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NON-IMMUNE MEDIATED MUSCULOSKELETAL DISEASE IN CROHN’S DISEASE PATIENTS BEING EVALUATED FOR INFLAMMATORY SPONDYLOARTHRITIS - A PILOT STUDY

Abstract BACKGROUND Musculoskeletal (MSK) disease is the most common extra-intestinal manifestation of inflammatory bowel disease (IBD). The emphasis in the published literature has been on the inflammatory arthritis associated with IBD, spondyloarthritis (SpA). There is a lack of data regarding common, non-inflammatory MSK diseases such as osteoarthritis and fibromyalgia. This distinction is important, as these two conditions have different prognoses, require different clinical approaches and management. OBJECTIVE To evaluate the prevalence of non-inflammatory MSK disease in a cohort of Crohn’s disease (CD) patients. METHODS This was a cross-sectional study of a validated CD cohort from a single center registry in New York City conducted from 9/2019 - 1/2021. Recruitment was limited due to the COVID-19 Pandemic. Patients were sent a four question MSK survey (Figure 1) addressing peripheral joint and back symptoms. Those who answered positively to any question were considered to have MSK symptoms. All patients underwent one study visit with a rheumatologist that included: 66/68 tender/swollen joint count (TJC/SJC), Spondyloarthritis Research Consortium of Canada Enthesitis Index (SPARCC), Bath Ankylosing Spondylitis Metrology Index (BASMI), American College of Rheumatology fibromyalgia criteria, ESR and CRP. Disease activity was measured via a modified Ankylosing Spondylitis Disease Activity Score (ASDAS), Harvey Bradshaw Index (HBI), and Inflammatory Bowel Disease Questionnaire (IBD-Q). RESULTS 26 CD patients participated. Median age was 45.6±17.7 years, 35% were male, median disease duration was 17.7±14.2 years and 73% were on immunomodulatory agents for CD. Median values (range) for the following physical exam and disease features were: TJC 10.8±13.2 (0-68), SJC 0.9±2.2 (0-66), SPARCC 2.8±3.1 (0-16), BASMI 1.5±1.0 (0-10, higher values: more motion limitation) ASDAS 1.5±0.9 (<1.3: inactive disease, >2.1: high disease activity), HBI 6.8±3.5 and IBD-Q 159±36. Median ESR and CRP were 18.9±22.2 mm/hr (normal 0-22) and 0.6±0.5 mg/dL (normal<0.7), respectively. 16/26 (62%) reported MSK symptoms. 7/16 (43.8%) had features of SpA, while 9/16 (56.3%) did not have evidence by history or exam of SpA and were therefore determined to have non-inflammatory MSK disease. 13/26 (50%) met fibromyalgia diagnostic criteria. CONCLUSION MSK conditions were very common in this pilot cohort. Though features of SpA were present in almost half of patients, non-inflammatory MSK disease was present in the majority of those with MSK symptoms. While both rheumatologists and gastroenterologists need to recognize the importance of SpA, it is additionally essential to understand that the most common MSK disease in IBD may be non-inflammatory, which has distinct implications for management. Future studies should examine the prevalence of these conditions in larger cohorts of IBD patients.

Although, microscopic colitis (MC) can be considered as spectrum of inflammatory bowel disease (IBD), MC is very different in many aspects; in terms of risk factors, symptoms, course of disease, treatment, and complication. Low bone mineral density (BMD) is previously known as complication of IBD. There are few data about MC and risk of bone density loss. We conduct this systematic review and meta-analysis to determine the association between MC and low BMD. METHODS: A comprehensive literature review was conducted using the MEDLINE, and EMBASE databases through October 2021 to identify studies that demonstrated association between clinical outcomes of interest, MC and low BMD. Pooled odds ratio (OR) and 95% confidence interval (CI) were calculated using a randomeffect, generic inverse variance method. RESULTS: After two rounds of review, four studies met our eligibility criteria and were included in analysis. The result showed statistically significant association between MC and low bone density (pooled OR ¼ 2.15, 95% CI: 1.06 -4.38, p ¼ 0.03) The forest plots and funnel plots are shown below. CONCLUSIONS: Our meta-analysis found significant association between MC and low bone density. Therefore, this data may suggest that BMD screening could be applied for MC patients, and such patients may have benefit from calcium and vitamin D supplementation. Further studies should be done to determine the significance of this issue.

NON-IMMUNE MEDIATED MUSCULOSKELETAL DISEASE IN CROHN'S DISEASE PATIENTS BEING EVALUATED FOR INFLAMMATORY SPONDYLOARTHRITIS -A PILOT STUDY
Monica Schwartzman, Randy Longman, Ellen Scherl, Sergio Schwartzman BACKGROUND: Musculoskeletal (MSK) disease is the most common extra-intestinal manifestation of inflammatory bowel disease (IBD). The emphasis in the published literature has been on the inflammatory arthritis associated with IBD, spondyloarthritis (SpA). There is a lack of data regarding common, non-inflammatory MSK diseases such as osteoarthritis and fibromyalgia. This distinction is important, as these two conditions have different prognoses, require different clinical approaches and management. OBJECTIVE: To evaluate the prevalence of non-inflammatory MSK disease in a cohort of Crohn's disease (CD) patients. METHODS: This was a cross-sectional study of a validated CD cohort from a single center registry in New York City conducted from 9/2019 -1/2021. Recruitment was limited due to the COVID-19 Pandemic.
Patients were sent a four question MSK survey ( Figure 1) addressing peripheral joint and back symptoms.
Those who answered positively to any question were considered to have MSK symptoms. All patients underwent one study visit with a rheumatologist that included: 66/68 tender/swollen joint count (TJC/SJC), Spondyloarthritis Research Consortium of Canada Enthesitis Index (SPARCC), Bath Ankylosing Spondylitis Metrology Index (BASMI), American College of Rheumatology fibromyalgia criteria, ESR and CRP. Disease activity was measured via a modified Ankylosing Spondylitis Disease Activity Score (ASDAS), Harvey Bradshaw Index (HBI), and Inflammatory Bowel Disease Questionnaire (IBD-Q). RESULTS: 26 CD patients participated. Median age was 45.6AE17.7 years, 35% were male, median disease duration was 17.7AE14.2 years and 73% were on immunomodulatory agents for CD.
16/26 (62%) reported MSK symptoms. 7/16 (43.8%) had features of SpA, while 9/16 (56.3%) did not have evidence by history or exam of SpA and were therefore determined to have non-inflammatory MSK disease. 13/26 (50%) met fibromyalgia diagnostic criteria. CONCLUSION: MSK conditions were very common in this pilot cohort. Though features of SpA were present in almost half of patients, non-inflammatory MSK disease was present in the majority of those with MSK symptoms. While both rheumatologists and gastroenterologists need to recognize the importance of SpA, it is additionally essential to understand that the most common MSK disease in IBD may be non-inflammatory, which has distinct implications for management. Future studies should examine the prevalence of these conditions in larger cohorts of IBD patients.

NON-IMMUNE MEDIATED MUSCULOSKELETAL DISEASE IN INFLAMMATORY BOWEL DISEASE: A SYSTEMATIC REVIEW OF THE LITERATURE Monica Schwartzman, Sergio Schwartzman
BACKGROUND: Musculoskeletal (MSK) disease is the most common extra-intestinal manifestation of inflammatory bowel disease (IBD); however, the full spectrum of MSK manifestations remains poorly characterized. The published literature is predominately focused on peripheral and axial inflammatory spondyloarthritis (SpA). However, the prevalence of more common, non-inflammatory MSK conditions, such as osteoarthritis (OA) and fibromyalgia (FM), has not been formally reported. In the general population, the prevalence of OA and FM are 10-14% and 2-3%, respectively. OBJECTIVE: To evaluate the prevalence of OA and FM in the published literature in IBD. METHODS: A systematic literature review of articles assessing the prevalence of MSK disease in IBD was performed using multiple databases through September 2021. References of included articles were searched for additional pertinent studies. RESULTS: 773 abstracts were screened and 94 studies included. Studies were heterogeneous precluding metaanalysis. Regarding study design, 36% were retrospective, 51% cross-sectional and 13% longitudinal. Median age at the time of the study was 41 years (range 29-51) and 49% (range 31%-100%) were male. The median number of IBD patients in each study was 243 (range 44-56,097). The prevalence of SpA (range) in the reviewed studies was: ankylosing spondylitis (AS) 3.5% (1%-27%), axial SpA 9.2% (1%-46%), and peripheral SpA 15.6% (1%-49%).
Only 20/94 studies (21%) stated the term OA in any part of the paper. Of these, 20% excluded OA, 15% used the term OA but did not specifically exclude or identify patients with OA in the results, 5% reported that OA data was unavailable and 60% described the prevalence of OA in the results. In the studies that described OA in the results, median prevalence of OA was 12% (range 0.4%-23.4%). Only 7/94 studies (8%) described FM in any part of the paper, and all described the prevalence of FM in the results with a median prevalence of 2.2% (range 0.8%-12%). CONCLUSION: While OA and FM are common conditions in the general population, most studies did not formally evaluate for these conditions in patients with IBD. When assessed, the median prevalence of OA was consistent with the general population, and additionally higher than the prevalence of AS and axial SpA in patients with IBD. The prevalence of FM was consistent with the general population.
Although both rheumatologists and gastroenterologists need to recognize the importance of SpA, it is as important to understand that the most common MSK disease in IBD may be non-inflammatory. This distinction is critical, as treatment of IBD patients incorrectly diagnosed with inflammatory SpA may subject patients unnecessarily to medication adverse events, while undertreatment of patients with unrecognized SpA may lead to preventable disease morbidity.

PAIN IN INFLAMMATORY BOWEL DISEASE (IBD): DOES OPIOID USE PREDICT WORSE HOSPITAL OUTCOMES?
Neethi Dasu, Yaser Khalid, Brian Blair, C. Jonathan Foster BACKGROUND: Opioid use has been hypothesized to be a marker for increased severity of (IBD) for patients because those patients are more likely to require surgical intervention and have uncontrolled pain. Previous studies have not compared outcomes between patients with opioid use and dependence with IBD compared to patients with IBD not using opioids. Our study aims to investigate hospital mortality, hospital length of stay (LOS), and total charges between both patient groups. METHODS: Data were extracted from the National Inpatient Sample (NIS) 2016-2019 Database. The NIS was searched for hospitalizations for adult patients with IBD, including ulcerative colitis (UC) and