Subido por juvenilson

Sacroiliitis in inflammatory bowel disease

Anuncio
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
Descargar