How to manage IBS-D effectively with rheumatoid arthritis?

Question

Hello doctor,

My wife is 44 and was recently diagnosed with irritable bowel syndrome with diarrhea after almost a year of misdiagnosis. She was initially thought to have microscopic colitis and was on Budesonide for four months before another colonoscopy with proper biopsies confirmed that it was actually IBS-D all along. The Budesonide was stopped, but her symptoms never really improved.

She is currently having five to six episodes of watery diarrhea daily, and the pain before each episode is so severe that it makes her cry. She also has rheumatoid arthritis and takes Hydroxychloroquine 400 mg, along with occasional NSAIDs for joint flares. The rheumatologist said the NSAIDs can make IBS-D worse, but the joint pain without them is unbearable.

Her CRP is 18, which is elevated, but both the gastroenterologist and the rheumatologist are arguing over whether it is from rheumatoid arthritis or a gut issue. The constant diarrhea is also causing electrolyte problems.

Her sodium level was 131 last week, which was very frightening for us. She has lost so much weight that the rheumatologist is worried her immune system is becoming weaker.

My wife has also stopped going out socially because she fears having an accident in public, and her mood has become very low.

Is there a treatment for IBS-D that is safe to use with her rheumatoid arthritis medications and that will not make the joint inflammation worse?

Please help.

Thank you.

Answer 1

Hello,

Welcome to icliniq.com.

I feel her case is quite complex, indeed. Her colonoscopy and biopsy findings are fine, but IBS-D (irritable bowel syndrome with predominant diarrhea) could cause her severe pain in the abdomen, urgency, and watery stools. However, her weight loss, electrolyte disturbance, and inflammation should be evaluated in more detail and managed properly.

First of all, NSAIDs (nonsteroidal anti-inflammatory drugs) prescribed to treat rheumatoid arthritis are very likely to irritate the intestinal mucosa and exacerbate the symptoms of diarrhea and abdominal pain. Therefore, her rheumatologist might try to minimize the use of NSAIDs or replace them with other methods of pain management with control of joint inflammation by Hydroxychloroquine and other drugs.

As for the IBS-D itself, there are quite a few drugs that manage her condition without affecting the treatment of her rheumatoid arthritis. For instance, Rifaximin treats the imbalance of bacteria in the intestine and decreases bloating and stool frequency. Besides, Eluxadoline slows down the movement of the intestine and reduces the feeling of urgency. Another group of medications that are widely used in low doses is neuromodulator drugs, namely, Amitriptyline.

Her sodium levels were low (131); it is necessary to address fluid and electrolyte balance. Chronic diarrhea can lead to dehydration, which makes hydration and electrolyte monitoring crucial.

A dietary intervention in the form of a targeted low-FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) approach could help her feel better, but her weight loss means that any restrictions have to be moderate.

Last but not least, the psychological component of having IBS is very important. Stress and anxiety related to the fear of accidents and social isolation are typical problems; gut-directed cognitive behavioral therapy could be helpful.

As the symptoms of IBS-D and rheumatoid arthritis tend to overlap, collaboration between a gastroenterologist and a rheumatologist is crucial for a patient's treatment. With proper medications, diet, and symptom-targeted treatment, the control of bowel movements becomes manageable.

I hope this helps.

Kindly follow up if you have more concerns.

Thank you.