Synopsis
Recognise peripheral and axial arthritis associated with inflammatory bowel disease, distinguish activity-linked from independent patterns, and coordinate treatment so joint control does not worsen intestinal disease.
- Inflammatory bowel disease may cause activity-linked asymmetric lower-limb oligoarthritis, more persistent small-joint polyarthritis, enthesitis, dactylitis or axial spondyloarthritis.
- Ask whether joint symptoms track bowel activity, but do not assume controlled diarrhoea excludes active axial or peripheral disease.
- Examine joints, entheses, digits and spine and ask about uveitis, psoriasis, bleeding, weight loss, perianal disease and current IBD medicines.
- A hot joint in an immunosuppressed patient needs aspiration and culture; infection and crystals remain possible despite a convincing enteropathic history.
- NSAIDs can worsen gastrointestinal symptoms or mucosal disease in some patients, so any trial should be cautious, short and coordinated when IBD is active.
- Conventional DMARDs may help persistent peripheral arthritis but do not reliably control axial disease.
- For active axial spondyloarthritis with active IBD, prefer a monoclonal TNF inhibitor or an exact JAK inhibitor licensed and NICE-recommended for both diagnoses; do not start an IL-17 inhibitor. Etanercept and gut-directed IL-12/23, IL-23 or integrin therapy do not reliably control axial inflammation; JAK use also needs cardiovascular, thrombotic, cancer, infection and pregnancy risk review.
- Monitor nutrition, anaemia, bone health, thrombosis, infection and corticosteroid exposure alongside bowel and joint activity.
Key red flags
Immunosuppression, biologic treatment, central access or systemic illness heightens concern for infection in one acutely hot joint.
Pain, photophobia, redness and visual change requires same-day ophthalmic review irrespective of current bowel or joint activity.
Investigation priorities
Define whether peripheral, axial and entheseal activity parallels objective intestinal inflammation.
Management branches
Lower-limb synovitis occurs with objective intestinal inflammatory activity and no septic-joint signal.
- Assess hydration, infection, bleeding, bowel severity and joint distribution and obtain appropriate blood, stool and synovial tests.
- Coordinate IBD treatment optimisation with gastroenterology and provide local or systemic joint symptom care that does not worsen bowel or renal risk.
- Reassess joint response after bowel control and refer persistent polyarthritis for conventional or targeted DMARD therapy.
Key medicines
SulfasalazineStart 500 mg once daily and increase the total daily dose by 500 mg each week as tolerated, usually to 1 g twice daily, under the specialist monitoring plan.Check baseline and serial FBC, liver and renal function; stop and seek urgent review for rash, fever, sore throat, bruising or jaundice. Withhold during a serious infection until recovery and specialist review. Check sulfonamide or salicylate allergy, G6PD risk and azathioprine or 6-mercaptopurine interaction; in pregnancy use folic acid 5 mg daily through the first trimester.
AdalimumabUlcerative colitis: 160 mg at week 0, 80 mg at week 2, then 40 mg subcutaneously every other week from week 4. Crohn disease: 80/40 mg, or 160/80 mg when rapid response is required with greater adverse-event risk, then 40 mg every other week from week 4.Do not start during active TB or another serious infection; screen for TB and hepatitis B and review demyelinating disease. Adalimumab is contraindicated in NYHA III or IV heart failure and should stop for new or worsening failure. Avoid live vaccine during therapy; if continued beyond 28 weeks of pregnancy, BSR advises deferring infant live vaccines until 6 months.