Gastrointestinal (GI) symptoms are very common among people with rheumatoid arthritis (RA). In one study, nearly 1 in 5 reported feeling abdominal pain or discomfort.1 When compared to people without RA, people with RA were more likely to have pain, fullness, nausea or stool leakage.1 Furthermore, these symptoms occurred frequently – at least once per week.1
Those symptoms might sound a lot like irritable bowel syndrome (IBS). IBS is defined as recurrent abdominal pain associated with defecation or a change in bowel habits that occurs at least one day per week during the previous three months.2
The fact is your gut has a limited repertoire. GI symptoms could have many causes. For people with RA, GI symptoms are often medication related. However, a few researchers wonder whether there is a link between immune activation and functional GI disorders, such irritable bowel syndrome (IBS).3 It’s an intriguing idea, but still speculative.
RA medications and GI symptoms
The link between non-steroidal anti-inflammatory drugs (NSAIDs) and GI problems is well established. Common upper GI problems include heartburn, reflux, and indigestion.4 Serious upper GI problems include bleeding, obstruction, perforation, and ulcers.4 COX-2 inhibitors may be less harmful for the upper GI than non-selective (traditional) NSAIDs.4 Use of proton-pump inhibitors can protect against these adverse effects.5 Behavior changes may also help to improve reflux and heartburn.
NSAID-related problems in the lower GI are not understood as well.4 However, use of NSAIDs is linked with gut inflammation and increased permeability.4 In rare cases, NSAIDs have been linked with colon problems, including bleeding, ulceration, strictures, perforation, and diarrhea.5
GI problems are also common side effects of traditional DMARDs, including methotrexate. Methotrexate is a mainstay of treatment for RA. However, one-third of patients discontinue the drug due to adverse events, mainly GI events.6 Taking folic acid or switching from oral to subcutaneous methotrexate may help with these side effects.7
Could it be IBS?
Irritable bowel syndrome affects about 10% to 25% of the general population.8 IBS is classified as a functional disorder, eg, one that is related to problems with gut-brain interaction, abnormalities in how food moves through the gut, and a variety of other factors.
So, why would IBS be linked with RA? There is some evidence that damage to the gut lining and imbalances in gut bacteria may contribute to functional GI disorders.3,9 The theory is that these abnormalities may also lead to immune activation and thus, autoimmune disorders.9
Population-based studies of the link between RA and IBS have produced conflicting results. A mail survey of Australians showed that about 20% of people with RA met the criteria for IBS, and that having RA was statistically associated with IBS.3 Two other studies found no link. One was a UK study of nearly 23,500 people in primary care practices.9 These results showed that rheumatologic disorders were more prevalent among people with functional GI disorders in general—except for people with IBS.9 That is, the people with IBS were no more likely than those without IBS to have a rheumatologic disorders. In another study—this one from Minnesota—people with RA were no more likely than people without RA to be diagnosed with IBS.1
Whatever the cause, having GI symptoms on top of everything else is frustrating and unpleasant. It is important to discuss them with your health care provider. Share what you have discovered about the timing and triggers. Working together, you may be able to determine the reason for the symptoms and make adjustments accordingly.
Myasoedova E, Talley NJ, Manek NJ, Crowson CS. Prevalence and risk factors of gastrointestinal disorders in patients with rheumatoid arthritis: results from a population-based survey in olmsted county, Minnesota. Gastroenterol Res Pract. 2011;2011:745829.
Lacy BE, Mearin F, Chang L, Chey WD, Lembo AJ, Simren M, Spiller R. Bowel Disorders. Gastroenterology. 2016;150:1393-1407.
Koloski N, Jones M, Walker MM, et al. Population based study: atopy and autoimmune diseases are associated with functional dyspepsia and irritable bowel syndrome, independent of psychological distress. Aliment Pharmacol Ther. 2019;49:546-555.
Sostres C, Gargallo CJ, Lanas A. Nonsteroidal anti-inflammatory drugs andupper and lower gastrointestinal mucosal damage. Arthritis Res Ther. 2013;15 (Suppl 3):S3.
Gullick NJ, Scott DL. Co-morbidities in established rheumatoid arthritis. Best Pract Res Clin Rheumatol. 2011;25:469-483.
Nikiphorou E, Negoescu A, Fitzpatrick JD, et al. Indispensable or intolerable? Methotrexate in patients with rheumatoid and psoriatic arthritis: a retrospective review of discontinuation rates from a large UK cohort. Clin Rheumatol. 2014;33:609-614.
Bello AE, Perkins EL, Jay R, Efthimiou P. Recommendations for optimizing methotrexate treatment for patients with rheumatoid arthritis. Open Access Rheumatol. 2017;9:67-79.
Canavan C, West J, Card T. The epidemiology of irritable bowel syndrome. Clin Epidemiol. 2014;6:71-80.
Ford AC, Talley NJ, Walker MM, Jones MP. Increased prevalence of autoimmune diseases in functional gastrointestinal disorders: case-control study of 23471 primary care patients. Aliment Pharmacol Ther. 2014;40:827-834.