chronic arthralgia associated with crohn's

[bwstone21]

To start off, I am only 25 years old, and have been diagnosed with crohn's since 19 (my father and his mother both had crohn's as well).  Up until 1.5 years ago I have experienced only pains involving my abdominal region, and between asacol and periodic prednisone, I have been fairly well controlled.  Although, about 1.5 years ago I had a flair up of my crohn's, started a prednisone taper (which helped) but the difference this time was this attack was preceded by a new pain in my knees and lower back.  I was refered to a reumatologist who found nothing to help my pain (10mg prednisone qd, NSAIDs like celebrex, vioxx, lodine, IBU, etc.) and all those meds did, except for the prednisone, was to upset my stomach and increase my abdomional pain.  i had MRIs on both knees and lower back, where my knees cam back fine, but my lower back did show degredation of the L4-L5 disc (or L5-S1, but the doctor wasn't very complete so im not really sure exactly).  He did say, however, that it seemed to be arthiritis in my back to the extent that he would come across in a man 40+ years of age.  But he was left prescribing vicodin for the pain (which I didn't like) but it was the only thing that helped.  Since then I have slowly had more pain to the point where I now need 3-4 qd (div 1/2tab q2-3h prn) Vicodin ES to controll my pain and now the pain radiates throughout my entire lower body from my low back to my ankles.  Additionally, my muscles fatigue easily and I get extreme pain intermittently in my left femur which is only mildy controlled by the hydrocodone.  I am about 10 months from graduationg Rx school, so I know from definition I am not an "addict" however I probably have a degree of physical dependance to opioids now.  but I am faced with the questions of why do I have this pain?  And do I just continue to keep upping the dose of hydrocodone or even worse move up to a stronger opioid?  Your help in guidance of diagnosis and/or treatment options would be greatly appreciated.
Thanks, B.

[Kevin Pho, MD]

Hello - thanks for asking your question.

As you know already, treating the underlying inflammatory bowel disease is helpful in treating the arthritis that is associated with it.  Corticosteroids, sulfasalazine and methotrexate are typically used and are helpful in both bowel and joint inflammation.

Other modalities you may want to discuss is azathioprine and the use of tumor necrosis factor agonists such as infliximab or subcutaneous administration of etanercept.  Each of these agents should be discussed with your rheumatologist.

As an aside, use of chronic short acting opiates (such as Vicodin) should be managed in conjunction with a pain specialist (typically an anesthesiologist or physiatrist).  The current standard of care would be transitioning to a long-acting opiate (such as Oxycontin or MS-Contin) and then using a short-acting opiate (such as Vicodin or Perocet) for breakthrough pain.  This option should be discussed with your personal physician.  

Followup with your personal physician is essential.

This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.

Thanks,
Kevin, M.D.

[kimbacat]

B.

if you are maintaining your CD on 5ASA's you might want to try switching to the older sulfasalazine which can help the joint pain.  I had a great response from Plaquenil (hydroxychloroquine).  I'm taking methotrexate and Remicade which are helping with the joint pain and tramadol for break thru pain.

take care