Woman lying down with gastroinestinal pain and flares to indicate rheumatoid arthritis
Credit: iStock/Mayo Studio

Pain, stiffness, and swollen joints are all hallmark signs of rheumatoid arthritis (RA), but this autoimmune or inflammatory condition can also increase your risk of having gastrointestinal (GI) problems. 

“As we know, RA is primarily a joint disease,” says Paul T. Kröner, MD, MSc., Assistant Professor of Medicine, Mayo Clinic Florida Advanced Endoscopy Fellow, Mayo Clinic Florida University of Liverpool. “Therefore, few patients think of an association between their RA and GI issues.”

However, there is a strong link. In fact, a study published in the Journal of Rheumatology found that people with RA had a 70 percent higher risk of having an upper GI problem and a 50 percent greater chance of having a lower GI issue than those who didn’t have RA.

How Are RA and GI Issues Connected?

Several factors may cause RA and an upset GI system to be intertwined:  

The gut 

Research suggests an association between RA and the gut microbiome (the bacteria population in our gut). Your body hosts communities of harmless bacteria known as the microbiota, which help keep us healthy. “A balanced intestinal microbiome plays a critical role in our immune system’s appropriate development and healthy equilibrium,” says Dr. Kröner. In some cases, RA can disturb the balance of the microbiome (called “dysbiosis”) for an extended period of time. That’s when conditions like irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD) may develop. 

Inflammation 

The same inflammation that affects your joints may also affect your digestive tract, and that can cause an onset of certain GI conditions, most commonly IBS.

Medication

Many drugs used to treat RA can unfortunately cause unpleasant side effects to your gut. Some examples include NSAIDs (nonsteroidal anti-inflammatory drugs), steroids, DMARDs (disease-modifying antirheumatic drugs), and biologics. Speak with your doctor about the right treatment plan for you.

Stress

Stress itself can be a driving force in the earlier onset and disease activity by promoting a pro-inflammatory state in our bodies,” says Dr. Kröner. Because stress can play a role in your immune response, it may cause symptoms like ulcers or bowel issues.

Obesity 

Extra weight can increase your risk of many health problems, including GI conditions, research shows. Additionally, obesity can make RA symptoms to act up because fat tissue releases cytokines, proteins that can cause or worsen inflammation.  

What Are Some Common GI Issues Linked to RA?

People with RA can develop a number of underlying gastrointestinal issues. The most common symptom is abdominal pain, so it’s important to speak with your health care provider if you’re experiencing any. Here are just some of the conditions that may be causing the pain. 

IBS or IBD

Research shows patients with RA have a higher chance of developing conditions like IBS and other IBDs such as Crohn’s disease or ulcerative colitis. On top of abdominal pain, you might also experience bloody stools, diarrhea, fatigue, and reduced appetite.

SIBO

“A condition called small intestinal bacterial overgrowth (SIBO) can develop with RA, causing uncomfortable bloating and diarrhea, in addition to abdominal pain, and may be related to the gut microbiome,” says Dr. Kröner.

Gastroesophageal reflux disease (GERD)

A study published in the Journal of Clinical Biochemistry and Nutrition found GERD and RA to have a strong connection. GERD can cause inflammation of the stomach lining (gastritis), leading to heartburn or indigestion and dysphagia (difficulty swallowing).

Ulcers

Ulcers in the stomach or bowels are also common with RA, and can cause abdominal pain. Lower extremity ulcers are the most common type in RA patients, according to a study published in Clinical Rheumatology 

Rheumatoid vasculitis

A small percentage (about two to five percent of people with RA, according to a study published in Romanian Journal of Internal Medicine) can develop this immune-mediated inflammation of the small-caliber blood vessels in the GI tract. Abdominal pain is quite common.

How to Treat RA and GI Problems

Treating your conditions begins by first getting your RA under control as best as possible. “GI symptoms are thought to stem from the heightened inflammatory state in uncontrolled RA, so achieving RA disease control is of utmost importance,” explains Dr. Kröner.

A good place to start is establishing a multidisciplinary team of health care professionals. You’ll want to work closely with (at least) a rheumatologist and a gastroenterologist, but others may be helpful too. 

“A dietitian/nutritionist and a mental health provider can significantly contribute to care,” says Dr. Kröner. “These specialists can acknowledge the common ground between involved medical specialties and share the ultimate goal of achieving disease and symptom control.”

Your team can help you determine your medication options — ones that will depend on what GI issues you’re dealing with along with your RA. A frequently overlooked cause of GI symptoms (like diarrhea, abdominal pain, nausea, vomiting) in patients with RA is medication adverse events.  

For example, a study published in Therapeutic Advances in Musculoskeletal Disease, found that patients treated with disease-modifying antirheumatic drugs (DMARDs) helped partially restore the microbiome and control disease progression and symptoms.  

However, these can also cause side effects like abdominal pain, bloating, constipation, and diarrhea, which can exacerbate other GI issues. “It’s extremely important to have a gastroenterologist work closely together with a rheumatologist to find joint solutions to these issues,” says Dr. Kröner. 

Lifestyle Changes to Improve RA and GI Issues

Experiencing both RA and GI problems simultaneously can be debilitating for some, but feeling better may come down to some lifestyle changes that focus on your physical and mental health. Start with these tips from experts who are treating patients daily with RA and GI issues. 

Try aerobic exercise 

It can be scary to work out when you’re not feeling your best. Many patients may fear damaging their joints,” Dr. Kröner explains. However, the right kind of exercise can actually do the opposite. Aerobic exercise — biking, swimming, or dancing — has a very low risk of harming RA, and can help improve pain and fatigue, reduce stress, and even improve overall mental well-being, he says.

Eat right

Dr. Kröner recommends eating foods that are high in fiber (fruits, beans, whole grains); antioxidants (berries, kale, pecans); and vitamin D (fatty fish, orange juice, vitamin D-fortified dairy). “These foods are anti-inflammatory and can help with weight control, assisting in maintaining the balance in our intestinal microbiome,” says Kröner. Avoid highly processed foods, heavily salted foods, and foods high in refined sugar, gluten, and trans-fatty acids.

Join a support group

“The fact that many patients experience GI symptoms in RA can actually be transformed into a benefit by organizing or joining support groups to share experiences, effective management measures, and stress coping strategies,” says Dr. Kröner. “This can provide us with much-needed hope or ideas.”  

Search for online communities sharing experiences on forums, seminars, roundtable discussions, Zoom meetings, and more. You can follow CreakyJoints on social media — Facebook, Instagram, Twitter, Tik Tok, YouTube — to connect with other patients who are seeking community for living with arthritis and other chronic illness. 

Manage your stress

“In the GI tract, stress is a centerpiece in disorders like IBS, and rheumatological conditions like RA are not the exception,” explains Dr. Kröner Try downloading a meditation app or writing in a journal to keep stress at bay. 

Seek mental health help

Mental health providers can help in developing personalized coping strategies and changing your relationship to negative thoughts. “Professional help can only lead to benefits,” Dr. Kröner says, noting that this is especially important for patients who have a history of chronic conditions like anxiety, depression, or post-traumatic stress disorder (PTSD), or who have experienced a traumatizing event in life such as loss of a loved-one, a disabling accident, or loss of a job. 

GI issues may be common among people with RA, but that doesn’t mean you have to live in greater discomfort. Work with your health care team to ease your symptoms and keep both conditions under control.

Be a More Proactive Patient with ArthritisPower

Join CreakyJoints’ patient-centered research registry to track your symptoms, disease activity, and medications — and share with your doctor. Sign up.

Bodkhe, R, et al. “The Role of Microbiome in Rheumatoid Arthritis Treatment.” Therapeutic Advances in Musculoskeletal Disease. July 30, 2019. doi: https://doi.org/10.1177/1759720X19844632.

Cojocaru, M, et al. “New Insight into the Rheumatoid Vasculitis.” Romanian Journal of Internal Medicine. June 2015. doi: https://doi.org/10.1515/rjim-2015-0017.

Gupta, V, et al. “Gut Microbial Determinants of Clinically Important Improvement in Patients with Rheumatoid Arthritis.” Genome Medicine. September 2021. https://doi.org/10.1186/s13073-021-00957-0.

Interview with Paul T. Kröner, MD, MSc., Assistant Professor of Medicine, Mayo Clinic Florida Advanced Endoscopy Fellow, Mayo Clinic Florida University of Liverpool.  

Murugesan, V. MBBS Irritable Bowel Syndrome and Rheumatoid Arthritis: Prevalence, Epidemiological Characteristics and Associated Risk Factors. American Journal of Gastroenterology. October 2018. https://journals.lww.com/ajg/fulltext/2018/10001/irritable_bowel_syndrome_and_rheumatoid_arthritis_.2784.aspx.

Myasoedova, E, et al. “Increased Incidence and Impact of Upper and Lower Gastrointestinal Events in Patients with Rheumatoid Arthritis in Olmsted County, Minnesota: A Longitudinal Population-Based Study.” July 2021. The Journal of Rheumatology. doi: https://doi.org/10.3899/jrheum.111311. 

Nam, S. “Obesity-Related Digestive Diseases and Their Pathophysiology.” Gut and Liver. May 2017. doi: https://doi.org/10.5009/gnl15557..

Nampei, A, et al. “Prevalence of Gastroesophageal Reflux Disease Symptoms and Related Factors in Patients with Rheumatoid Arthritis.” Journal of Clinical Biochemistry and Nutrition. March 2013. doi: https://doi.org/10.3164/jcbn.12-83.

Ribaldone, D et al. Inflammation in Gastrointestinal Disorders: Prevalent Socioeconomic Factors. Clinical and Experimental Gastroenterology. July 19 2019. doi: https://doi.org/10.2147/CEG.S210844.

Shanmugam, V, et al. “Lower Extremity Ulcers in Rheumatoid Arthritis: Features and Response to Immunosuppression.” Clinical Rheumatology. June 2011. doi: https://doi.org/10.1007/s10067-011-1710-9.