 1040-8711 Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved. www.co-rheumatology.com Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved. 275 Spondyloarthritis including psoriatic arthritis Pathogenesis of inflammatory bowel disease associated arthritis The term “gut-joint axis” was originally coined to denote the intricate relationship between gastrointestinal inflammation and SpA. The association between AS and IBD was first elucidated in seminal publications in 1950 s [31,32]. Approximately 10– 15% AS patients develop IBD and up to 50% of SpA patients have subclinical gastrointestinal inflammation with more than 50% having ileal inflammation [33]. Furthermore, patients with axSpA tend to show chronic inflammatory changes on gut histology, as opposed to acute inflammatory changes in peripheral SpA [34,35]. These findings might suggest that subclinical gut inflammation in axSpA patients is similar to Crohn’s disease. Conversely, only 4% of patients with IBD develop AS with higher incidence associated with longer duration of IBD and up to 40% Crohn’s disease patients were found to have sacroiliitis on MRI-based studies [24,25]. Despite HLA-B27 being the single most important genetic risk factor in AS with an estimated heritability of more than 90% [36–38], it does not play a role in IBD. Similarly, mutation of NOD2 is an established risk factor for IBD [39,40] without any association with AS. However, one study showed that subgroup of SpA patients with histological gut inflammation are more likely to carry NOD2 variant compared to those without [41]. IL-23R mutation, endoplasmic reticulum aminopeptidase (ERAP) 1 and 2 are all genetic loci associated with both AS and IBD, suggesting a genetic link between the two diseases [42–46]. In 2016, a large multicenter genome-wide association study (GWAS) of 52 262 cases of European patients showed over 150 genetic loci linked to AS, Crohn’s disease and ulcerative colitis with a significant overlap of several risk alleles between these three diseases and it was suggested that coexistence of Crohn’s disease or ulcerative colitis with AS is a result of biological pleiotropy, a phenomenon, which indicates two or more distinct phenotypic traits that result from a single genetic loci or mutation [47]. Other studies also showed Crohn’s disease and ulcerative colitis share several risk alleles and they are functionally related to intestinal barrier function [48]. Intestinal type 3 immune cells and cytokines are integral to maintaining the gut barrier homeostasis and intestinal permeability, dysregulation of which, is central to pathogenesis of both IBD and SpA [49,50]. Healthy human entheseal tissue from spine contain gdT and innate lymphoid cells [51,52]. Both IL-23 and IL-17 concentration increase in intestinal lining of Crohn’s disease patients and IL-17 concentration is elevated in serum of AS patients [53,54]. In the setting of IL-23 overexpression in IBD, IL-23 276 www.co-rheumatology.com responsive gdT cells, innate lymphoid cells, Th17 cells elaborate IL-17 and 22, hypothetically resulting in axial inflammation [55]. Another dominant cytokine that plays a critical role in IBD and sacroiliitis pathogenesis is tumor necrosis factor a (TNFa) establishing the strong link between the two diseases [56–59]. Risk factors and clinical presentation of inflammatory bowel disease associated sacroiliitis Sacroiliitis in IBD presents in a similar manner as other subtypes of axSpA, including chronic back pain with or without other EIMs of IBD, that is peripheral arthritis, enthesitis, dactylitis, uveitis, erythema nodosum, pyoderma gangrenosum. Psoriasis can frequently accompany IBD given shared immunological and genetic features [60,61]. Fortysix percent of IBD patients can present with back pain and only 10–30% of them have inflammatory back pain (IBP) meeting ASAS or Calin criteria [5 ,16]. Although IBP (age 40 years, insidious onset, nocturnal awakening, improvement with exercise and no improvement with rest) is an established SpA feature in ASAS criteria, longitudinal IBD cohort study showed only two-thirds of IBD patients with IBP were diagnosed with axSpA and one third carried a diagnosis of AS (7.7 and 4.5% of all IBD patients, respectively). AxSpA incidence in IBD peaks between 20 and 30 years of age [8]. As discussed earlier, male sex associated with sacroiliitis diagnosed on X-ray or CT, while female sex associated more with sacroiliitis on MRE. Both IBD and axSpA can have insidious onset and chronology of first appearance of either disease can be difficult to ascertain. A large Swiss IBD cohort of 1249 patients [62] revealed axSpA/AS was diagnosed in 40% of cases before IBD diagnosis and majority presented 2 months prior to IBD diagnosis (range 0–16 years). However, majority of EIMs in this cohort, including axSpA were diagnosed more often after IBD diagnosis. AxSpA is more commonly associated with Crohn’s disease than ulcerative colitis [8,63–65] in studies where IBD patients were phenotyped clinically for SpA but image-based studies (CT, CTE) did not show such difference. It is traditionally accepted that IBD activity and axSpA disease activity does not correlate. However, this could be due to the fact that earlier studies defined sacroiliitis based on radiographs as a binary outcome and correlation with IBD disease activity could not be established. Most of these studies were also retrospective and did not have data on validated measures of IBD and axSpA activity. Ossum et al. [16] suggested correlation of axSpA with more active IBD & Volume 36 Number 4 July 2024 Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved. Sacroiliitis in inflammatory bowel disease Malik and Weisman (both acute and chronic). A very small (n ¼ 8) study reported positive correlation between high Crohn’s disease activity index (CDAI) and BASDAI and BASFI [66]. Our study that utilized MRE ASAS positivity, CDAI, MRE-based Crohn’s disease activity, endoscopic Crohn’s disease activity and did not find any association between active sacroiliitis and Crohn’s disease activity [29]. Relationship with IBD phenotype (location and nature of IBD), such as upper GI involvement, perianal disease [22] have been reported, but these were not consistently reproduced. HLA-B27 is a known genetic marker for axSpA, but it is present only in 10–30% of all IBD patients [16,67]. Up to 90% of patients with AS in IBD were found to have B27 positivity is earlier studies [68], but more recent studies show B27 positivity only in 57–62% IBD-associated axSpA [16,25,67,69], suggesting half of IBD associated sacroiliitis patients will be B27 negative. Role of imaging in early detection of inflammatory bowel disease associated sacroiliitis Asymptomatic sacroiliitis on imaging studies suggests that sacroiliitis in IBD patients can remain underdiagnosed. This delay is analogous to delay in AS diagnosis in general and might be related to other reasons, such as- discrepancy between IBD and axSpA disease activity, asymptomatic phase and low number of rheumatology referral in community settings [8]. HLA-B27 positivity confers increased risk of AS/axSpA, especially with history of uveitis [70] but B27 is negative in half of IBD patients with axSpA and uveitis is an infrequent EIM, affecting only less than 15% of IBD patients [62,64]. There is paucity of established classification criteria, serum biomarkers or IBD related risk factors carrying strong association with IBD-associated sacroiliitis that would trigger referral to rheumatologists. So, imaging plays a crucial role, not only in diagnosis of axSpA in IBD patients presenting with back pain but also as a potential screening tool. Standard CT, CTE and MRE of abdomen-pelvis are routinely obtained in IBD patients in clinical setting to assess IBD disease activity and complications (e.g. perforations or obstruction, etc.). As noted above, retrospective studies showed 20% patients of IBD patients had sacroiliitis on these imaging modalities after these images were read by musculoskeletal radiologists using validated scoring system. Up to 90% of these IBD patients were never seen by rheumatologists [17,18,29]. Presence of erosions, subchondral sclerosis, ankyloses are imaging features commonly attributed to sacroiliitis on CT (Fig. 1). But CT evidence of sacroiliitis reflects structural damage that results from a preceding phase of inflammation and does not provide information on extent of sacroiliitis activity and overlooks the early phase of inflammation. STIR sequences of MRI allow detection of sacroiliitis in its early stages in the form of BME, and can assess degree of inflammation while simultaneously showing structural lesions (erosions, ankylosis, fat metaplasia and backfill) on T1-weighted images. MRE is a noninvasive study utilized by gastroenterologists to monitor Crohn’s disease activity, mucosal healing and has correlation with endoscopic Crohn’s disease activity [71]. It is preferred over CT due to lack of ionizing radiation. MRE allows visualization of sacroiliac joints and STIR images can detect BME, while T1-weighted images can show erosion, fat metaplasia and ankylosis [29] (Fig. 2a, b). MRE or CTE-based sacroiliitis FIGURE 1. (a) Computed tomography enterography (CTE) obtained in a 66-year-old woman with Crohn’s disease with symptoms of intermittent back pain (2--3 flares/year, lasting for a week each episode) for the past 25 years was noted to have bilateral SIJ sclerosis (arrows) and erosions (arrowheads) with irregular joint space. (b) A 27-year-old male patient with Crohn’s disease who presented to emergency room with abdominal pain due to Crohn’s flare. CT showing dense subchondral sclerosis (arrows) and ankylosis (asterisk). 1040-8711 Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved. www.co-rheumatology.com Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved. 277 Spondyloarthritis including psoriatic arthritis FIGURE 2. (a) Magnetic resonance enterography (MRE) obtained on 26-yearold male patient with Crohn’s disease to monitor CD activity. MRE STIR image show acute bone marrow edema (arrows) along bilateral SIJs. (b) A 46-year-old female patient with CD and T1W images on MRE showing irregular joint space, fat metaplasia (asterisk) and sclerosis (arrowhead). has not been validated as of yet and prospective studies should be undertaken to establish their role as a screening tool to detect sacroiliitis in IBD patients, which can prompt early referral to rheumatologists for further management. Contemporary treatment options for inflammatory bowel disease associated sacroiliitis Management of active axSpA/sacroiliitis in IBD is extrapolated from established guideline for management of axSpA/AS and IBD (Table 1) [72–76]. Choice of pharmacological agent should be based on shared decision between patients and providers and need to be individualized based on patient’s clinical presentation, that is presence of other EIMs (especially uveitis, peripheral arthritis), disease status (active vs. quiescent axSpA or IBD), etc. NSAIDs are the preferred first-line agents for treatment of axSpA/ AS, but its use is limited in IBD amidst conflicting data regarding safety in IBD and concern for flares [77–79]. Although some studies suggest relative safety of selective cyclooxygenase-2 (COX-2) inhibitors in IBD [80,81], Italian expert panel suggested limiting COX-2 use to less than 2 weeks in quiescent IBD and avoiding altogether when IBD is active [82]. TNF-a inhibitors (TNFi) are the most preferred agents in patients with active axSpA/AS with Crohn’s disease or ulcerative colitis given their well Table 1. Treatment recommendations for axial spondyloarthritis, Crohn’s disease and ulcerative colitis Medication class Medications NSAIDs csDMARDs Parenteral MTX axSpA CD UC Notes þ May cause IBD flare þ þ Monotherapy in CD, combination with biologic in both CD and UC Mild CD colitis or UC, IBD patients with pSpA. axSpA patients with pSpA þ þ Adalimumab þ þ þ Infliximab þ þ þ Certolizumab þ þ Etanercept þ Golimumab þ þ Tofacitinib þ þ Upadacitinib þ þ þ Sulfasalazine TNF-a inhibitors JAK inhibitors Secukinumab þ Ixekizumab þ a4b7 integrin inhibitor Vedolizumab þ þ IL-12 and 23 inhibitor Ustekinumab þ þ Risankizumab þ IL-17A inhibitor Not recommended in CD with perianal fistula Awaits approval for UC csDMARDs, conventional synthetic disease-modifying antirheumatic drugs; IL, Interleukin; JAK, Janus Kinase inhibitor; MTX, methotrexate; TNF, tumor necrosis factor. 278 www.co-rheumatology.com Volume 36 Number 4 July 2024 Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved. Sacroiliitis in inflammatory bowel disease Malik and Weisman established efficacy in these diseases, particularly infliximab and adalimumab. Etanercept, a TNF-a receptor fusion protein, showed no efficacy in IBD in clinical trial and can precipitate flares [83,84]. Certolizumab is approved for Crohn’s disease, but it is least preferred by experts compared to other biologic DMARDs for moderate to severe Crohn’s disease and perianal disease [74]. Golimumab is approved only for ulcerative colitis, not Crohn’s disease. Recent approval of Janus kinase (JAK) inhibitors (JAKi) for treatment of axSpA/AS as well as for IBD expanded the therapeutic armamentarium of axSpA-IBD management with few exceptions (Table 1). Upadacitinib, a selective JAK1 inhibitor is approved for axSpA, ulcerative colitis and Crohn’s disease but JAK1, 3 inhibitor (tofacitinib) is not approved for Crohn’s disease. Despite the critical role of IL-23/Th17 pathway in IBD and axSpA pathogenesis, mAb therapies designed to target this pathway showed unexpected and paradoxical results in clinical trials. IL-17 inhibitors (IL-17i) performed worse than placebo in IBD phase II clinical trial [85] but showed remarkable efficacy in axSpA in clinical trials, which included only small amount of quiescent IBD patients with axSpA [86,87]. Several case reports allude to new onset IBD in SpA patients treated with secukinumab [88]. But pooled data from 21 clinical trials suggests incidence is rather low [89] and large populationbased study showed risk of incident IBD is similar to etanarcept [90]. On the other hand, IL-12/23i ustekinumab, an inhibitor of p40 subunit of IL-12/23 showed great efficacy in both Crohn’s disease and ulcerative colitis [91,92] but failed to show efficacy in axSpA [93]. Similarly, risankizumab blocks p19 subunit of IL-23 and efficacious in both Crohn’s disease and ulcerative colitis (awaits approval for ulcerative colitis) but, not in axSpA [94]. McGonagle attributed this discrepant response partially to IL-17 producing gdT cells in human spinal entheses are independent of IL-23 production [95]. IBD treatment guidelines also recommend vedolizumab, an a4b7 integrin inhibitor, for moderate to severe Crohn’s disease and UC but efficacy in axSpA remains unknown. A case series of 11 IBD patients [96] described acute axSpA with acute BME on MRI spine and SIJ in seven patients on vedolizumab (five without any known prior SpA), but Orlando et al. [97] reported no worsening of SpA in 53 IBD patients followed for 6 weeks. These discrepant responses to approved therapeutics in IBD and axSpA exemplify need for combination biologic therapy, especially in IBD subgroups with severe gastrointestinal and SIJ disease activity and history of nonresponse to more than one biologics. A phase 2 proof-ofconcept study utilizing guselkumab and golimumab combination therapy versus monotherapy of either biologic showed superiority of combination therapy in achieving more stringent definition of clinical remission in ulcerative colitis patients without significantly increasing risk of infection [98 ]. This opens the door to use the same approach to address active axSpA in IBD patients. && CONCLUSION Sacroiliitis is an under recognized comorbidity in IBD patients, most of whom are at prime years of their lives and less than 10% of these patients are referred to rheumatology for evaluation. Routine screening of IBD patients with validated questionnaires, timely detection of sacroiliitis on abdominopelvic CT, CTE and MRE obtained in IBD patients as a standard of care can improve referral. Awareness of this entity amongst IBD patients, IBD gastroenterologists and abdominal radiologists through educational activities could result in early detection of sacroiliitis in clinical settings and improve outcome. Image-based artificial intelligence decision support tools using existing CT or MRI studies may further facilitate early diagnosis and referral of these patients in near future. Furthermore, advances in next-generation sequencing, exosome profiling, and proteomics may result in identification of blood-based biomarkers for diagnosis and prognosis of patients with IBD-associated sacroiliitis. Disconnect in targeted therapeutics in IBD and axSpA expound on as yet unidentified shared immunological pathways between the two diseases. Future basic and translational studies are needed to unveil shared pathways, leading to discovery of novel therapeutic targets that can improve outcomes of IBD patients with axSpA. Acknowledgements None. Financial support and sponsorship None. Conflicts of interest There are no conflicts of interest. REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Moll JM, Haslock I, Macrae IF, Wright V. Associations between ankylosing spondylitis, psoriatic arthritis, Reiter’s disease, the intestinal arthropathies, and Behcet’s syndrome. Medicine (Baltimore) 1974; 53:343–364. 1040-8711 Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved. www.co-rheumatology.com Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved. 279 Spondyloarthritis including psoriatic arthritis 2. Feldtkeller E, Khan MA, van der Heijde D, et al. Age at disease onset and diagnosis delay in HLA-B27 negative vs. positive patients with ankylosing spondylitis. Rheumatol Int 2003; 23:61–66. 3. Ward MM, Reveille JD, Learch TJ, et al. Impact of ankylosing spondylitis on work and family life: comparisons with the US population. Arthritis Rheum 2008; 59:497–503. 4. Ozg€ ul A, Peker F, Taskaynatan MA, et al. Effect of ankylosing spondylitis on health-related quality of life and different aspects of social life in young patients. Clin Rheumatol 2006; 25:168–174. 5. Lim CSE, Tremelling M, Hamilton L, et al. Prevalence of undiagnosed axial & spondyloarthritis in inflammatory bowel disease patients with chronic back pain: secondary care cross-sectional study. Rheumatology (Oxford) 2023; 62:1511–1518. Important study highlighting delay in diagnosis of IBD-associated sacroiliitis. 6. Rudwaleit M, Khan MA, Sieper J. The challenge of diagnosis and classification in early ankylosing spondylitis: do we need new criteria? Arthritis Rheum 2005; 52:1000–1008. 7. Lewis JD, Parlett LE, Jonsson Funk ML, et al. Incidence, prevalence, and racial and ethnic distribution of inflammatory bowel disease in the United States. Gastroenterology 2023; 165:1197–1205; e2. 8. Karreman MC, Luime JJ, Hazes JMW, Weel A. The prevalence and incidence of axial and peripheral spondyloarthritis in inflammatory bowel disease: a systematic review and meta-analysis. J Crohns Colitis 2017; 11:631–642. 9. Evans J, Sapsford M, McDonald S, et al. Prevalence of axial spondyloarthritis in patients with inflammatory bowel disease using cross-sectional imaging: a systematic literature review. Ther Adv Musculoskelet Dis 2021; 13:1759720x21996973. 10. Queiro R, Maiz O, Intxausti J, et al. Subclinical sacroiliitis in inflammatory bowel disease: a clinical and follow-up study. Clin Rheumatol 2000; 19:445–449. 11. Bandinelli F, Terenzi R, Giovannini L, et al. Occult radiological sacroiliac abnormalities in patients with inflammatory bowel disease who do not present signs or symptoms of axial spondylitis. Clin Exp Rheumatol 2014; 32:949–952. 12. McEniff N, Eustace S, McCarthy C, et al. Asymptomatic sacroiliitis in inflammatory bowel disease. Assessment by computed tomography. Clin Imaging 1995; 19:258–262. 13. Sepriano A, Rubio R, Ramiro S, et al. Performance of the ASAS classification criteria for axial and peripheral spondyloarthritis: a systematic literature review and meta-analysis. Ann Rheum Dis 2017; 76:886–890. 14. Rudwaleit M, van der Heijde D, Landewe R, et al. The development of Assessment of SpondyloArthritis international Society classification criteria for axial spondyloarthritis (part II): validation and final selection. Ann Rheum Dis 2009; 68:777–783. 15. Shivashankar R, Loftus EV Jr, Tremaine WJ, et al. Incidence of spondyloarthropathy in patients with Crohn’s disease: a population-based study. J Rheumatol 2012; 39:2148–2152. 16. Ossum AM, Palm , Lunder AK, et al. Ankylosing spondylitis and axial spondyloarthritis in patients with long-term inflammatory bowel disease: results from 20 years of follow-up in the IBSEN Study. J Crohns Colitis 2018; 12:96–104. 17. Kelly OB, Li N, Smith M, et al. The prevalence and clinical associations of subclinical sacroiliitis in inflammatory bowel disease. Inflamm Bowel Dis 2019; 25:1066–1071. 18. Chan J, Sari I, Salonen D, et al. Prevalence of sacroiliitis in inflammatory bowel disease using a standardized computed tomography scoring system. Arthritis Care Res 2018; 70:807–810. 19. Lim CSE, Hamilton L, Low SBL, et al. Identifying axial spondyloarthritis in patients with inflammatory bowel disease using computed tomography. J Rheumatol 2023; 50:895–900. 20. Bruining DH, Siddiki HA, Fletcher JG, et al. Prevalence of penetrating disease and extraintestinal manifestations of Crohn’s disease detected with CT enterography. Inflamm Bowel Dis 2008; 14:1701–1706. 21. Paparo F, Bacigalupo L, Garello I, et al. Crohn’s disease: prevalence of intestinal and extraintestinal manifestations detected by computed tomography enterography with water enema. Abdom Imaging 2012; 37:326–337. 22. Hwangbo Y, Kim HJ, Park JS, et al. Sacroiliitis is common in Crohn’s disease patients with perianal or upper gastrointestinal involvement. Gut Liver 2010; 4:338–344. 23. Bandyopadhyay D, Bandyopadhyay S, Ghosh P, et al. Extraintestinal manifestations in inflammatory bowel disease: prevalence and predictors in Indian patients. Indian J Gastroenterol 2015; 34:387–394. 24. Malik F, Scherl E, Weber U, et al. Utility of magnetic resonance imaging in Crohn’s associated sacroiliitis: a cross-sectional study. Int J Rheum Dis 2021; 24:582–590. 25. Orchard TR, Holt H, Bradbury L, et al. The prevalence, clinical features and association of HLA-B27 in sacroiliitis associated with established Crohn’s disease. Aliment Pharmacol Ther 2009; 29:193–197. 26. Ottaviani S, Tr eton X, Forien M, et al. Screening for spondyloarthritis in patients with inflammatory bowel diseases. Rheumatol Int 2023; 43:109–117. 27. Leclerc-Jacob S, Lux G, Rat AC, et al. The prevalence of inflammatory sacroiliitis assessed on magnetic resonance imaging of inflammatory bowel disease: a retrospective study performed on 186 patients. Aliment Pharmacol Ther 2014; 39:957–962. 280 www.co-rheumatology.com 28. Gotler J, Amitai MM, Lidar M, et al. Utilizing MR enterography for detection of sacroiliitis in patients with inflammatory bowel disease. J Magn Reson Imaging 2015; 42:121–127. 29. Levine I, Malik F, Castillo G, et al. Prevalence, predictors, and disease activity of sacroiliitis among patients with Crohn’s disease. Inflamm Bowel Dis 2020; 27:809–815. 30. Malik F, Gyftopoulos S, Axelrad J, et al. MRI confirms MRE evidence of sacroiliitis in many with Crohn’s disease: a prospective study for the screening of axSpA in high-risk populations. Arthritis Rheumatol (Hoboken, NJ) 2023; 75(S9):3697–3698. 31. Wilkinson M, Bywaters EG. Clinical features and course of ankylosing spondylitis; as seen in a follow-up of 222 hospital referred cases. Ann Rheum Dis 1958; 17:209–228. 32. Zvaifler NJ, Martel W. Spondylitis in chronic ulcerative colitis. Arthritis Rheum 1960; 3:76–87. 33. Leirisalo-Repo M, Turunen U, Stenman S, et al. High frequency of silent inflammatory bowel disease in spondylarthropathy. Arthritis Rheum 1994; 37:23–31. 34. Mielants H, Veys EM, De Vos M, et al. The evolution of spondyloarthropathies in relation to gut histology. I. Clinical aspects. J Rheumatol 1995; 22: 2266–2272. 35. De Vos M, Mielants H, Cuvelier C, et al. Long-term evolution of gut inflammation in patients with spondyloarthropathy. Gastroenterology 1996; 110: 1696–1703. 36. Schlosstein L, Terasaki PI, Bluestone R, Pearson CM. High association of an HL-A antigen, W27, with ankylosing spondylitis. N Engl J Med 1973; 288:704–706. 37. Brown MA, Kennedy LG, MacGregor AJ, et al. Susceptibility to ankylosing spondylitis in twins: the role of genes, HLA, and the environment. Arthritis Rheum 1997; 40:1823–1828. 38. Brewerton DA, Hart FD, Nicholls A, et al. Ankylosing spondylitis and HL-A 27. Lancet 1973; 1:904–907. 39. Ogura Y, Bonen DK, Inohara N, et al. A frameshift mutation in NOD2 associated with susceptibility to Crohn’s disease. Nature 2001; 411: 603–606. 40. Hugot JP, Chamaillard M, Zouali H, et al. Association of NOD2 leucinerich repeat variants with susceptibility to Crohn’s disease. Nature 2001; 411:599–603. 41. Laukens D, Peeters H, Marichal D, et al. CARD15 gene polymorphisms in patients with spondyloarthropathies identify a specific phenotype previously related to Crohn’s disease. Ann Rheum Dis 2005; 64:930–935. 42. Duerr RH, Taylor KD, Brant SR, et al. A genome-wide association study identifies IL23R as an inflammatory bowel disease gene. Science 2006; 314:1461–1463. 43. Dong H, Li Q, Zhang Y, et al. IL23R gene confers susceptibility to ankylosing spondylitis concomitant with uveitis in a Han Chinese population. PLoS One 2013; 8:e67505. 44. Rueda B, Orozco G, Raya E, et al. The IL23R Arg381Gln nonsynonymous polymorphism confers susceptibility to ankylosing spondylitis. Ann Rheum Dis 2008; 67:1451–1454. 45. Vitulano C, Tedeschi V, Paladini F, et al. The interplay between HLA-B27 and ERAP1/ERAP2 aminopeptidases: from antiviral protection to spondyloarthritis. Clin Exp Immunol 2017; 190:281–290. 46. Castro-Santos P, Moro-García MA, Marcos-Fernandez R, et al. ERAP1 and HLA-C interaction in inflammatory bowel disease in the Spanish population. Innate Immun 2017; 23:476–481. 47. Stearns FW. One hundred years of pleiotropy: a retrospective. Genetics 2010; 186:767–773. 48. McCole DF. IBD candidate genes and intestinal barrier regulation. Inflamm Bowel Dis 2014; 20:1829–1849. 49. Lee JS, Tato CM, Joyce-Shaikh B, et al. Interleukin-23-independent IL-17 production regulates intestinal epithelial permeability. Immunity 2015; 43:727–738. 50. Pickert G, Neufert C, Leppkes M, et al. STAT3 links IL-22 signaling in intestinal epithelial cells to mucosal wound healing. J Exp Med 2009; 206:1465–1472. 51. Cuthbert RJ, Watad A, Fragkakis EM, et al. Evidence that tissue resident human enthesis ((T-cells can produce IL-17A independently of IL-23R transcript expression. Ann Rheum Dis 2019; 78:1559–1565. 52. Cuthbert RJ, Fragkakis EM, Dunsmuir R, et al. Brief Report: Group 3 innate lymphoid cells in human enthesis. Arthritis Rheumatol 2017; 69:1816–1822. 53. Ciccia F, Bombardieri M, Principato A, et al. Overexpression of interleukin-23, but not interleukin-17, as an immunologic signature of subclinical intestinal inflammation in ankylosing spondylitis. Arthritis Rheum 2009; 60:955–965. 54. Gracey E, Yao Y, Green B, et al. Sexual dimorphism in the Th17 signature of ankylosing spondylitis. Arthritis Rheumatol 2016; 68:679–689. 55. Moschen AR, Tilg H, Raine T. IL-12, IL-23 and IL-17 in IBD: immunobiology and therapeutic targeting. Nat Rev Gastroenterol Hepatol 2019; 16: 185–196. 56. Braun J, Bollow M, Neure L, et al. Use of immunohistologic and in situ hybridization techniques in the examination of sacroiliac joint biopsy specimens from patients with ankylosing spondylitis. Arthritis Rheum 1995; 38:499–505. Volume 36 Number 4 July 2024 Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved. Sacroiliitis in inflammatory bowel disease Malik and Weisman 57. Crew MD, Effros RB, Walford RL, et al. Transgenic mice expressing a truncated Peromyscus leucopus TNF-alpha gene manifest an arthritis resembling ankylosing spondylitis. J Interferon Cytokine Res 1998; 18: 219–225. 58. Braegger CP, Nicholls S, Murch SH, et al. Tumour necrosis factor alpha in stool as a marker of intestinal inflammation. Lancet 1992; 339: 89–91. 59. Maeda M, Watanabe N, Neda H, et al. Serum tumor necrosis factor activity in inflammatory bowel disease. Immunopharmacol Immunotoxicol 1992; 14:451–461. 60. Fu Y, Lee CH, Chi CC. Association of psoriasis with inflammatory bowel disease: a systematic review and meta-analysis. JAMA Dermatol 2018; 154:1417–1423. 61. Cho JH. The genetics and immunopathogenesis of inflammatory bowel disease. Nat Rev Immunol 2008; 8:458–466. 62. Vavricka SR, Rogler G, Gantenbein C, et al. Chronological order of appearance of extraintestinal manifestations relative to the time of IBD diagnosis in the Swiss Inflammatory Bowel Disease Cohort. Inflamm Bowel Dis 2015; 21:1794–1800. 63. Veloso FT, Carvalho J, Magro F. Immune-related systemic manifestations of inflammatory bowel disease. A prospective study of 792 patients. J Clin Gastroenterol 1996; 23:29–34. 64. Vavricka SR, Brun L, Ballabeni P, et al. Frequency and risk factors for extraintestinal manifestations in the Swiss inflammatory bowel disease cohort. Am J Gastroenterol 2011; 106:110–119. 65. Lakatos L, Pandur T, David G, et al. Association of extraintestinal manifestations of inflammatory bowel disease in a province of western Hungary with disease phenotype: results of a 25-year follow-up study. World J Gastroenterol 2003; 9:2300–2307. 66. Liu S, Ding J, Wang M, et al. Clinical features of Crohn disease concomitant with ankylosing spondylitis: a preliminary single-center study. Medicine (Baltimore) 2016; 95:e4267. 67. Turkcapar N, Toruner M, Soykan I, et al. The prevalence of extraintestinal manifestations and HLA association in patients with inflammatory bowel disease. Rheumatol Int 2006; 26:663–668. 68. Mallas EG, Mackintosh P, Asquith P, Cooke WT. Histocompatibility antigens in inflammatory bowel disease. Their clinical significance and their association with arthropathy with special reference to HLA-B27 (W27). Gut 1976; 17:906–910. 69. Rios Rodriguez V, Sonnenberg E, Proft F, et al. Presence of spondyloarthritis associated to higher disease activity and HLA-B27 positivity in patients with early Crohn’s disease: clinical and MRI results from a prospective inception cohort. Joint Bone Spine 2022; 89:105367. 70. Monnet D, Breban M, Hudry C, et al. Ophthalmic findings and frequency of extraocular manifestations in patients with HLA-B27 uveitis: a study of 175 cases. Ophthalmology 2004; 111:802–809. 71. Ord as I, Rimola J, Rodríguez S, et al. Accuracy of magnetic resonance enterography in assessing response to therapy and mucosal healing in patients with Crohn’s disease. Gastroenterology 2014; 146:374–382; e1. 72. Ramiro S, Nikiphorou E, Sepriano A, et al. ASAS-EULAR recommendations for the management of axial spondyloarthritis: 2022 update. Ann Rheum Dis 2023; 82:19–34. 73. Ward MM, Deodhar A, Gensler LS, et al. 2019 update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network Recommendations for the treatment of ankylosing spondylitis and nonradiographic axial spondyloarthritis. Arthritis Care Res 2019; 71:1285–1299. 74. Feuerstein JD, Ho EY, Shmidt E, et al. AGA Clinical Practice Guidelines on the medical management of moderate to severe luminal and perianal fistulizing Crohn’s disease. Gastroenterology 2021; 160:2496–2508. 75. Feuerstein JD, Isaacs KL, Schneider Y, et al. AGA Clinical Practice Guidelines on the management of moderate to severe ulcerative colitis. Gastroenterology 2020; 158:1450–1461. 76. Ko CW, Singh S, Feuerstein JD, et al. AGA Clinical Practice Guidelines on the management of mild-to-moderate ulcerative colitis. Gastroenterology 2019; 156:748–764. 77. Klein A, Eliakim R. Non steroidal anti-inflammatory drugs and inflammatory bowel disease. Pharmaceuticals (Basel) 2010; 3:1084–1092. 78. Kefalakes H, Stylianides TJ, Amanakis G, Kolios G. Exacerbation of inflammatory bowel diseases associated with the use of nonsteroidal anti-inflammatory drugs: myth or reality? Eur J Clin Pharmacol 2009; 65:963–970. 79. Lichtenstein GR, Loftus EV, Isaacs KL, et al. ACG Clinical Guideline: management of Crohn’s disease in adults. Am J Gastroenterol 2018; 113:481–517. 80. Moninuola OO, Milligan W, Lochhead P, Khalili H. Systematic review with meta-analysis: association between acetaminophen and nonsteroidal antiinflammatory drugs (NSAIDs) and risk of Crohn’s disease and ulcerative colitis exacerbation. Aliment Pharmacol Therap 2018; 47:1428–1439. 81. Miao XP, Li JS, Ouyang Q, et al. Tolerability of selective cyclooxygenase 2 inhibitors used for the treatment of rheumatological manifestations of inflammatory bowel disease. Cochrane Database Syst Rev 2014; Cd007744. 82. Olivieri I, Cantini F, Castiglione F, et al. Italian Expert Panel on the management of patients with coexisting spondyloarthritis and inflammatory bowel disease. Autoimmun Rev 2014; 13:822–830. 83. Sandborn WJ, Hanauer SB, Katz S, et al. Etanercept for active Crohn’s disease: a randomized, double-blind, placebo-controlled trial. Gastroenterology 2001; 121:1088–1094. 84. O’Toole A, Lucci M, Korzenik J. Inflammatory bowel disease provoked by etanercept: report of 443 possible cases combined from an IBD referral center and the FDA. Dig Dis Sci 2016; 61:1772–1774. 85. Hueber W, Sands BE, Lewitzky S, et al. Secukinumab, a human anti-IL-17A monoclonal antibody, for moderate to severe Crohn’s disease: unexpected results of a randomised, double-blind placebo-controlled trial. Gut 2012; 61:1693–1700. 86. Baeten D, Sieper J, Braun J, et al. Secukinumab, an interleukin-17A inhibitor, in ankylosing spondylitis. N Engl J Med 2015; 373:2534–2548. 87. van der Heijde D, Cheng-Chung Wei J, Dougados M, et al. Ixekizumab, an interleukin-17A antagonist in the treatment of ankylosing spondylitis or radiographic axial spondyloarthritis in patients previously untreated with biological disease-modifying antirheumatic drugs (COAST-V): 16 week results of a phase 3 randomised, double-blind, active-controlled and placebo-controlled trial. Lancet 2018; 392:2441–2451. 88. Fauny M, Moulin D, D’Amico F, et al. Paradoxical gastrointestinal effects of interleukin-17 blockers. Ann Rheum Dis 2020; 79:1132–1138. 89. Schreiber S, Colombel JF, Feagan BG, et al. Incidence rates of inflammatory bowel disease in patients with psoriasis, psoriatic arthritis and ankylosing spondylitis treated with secukinumab: a retrospective analysis of pooled data from 21 clinical trials. Ann Rheum Dis 2019; 78:473–479. 90. Penso L, Bergqvist C, Meyer A, et al. Risk of inflammatory bowel disease in patients with psoriasis and psoriatic arthritis/ankylosing spondylitis initiating interleukin-17 inhibitors: a nationwide population-based study using the French National Health Data System. Arthritis Rheumatol 2022; 74:244–252. 91. Feagan BG, Sandborn WJ, Gasink C, et al. Ustekinumab as induction and maintenance therapy for Crohn’s disease. N Engl J Med 2016; 375:1946–1960. 92. Rowan CR, Boland K, Harewood GC. Ustekinumab as induction and maintenance therapy for ulcerative colitis. N Engl J Med 2020; 382:91. 93. Deodhar A, Gensler LS, Sieper J, et al. Three multicenter, randomized, doubleblind, placebo-controlled studies evaluating the efficacy and safety of ustekinumab in axial spondyloarthritis. Arthritis Rheumatol 2019; 71:258–270. 94. Baeten D, stergaard M, Wei JC, et al. Risankizumab, an IL-23 inhibitor, for ankylosing spondylitis: results of a randomised, double-blind, placebo-controlled, proof-of-concept, dose-finding phase 2 study. Ann Rheum Dis 2018; 77:1295–1302. 95. McGonagle D, Watad A, Sharif K, Bridgewood C. Why inhibition of IL-23 lacked efficacy in ankylosing spondylitis. Front Immunol 2021; 12:614255. 96. Dubash S, Marianayagam T, Tinazzi I, et al. Emergence of severe spondyloarthropathy-related entheseal pathology following successful vedolizumab therapy for inflammatory bowel disease. Rheumatology (Oxford) 2019; 58:963–968. 97. Orlando A, Orlando R, Ciccia F, et al. Clinical benefit of vedolizumab on articular manifestations in patients with active spondyloarthritis associated with inflammatory bowel disease. Ann Rheum Dis 2017; 76:e31. 98. Feagan BG, Sands BE, Sandborn WJ, et al. Guselkumab plus golimumab && combination therapy versus guselkumab or golimumab monotherapy in patients with ulcerative colitis (VEGA): a randomised, double-blind, controlled, phase 2, proof-of-concept trial. Lancet Gastroenterol Hepatol 2023; 8:307–320. An exciting clinical trial data that will encourage more combination biologic, very much applicable in this patient population 1040-8711 Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved. www.co-rheumatology.com Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved. 281