Debilitating Joint Pain in Ulcerative Colitis Patients

A poster presentation at the Advances in Inflammatory Bowel Diseases annual meeting revealed that more than a third of patients with ulcerative colitis also experienced debilitating joint pain.

In this second of four exclusive episodes, MedPage Today brought together three expert leaders in the field -- moderator Jason K. Hou, MD, of Baylor College of Medicine, is joined by Shirley Cohen-Mekelburg, MD, of the University of Michigan, and Frank I. Scott, MD, of the University of Colorado, Anschutz Medical Campus -- for a virtual roundtable discussion on this cross-sectional study.

Following is a transcript of their remarks:

Hou: Hello, everybody. My name is Dr. Jason Hou, associate professor of medicine at Baylor College of Medicine. I'd like to welcome you all to the MedPage Today virtual roundtable. We're here discussing posters and presentations from AIBD 2022. With me today for the discussion is Dr. Frank Scott, associate professor of medicine at the University of Colorado, as well as Dr. Shirley Cohen-Mekelburg, assistant professor of medicine at the University of Michigan and Ann Arbor VA. Welcome, Dr. Scott. Welcome, Dr. Cohen-Mekelburg.

Moving on to the next abstract I thought would be very interesting for discussion, this is a poster that was presented by Dr. [Marlana] Radcliffe and colleagues in the group from the University of North Carolina called "Joint Pain Is Associated With Impaired Quality of Life in Patients with Ulcerative Colitis." This was a cross-sectional study of about 630 patients out of the large patient-centered cohort called IBD Partners that I think many of us are very well familiar with.

They looked at patient-reported joint pain and compared it to quality-of-life patient-reported outcomes from PROMIS measures specifically focused on outcomes of depression, anxiety, fatigue, and impaired social satisfaction. They did multivariable logistic regression to look at these associations. They found high frequency of joint pain, 36% of patients reporting pain. Almost a half, 40%, of the patients were on biologics. This is somewhat reflective or says something about the core of patients that are participating in Partners. But they did find statistically significant associations with social impairment, fatigue, anxiety, depression across all of the patient-reported outcome measures in patients who have joint pain.

So, again, back to you, Frank and Shirley, what are your thoughts about this? Is this a big problem that you're seeing in practice and what are your clinical takeaways from this observation?

Scott: Thanks, Jason. I think this is really important work here, and I think it highlights the importance for our IBD patients of taking a really careful review of systems and ensuring that we're asking our patients not only about the joint-related symptoms that are noted here, but also the potential psychiatric symptoms that they're associated with here.

It doesn't surprise me that we see this interaction between psychiatric well-being and joint symptoms because multiple studies have demonstrated how debilitating our arthralgias, arthritis can be for our patients. And you could clearly see how this can negatively affect quality of life. And I think it's really important to highlight just the degree of effect this can have on our patients' quality of life.

Cohen-Mekelburg: I agree and I really like this study because there is much less knowledge on the extraintestinal manifestations of IBD, as compared to the intestinal manifestations and their impact on IBD and patients' lives. Understanding patient-reported outcomes is kind of key to studying these topics. And I think this study provides a nice platform for that.

As we've discussed with other topics, it is interesting to think about, just conceptually, the directionality of some of these associations -- does fatigue and depression lead to more joint symptoms versus do joint symptoms lead to more fatigue and depression? Or, is joint pain really a marker of active disease, which we know can be associated with both fatigue and depression? And so a lot of those things are to be teased out and we've learned a lot in the last 5, 10 years from other studies as well. And so I think this adds to that literature.

Scott: That's a great point, Shirley. I think one of the takeaways that I would take from this study would be that if we see one of these, we should be asking about the other. We should be asking about these for all of our patients across the board. But if you see somebody with significant depression or anxiety, you should be asking about other joint symptoms and vice-versa. It really highlights that sort of broad ROS [review of systems] that we should be conducting for our patients. And appropriate referral to our colleagues and allied health professionals when necessary.

Cohen-Mekelburg: Sure. And it's interesting in clinical practice, we see a lot of patients with joint symptoms and there's the group of patients that we frequently co-manage with rheumatology, for example. But I think, less frequently do we think about screening for depression or anxiety and referring, let's say to mental health. And, we know that there's recommendations out there to screen annually IBD patients for these conditions, but I think in practice we're not very good at doing that. And so this could be a good signal to do so.

Hou: Those are excellent points from both of you, [Dr.] Scott and Shirley. How does this have an impact on your selection from a sequencing standpoint of treatment?

Cohen-Mekelburg: I think it's a good question. I think there's been some recent papers recently showing that patients on vedolizumab, or Entyvio, tend to have residual joint pain if they have them at baseline. And I don't know if it necessarily changes the order in which I would use a medication, but I think more just awareness of comorbidities and knowing how to address those. And some of those are not necessarily by the type of biologic you're using, but more comprehensive, like whole person care, if you will.

Scott: Fully agree. Shirley, you highlighted vedolizumab is particularly problematic here, and I think that is one thing you need to consider when you're looking at the universe of other symptoms that our patients are maybe experiencing and/or comorbidities, and another example along those lines with the ankylosing spondylitis and how that might influence your medication selection. As we know that some of our IL-12/23 agents may not be as effective in that disease process as well.

Cohen-Mekelburg: Interestingly, I was looking through the tables they have as far as identifying the factors associated with the patients who reported joint pain, and I think a few of those signals were a high body mass index, smoking, increased stool frequency. And we know the relationship between smoking and active disease, as well as stool frequency being associated with active disease. I thought it was interesting with the high BMI, obviously there's confounders, but obesity can lead to non-inflammatory joint pains. But you wonder also about medications and adequacy; for example, weight-based treatments versus non-weight-based treatments. I don't know if you have thoughts on that.

Scott: I think your identification of the association between these risk factors that are associated with the depressive symptoms and the joint symptoms does highlight the potential that, could this all represent undertreated disease as well. We also are learning a lot more about the interaction between depression, anxiety, and IBD in terms of disease activity as well. And, so you could even consider sort of repositioning this as both the depressive symptoms and anxiety symptoms and the joint-related symptoms all being potentially representative of completely controlled inflammatory bowel disease as well.

Cohen-Mekelburg: Yeah, it would be interesting to see if this relationship between joint pains and quality of life persisted if they accounted for intestinal disease activity, separating the folks who this is more of a residual symptom rather than active disease.

Scott: Sure. Incorporating endoscopic disease activity assessment or inflammatory markers into the equation too.

Hou: Excellent points, Frank and Shirley. Once again, a nice poster identifying high prevalence of joint symptoms and this association with significant social impairment and mental health patient-reported outcomes. So as both of you mentioned, important to ask this, we really should be screening for these mental health issues in all the patients, but I think highlights, especially in patients who are describing -- first, you gotta ask about extraintestinal manifestations and those especially with joint pains. Be sure that we're screening those patients for that and get them plugged in accordingly. So, thank you for that great conversation.

Watch episode one of this discussion: Early-Life Antibiotic Exposure Linked to Increased Risk of Childhood IBD

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