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Paradoxical IBD on Anti-TNF — SCE Rheumatology MCQ

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HardSpondyloarthropathyParadoxical IBD on Anti-TNFSCE Rheumatology

A 48-year-old woman with PsA has been on Adalimumab for 2 years with good control of joints and skin. She develops paradoxical new-onset inflammatory bowel disease-like symptoms with bloody diarrhoea. Colonoscopy shows granulomatous inflammation consistent with Crohn disease. What is the most appropriate management?

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Correct answer: D — Paradoxical IBD can occur on anti-TNF therapy; gastroenterology co-management is essential and Adalimumab may need to be continued or dose-optimised as it treats both PsA and Crohn

Paradoxical new-onset IBD on anti-TNF therapy is rare but recognised. In this case Adalimumab is actually licensed for Crohn disease so it may be continued or dose-optimised (shorter intervals or higher dose) in conjunction with gastroenterology management. Switching to an IL-17 inhibitor (Secukinumab) would be contraindicated as IL-17 inhibitors can worsen IBD. Co-management between rheumatology and gastroenterology is essential. If Adalimumab is truly failing for the IBD component Infliximab Ustekinumab or Vedolizumab may be considered.

Reference: BSR 2022 PsA guidelines; ECCO IBD guidelines