Ankylosing Spondylitis and IBD
Rheumatic ConditionsAnkylosing Spondylitis
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Inflammatory Bowel Disease and Ankylosing Spondylitis

Inflammatory Bowel Disease and Ankylosing Spondylitis
Canva (2); Everyday Health
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Updated on February 10, 2025
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Ankylosing spondylitis (AS) is a chronic form of inflammatory arthritis that causes pain and stiffness in the joints, particularly the joints, ligaments, and tendons of the spine. AS can also involve gastrointestinal symptoms and, in some cases, chronic inflammatory bowel diseases (IBD), such as Crohn’s disease or ulcerative colitis , may be present.

Here, we’ll look at the connection between AS and IBD, treatment approaches that work for both conditions, and when to see a doctor about new symptoms.

IBD and Ankylosing Spondylitis: What’s the Link?

Ankylosing spondylitis and IBD are both chronic inflammatory diseases, but having both conditions is uncommon.

That said, statistics suggest that people with IBD are more likely to have AS than those without the condition. Less than 0.5 percent of the general population has AS, but around 3 percent of those with IBD have it.

Even if a person does not have a diagnosis of both AS and IBD, gut symptoms are a known extra-articular (not joint-related) feature of ankylosing spondylitis, and joint inflammation is a known extraintestinal (not related to the gut) feature of IBD.

Experts don’t yet know how AS and IBD are linked, but both respond to similar drugs — TNF inhibitors — suggesting a common underlying mechanism.

Research suggests a strong overlap between certain genetic features of people with IBD and those with AS.

It’s thought that changes in the HLA-B27 gene may increase the risk of both IBD and AS. One study found that among 599 people who had received a diagnosis of IBD 20 years before, 4.5 percent had since developed AS, and 7.7 percent had a diagnosis of axial spondyloarthritis, a type of arthritis that affects the sacroiliac joints at the bottom of the spine or the vertebrae.

HLA-B27 was a strong link.

Other research supports this theory. A study published in 2023 concluded that people with ulcerative colitis were more likely to develop AS in the future, especially if they tested positive for a change in the HLA-B27 gene.

Another theory is that IBD causes the immune system to be intolerant of the gut microbiome — the healthy bacteria in the gut — leading to too many inflammatory cells in the digestive system. If these cells move to other areas such as the spine, ankylosing spondylitis could result.

John Miller, MD, an assistant professor in the division of rheumatology at Johns Hopkins Medical School in Baltimore, notes that around 50 percent of people with AS show signs of subclinical gut inflammation.

However, Dr. Miller says that we currently don’t have a strong understanding of causation when it comes to AS and IBD — whether an altered immune system allows certain bacteria to develop in the gastrointestinal (GI) tract, or whether the growth of certain bacteria leads to an altered immune response in some people.

He added that some people develop symptoms of AS in their spine or other joints before they have any GI symptoms, while, for others, the order is reversed.

“We kind of separate these diseases into discrete boxes, but I think there’s a lot of overlap,” says Miller. In fact, the authors of a study published in 2022 called for researchers in ankylosing spondylitis and IBD to work more closely together.

Can AS Cause IBD?

It seems unlikely that ankylosing spondylitis can cause IBD. However, people with AS may experience the following in addition to joint and back problems:

  • Diarrhea and bloating
  • Changes in bowel habits
  • Blood in stool
  • Abdominal cramps and pain
  • Nutritional deficiencies
  • A frequent need to go to the bathroom, including during the night

These can indicate IBD but don’t necessarily mean a person with AS has IBD.

Treating IBD and Ankylosing Spondylitis

Your doctor may treat AS with gastrointestinal symptoms or AS with IBD differently than if you have AS without gut involvement.

Options for AS with gut symptoms or IBD include:

All medications come with risks and side effects, so it’s essential to discuss the options with your doctor and follow their instructions precisely.

TNF Inhibitors for Both IBD and AS

TNF inhibitors are biologic drugs that target TNF, a substance involved in inflammation. They can address both AS and IBD.

“Some of the anti-TNF therapies that have currently been approved for Crohn’s disease and ulcerative colitis can be used to treat ankylosing spondylitis,” says Ashwin Ananthakrishnan, MBBS, MPH, a gastroenterologist at Massachusetts General Hospital in Boston and an assistant professor of medicine at Harvard Medical School.

TNF inhibitors that have approval to treat both AS and IBD include:

  • infliximab (Remicade)

  • adalimumab (Humira)

  • golimumab (Simponi)

  • certolizumab (Cimzia)

  • tofacitinib (Xeljanz)

  • upadacitinab (Rinvoq)

It is important to use the right drugs if you have both conditions. Dr. Ananthakrishnan cautions that secukinumab and ixekizumab — drugs that treat AS — have not shown benefits for IBD and may even potentially worsen it.

In addition, Ananthakrishnan says that the dosing of these drugs might be different for the two conditions.

Given this, says Ananthakrishnan, “It’s more important than ever for gastroenterologists and rheumatologists to collaborate before starting treatment.”

JAK Inhibitors

Janus kinase inhibitors, commonly known as JAK inhibitors, are another type of drug that reduces inflammation. They do this by changing the way the immune system works.

JAK inhibitors are also known as disease-modifying antirheumatic drugs, or DMARDs.

One JAK inhibitor, tofacitinab (Xeljanz), is approved as a treatment for both IBD and ankylosing spondylitis.

Sulfasalazine

Another DMARD, sulfasalazine (Etanercept) is an anti-inflammatory drug that can treat both IBD and AS.

 Experts do not know precisely how it works, but it reduces inflammation in the body, possibly by regulating the gut microbiome.

NSAIDs

NSAIDs are often a first-line treatment for AS, but a doctor may advise against them if you also have IBD or intestinal symptoms, as they can cause or worsen stomach problems.

Examples of NSAIDs include:

  • aspirin
  • ibuprofen (Advil or Motrin)
  • naproxen (Aleve)

Always follow your doctor’s recommendations when using NSAIDs. They may irritate the digestive tract, worsen GI symptoms, and even lead to new inflammation, according to Miller.

Lifestyle Remedies

The following lifestyle approaches can support medication use when treating AS and IBD.

  • Stopping smoking, as smoking is known to worsen AS in particular.

  • Physical activity, such as swimming and walking, can help keep your joints moving and your spine mobile.
  • Drinking plenty of water can benefit your overall health.
  • Avoiding processed sugars may help reduce inflammatory symptoms.

When to See a Doctor

Any new symptoms warrant a call to your doctor, as they may affect your treatment. Speak with your doctor if you have:

  • Signs of AS with gastrointestinal symptoms
  • An existing AS diagnosis and start to notice bowel changes
  • IBD and begin to experience joint or back pain

“It’s important to bring up GI symptoms like diarrhea, blood in the stool, or bloating after meals,” Miller says.

“If we see new scan findings or new GI symptoms, it’s not a complete surprise,” says Miller. “Sometimes it’s AS that presents first; sometimes it’s GI symptoms that present first.”

The Takeaway

  • Ankylosing spondylitis and inflammatory bowel disease both involve inflammation and changes to the way the immune system works.
  • People with AS seem to have a higher risk of developing IBD, or, if not IBD, gastrointestinal symptoms.
  • Experts don’t know exactly why this happens, but AS and IBD may share an underlying cause. There may be a genetic link.
  • A range of drugs can treat both IBD and AS, but you’ll need to work with a doctor to find a suitable dose and drug for your needs.
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Sian Yik Lim, MD

Medical Reviewer
Castle Connolly Top Doctor
Sian Yik Lim, MD, is a board-certified rheumatologist at Hawaii Pacific Health. He is a clinical certified densitometrist, certified by the International Society of Clinical Densitometry. He completed his rheumatology fellowship at Massachusetts General Hospital and was also a research fellow at Harvard Medical School. His research interests include osteoporosis, gout, and septic arthritis. Dr. Lim has published in JAMA, Current Opinions in Rheumatology, Osteoporosis International, Bone, Rheumatology, and Seminars in Arthritis and Rheumatism.

Lim has authored several book chapters, including one titled “What is Osteoporosis” in the book Facing Osteoporosis: A Guide for Patients and their Families. He was also an editor for Pharmacological Interventions for Osteoporosis, a textbook involving collaboration from a team of bone experts from Malaysia, Australia, and the United States.
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Yvette Brazier

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Yvette Brazier's career has focused on language, communication, and content production, particularly in health education and information. From 2005 to 2015, she supported learning in the health science department of a higher education establishment, teaching the language of health, research, and other language application skills to paramedic, pharmacy, and medical imaging students.

From 2015 to 2023, Yvette worked as a health information editor at Medical News Today and Healthline. Yvette is now a freelance writer and editor, preparing content for Everyday Health, Medical News Today, and other health information providers.

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