Review Italian Expert Panel on the management of patients with coexisting spondyloarthritis and inflammatory bowel disease Ignazio Olivieri a , Fabrizio Cantini b , Fabiana Castiglione c , Carla Felice d , Paolo Gionchetti e , Ambrogio Orlando f , Carlo Salvarani g , Raffaele Scarpa h , Maurizio Vecchi i , Alessandro Armuzzi d, ⁎ a Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera, Italy b Division of Rheumatology, Misericordia e Dolce Hospital, Prato, Italy c Gastroenterology Unit, University Federico II, Naples, Italy d IBD Unit, Complesso Integrato Columbus, Catholic University, Rome, Italy e IBD Unit, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Italy f IBD Unit, Internal Medicine, A.O. Ospedali Riuniti “Villa Sofia-Cervello”, Palermo, Italy g Rheumatology Unit, Department of Internal Medicine, Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy h Rheumatology Unit, Department of Clinical and Experimental Medicine, University Federico II, Naples, Italy i Gastroenterology and Gastrointestinal Endoscopy Unit, IRCCS Policlinico San Donato, Department of Biomedical Sciences for the Health, University of Milan, Milan, Italy abstract article info Article history: Received 9 March 2014 Accepted 30 March 2014 Available online 13 April 2014 Keywords: Spondyloarthritis Inflammatory bowel disease Integrated management Crohn's disease Ulcerative colitis Therapeutic algorithm Spondyloarthritis (SpA) is a group of diseases with similar clinical, radiologic and serologic features, including SpA associated with inflammatory bowel disease (IBD-associated SpA). Several studies have estimated the occur- rence of SpA in IBD patients as ranging from 17% to 39%, confirming that SpA is the most frequent extra-intestinal manifestation in patients with IBD. In this paper, the expert panel presents some red flags to guide clinicians – both rheumatologists and gastroenterologists – to make a correct diagnosis of IBD-associated SpA in clinical prac- tice. IBD-associated SpA classification, clinical presentation and diagnostic work-up are also presented. From the therapeutic point of view, only separate recommendations/guidelines are currently available for the treatment of Crohn's disease, ulcerative colitis and for both axial and peripheral SpA. However, when IBD and SpA coexist, the therapeutic strategy should be modulated to take into account the variable manifestations of IBD in terms of intestinal and extra-intestinal features, and the clinical manifestations of SpA, with particular attention to periph- eral enthesitis, dactylitis and anterior uveitis. To our knowledge, this is the first attempt to define therapeutic algorithms for the integrated management of different IBD-associated SpA clinical scenarios. © 2014 Elsevier B.V. All rights reserved. Contents 1. Epidemiology and clinical course of IBD-associated SpA: data from rheumatology and gastroenterology . . . . . . . . . . . . . . . . . . . . . 823 2. Need for integrated approach for IBD-associated SpA patient management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 823 3. IBD-associated SpA: disease classification, diagnosis and manifestations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 824 3.1. Rheumatologist's side . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 824 3.1.1. Classification of SpA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 824 3.1.2. IBD-associated SpA clinical presentation and diagnostic work-up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 824 3.2. Gastroenterologist's side . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 824 3.2.1. IBD classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 824 Autoimmunity Reviews 13 (2014) 822–830 Abbreviations: ACR, American College of Rheumatology; AS, ankylosing spondylitis; ASAS, Assessment in SpondyloArthritis; axSpA, axial SpA; CD, Crohn's disease; ECCO, European Crohn's and Colitis Organisation; ESSG, European Spondylarthropathy Study Group; EULAR, European League Against Rheumatism; IBD, inflammatory bowel disease; MRI, magnetic res- onance imaging; nr-axSpA, non-radiographic axial SpA; PsA, psoriatic arthritis; ReA, reactive arthritis; SpA, spondyloarthritis; UC, ulcerative colitis; uSpA, undifferentiated SpA. ⁎ Corresponding author at: IBD Unit, Complesso Integrato Columbus, Catholic University, Via G. Moscati 31, 00168 Rome, Italy. Tel.: +39 063503310; fax: +39 063054641. E-mail address: alearmuzzi@yahoo.com (A. Armuzzi). http://dx.doi.org/10.1016/j.autrev.2014.04.003 1568-9972/© 2014 Elsevier B.V. All rights reserved. Contents lists available at ScienceDirect Autoimmunity Reviews journal homepage: www.elsevier.com/locate/autrev