What’s the Connection Between Crohn's Disease and Arthritis?
If you have Crohn's disease, you may also experience enteropathic arthritis. This type of arthritis is an extraintestinal symptom of Crohn's, meaning it's a symptom that occurs outside the gut.
The severity of Crohn's-related joint symptoms often mirrors the severity of intestinal symptoms, but not always.
Learn more about the link between Crohn's disease and arthritis and how to manage it.
The exact reason for enteropathic arthritis remains unclear, but it likely results from a combination or interaction of several factors.
Both Crohn's — a type of inflammatory bowel disease (IBD) — and arthritis involve inflammation. Crohn's may increase the risk of inflammation in other parts of your body through various mechanisms.
"Although primarily a disease of the gastrointestinal tract, Crohn's can affect multiple organs," says Jane Onken, MD, a professor of medicine specializing in gastroenterology at Duke University School of Medicine in Durham, North Carolina. Extraintestinal manifestations include oral ulcers, inflammatory conditions of the eye, certain skin lesions, and joint aches.
Arthritis that stems from Crohn's can manifest as peripheral or axial arthritis, spondyloarthritis, ankylosing spondylitis, and symmetrical polyarthritis.
Genetic Predisposition
People with Crohn's who develop arthritis often have changes in certain genes.
Those with spondyloarthritis and Crohn's, for example, may have changes in the HLA-B27 gene, which relates to a protein on white blood cells. This protein can cause your immune system to attack healthy cells in your joints.
People with Crohn's who have changes in the CARD9 gene may also develop inflammation elsewhere in the body because of reactions started by bacterial and fungal proteins in the gut.
Luminal Microbiota
The luminal microbiota is the community of bacteria and other microorganisms that live within the gut. A balanced gut microbiome helps you digest food and keeps the gut healthy.
Changes to the luminal microbiota may trigger immune reactions, leading to diseases such as Crohn's and some types of arthritis.
Leaky Gut
The inflammation involved in Crohn's can make the gut more permeable, or "leaky," allowing bacteria and immune cells to more easily cross into the bloodstream and other parts of the body.
This could trigger an immune response elsewhere in the body, including the joints.
Immune System Dysfunction
Crohn's and joint inflammation may result from an autoimmune disorder in which the immune system attacks healthy tissue in the gut and elsewhere. More studies are needed to explore this possibility.
Medication Use
Some Crohn's medications can cause joint pain that's not necessarily arthritis.
Drugs that have joint pain as a side effect include:
infliximab
azathioprine, in some people
steroids, when used for too long or stopped too quickly
Dr. Onken says that doctors often prescribe prednisone, a steroid, to treat both gut and arthritis symptoms in Crohn's. "A potentially debilitating side effect of prolonged or frequent prednisone use is bone loss that can lead to osteoporosis, compression fractures of the spine, and more."
For this reason, she says, "It's important to try to minimize the use of prednisone whenever possible."
People who use prednisone for a long time need close monitoring of bone density.
"Some Crohn's patients are also at risk for bone loss due to vitamin D deficiency, so levels should be checked and replaced when necessary," Onken says.
There's no evidence that arthritis causes Crohn's disease. Joint symptoms can sometimes appear before gut symptoms, but they are likely linked to Crohn's.
About 6 to 46 percent of people with IBD — either ulcerative colitis or Crohn's — develop musculoskeletal problems, such as joint pain and arthritis. This makes arthritis the most common extraintestinal complication of Crohn's.
Some research shows that peripheral arthritis, sacroiliitis, and ankylosing spondylitis are present in 13 percent, 10 percent, and 3 percent of patients with IBD, respectively.
The risk of most types of arthritis typically increases with age. But Crohn's often appears before the age of 30, and arthritis symptoms can develop at any time after it begins, or even before.
Black people with IBD show higher rates of joint pain, ankylosing spondylitis, and sacroiliitis than their white counterparts.
There are different types of Crohn's-linked arthritis. You may have one or a combination of types.
Peripheral Arthritis
Peripheral arthritis affects the joints in your arms and legs, including your hands, wrists, elbows, knees, ankles, and feet. High levels of Crohn's-related intestinal inflammation tend to correlate with high levels of joint inflammation.
Common features include:
Asymmetric symptoms, occurring on one side only
Symptoms in the lower limbs
Enthesitis, a swelling of tissues where tendons attach to the bone
While painful, it doesn't usually lead to bone erosion or joint deformity.
Axial Arthritis
Also called spondylitis or spondyloarthropathy, axial arthritis is strongly linked to the HLA-B27 gene.
Axial arthritis affects your:
Lower spine
Joints at the bottom of your back
Hips
It may start before you notice any signs of Crohn's.
The severity of axial arthritis symptoms can vary from features only noticeable on a scan to symptoms that affect your mobility and daily life. It doesn't always correspond with the severity of intestinal symptoms.
For most people, the outlook for axial spondylitis depends on how quickly IBD progresses. If joint symptoms only affect a limited part of your body, you're unlikely to experience severe loss of function.
But some people develop progressive spondylitis, which is more severe and can lead to persistent spinal pain, hip damage, and spinal fusion.
Ankylosing Spondylitis
Ankylosing spondylitis affects the spine and lower back.
In fact, some experts have suggested that higher levels of a protein known as calprotectin in the stool of people with ankylosing spondylitis might predict the appearance of Crohn's within five years.
Symmetrical Polyarthritis
Polyarthritis is when arthritis affects five or more joints at the same time. Symmetrical polyarthritis is when it affects corresponding joints on both sides of your body — for instance, both hands.
With Crohn's, it will most likely affect your hands. Symptoms can last a long time and don't necessarily correspond with flares of intestinal symptoms.
"Although patients with Crohn's can also be diagnosed with other autoimmune conditions that involve joints, such as psoriatic arthritis and rheumatoid arthritis, these conditions meet their own diagnostic criteria and do not involve the GI tract, so are not considered enteropathic arthropathies," says Onken.
Crohn's-related arthritis can differ from arthritis that's not linked to Crohn's in the following ways:
Crohn's is linked to specific types of arthritis, such as peripheral, axial, and spondyloarthritis.
Depending on the type, Crohn's-related arthritis symptoms may worsen during an intestinal flare.
Intestinal symptoms often appear first, but not always.
In some cases, surgery to resolve Crohn's may also resolve joint pain.
Flares tend to be self-limiting and usually disappear after around six weeks.
Treatment for Crohn's-linked arthritis needs to address both conditions.
Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil, Motrin), can help relieve pain but may worsen the symptoms of Crohn's. But the NSAIDs naproxen (Aleve) and celecoxib (Celebrex) may help under certain circumstances.
Here are some other options:
Disease-modifying antirheumatic drugs (DMARDs), such as sulfasalazine (Azulfidine)
Tumor necrosis factor (TNF) inhibitors, such as infliximab (Remicade)
Interleukin inhibitors, such as ustekinumab (Stelara)
Steroids to manage flares, such as methylprednisolone (Medrol), although long-term use can have side effects, such as bone damage
Your team should include both a gastroenterologist and a rheumatologist. They will work with you to find a treatment that addresses both your Crohn's symptoms and your arthritis in a way that best suits your needs.
Alongside medical treatment, various home remedies can help you manage arthritis with Crohn's.
Examples include:
Physical therapy to maintain mobility and range of motion
An anti-inflammatory diet, such as an easy-to-digest version of a Mediterranean diet, which may help with both Crohn's and arthritis
Heating pads to relieve pain
The RICE method (rest, ice, compression, elevation)
Relaxation techniques, such as breathing exercises and guided imagery
Discuss any dietary changes or exercise program with your doctor or physical therapist. They will help you make an individual plan.
For instance, you may need a specially adapted Mediterranean diet if you can't tolerate ingredients such as whole grains or legumes.
You may also need to stop exercising if you have an inflamed joint.
Managing Seasonal Changes
Some people say their arthritis gets worse in the winter — possibly due to changes in atmospheric pressure, according to Neilanjan Nandi, MD, a gastroenterologist and an associate professor at Penn Medicine in Philadelphia.
The Arthritis Foundation notes that high humidity, strong winds, and low pressure may contribute, but more research is needed.
Dressing warmly and exercising to maintain flexibility is key to keeping symptoms under control during the colder months, Dr. Nandi says.
People with Crohn's disease may develop enteropathic arthritis, or joint pain due to Crohn's. Experts don't know precisely why it happens, but it likely stems from a combination of genetic, environmental, and other factors.
Types of arthritis linked to Crohn's include peripheral, axial, spondyloarthritis, and symmetrical polyarthritis.
Home remedies for Crohn's-related arthritis include gentle exercise, a modified anti-inflammatory diet, and heat and cold treatment.
The outlook will depend on the type of arthritis, but Crohn's-related arthritis does not usually lead to bone erosion.
