RA and Gastrointestinal Problems 

Your medications, comorbid conditions or the disease itself might be causing your tummy troubles.  

Studies show that people with RA are more likely to have stomach problems than the general population.

The gastrointestinal (GI) tract has an upper and lower section. And RA can affect either one. Research shows that people with RA are about 70%  more likely to develop a gastrointestinal problem than people without RA.

There are several culprits. While medication side effects are the most likely offender, an increased risk of infection or unchecked inflammation can also be the cause. And sometimes, your troubles have nothing to do with RA at all.

“GI symptoms are a common topic of conversation when my patients come in for their checkup. While there are several potential problems, the odds are the digestive issue is caused by either a medication side effect or it is related to something completely different than the patient’s RA,” says Laura Cappelli, MD, Assistant Professor of Medicine in the Division of Rheumatology at Johns Hopkins University. “Since RA can affect the entire body, it is important that patients talk about any medical issue they are experiencing with their rheumatologist.”

Here are some of the reasons your belly might be bothersome:

1. It is a side effect of your medication.

Drugs prescribed for RA can do a great job of keeping symptoms like pain and inflammation in check. But disease-modifying antirheumatic drugs (DMARDs), nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids (prednisone) are notorious for causing digestive troubles including pain, bloating, constipation and diarrhea. 
A 2018 study from the International Journal of Rheumatic Disease found that individuals taking high-dose methotrexate (12 mg/week) were more likely to experience reflux and abdominal pain than those on a lower dose (6 mg/week). 
NSAIDs can also irritate the stomach. These drugs have been strongly linked with upper-GI problems including bleeding, ulcers and inflammation of the esophagus. In the past few years, the wiser and more short-term use of NSAIDs has helped reduce the incidence of these problems.  

2. It is a coincidence. Something else is the cause.

Stomach conditions like gastroesophageal reflux disease (GERD) and irritable bowel syndrome (IBS) can develop in anyone and are very common in otherwise healthy individuals. 
Dr. Cappelli says it is important that patients and rheumatologists do not ignore these issues. “Yes, our patients have a chronic illness. Unfortunately, it does not make them immune to developing these other common problems, and it does not necessarily mean they are more likely to develop them,” she says. 

3. You have an infection.

While DMARDs help calm overactive immune systems, they also lower the body’s ability to fight infection. As a result, bacterial infections like diverticulitis or infectious colitis may develop inside the GI tract.   
“These medications impair how well you fight bacteria so patients may end up developing more severe infections. We always make sure patients with RA are aware of the signs and symptoms of infection and we tend to be more aggressive with giving them antibiotics,” says Dr. Cappelli. 
Although RA patients are more likely to develop these infections, Dr. Cappelli says, the stomach is not particularly special. Patients are just as likely to develop infections like pneumonia or sinusitis elsewhere in the body. 

4. You have another overlapping disease.

Dr. Cappelli estimates that nearly five percent of people with RA have another autoimmune disease. Common coexisting disorders, including inflammatory bowel disease (IBD), autoimmune hepatitis and celiac disease, directly affect the GI tract.  
One 2018 study published in International Journal of Rheumatic Diseases found that as many as 42% of people with RA in Australia develop a musculoskeletal pain condition called fibromyalgia. Symptoms of fibromyalgia include abdominal pain, bloating, constipation and diarrhea. There is also a strong link between fibromyalgia and IBS.  
“When patients have a constellation of disorders such as RA, fibromyalgia and IBS, it can be very tough to know which symptoms are related to what problem. It is important to work closely with your doctor,” says Dr. Cappelli. 

5. Your disease is attacking the stomach.

RA affects more than just the joints — it also attacks other organs in the body including the lungs, eyes and stomach. Approximately 5% of patients will develop a condition called rheumatoid vasculitis that causes inflammation to develop in the GI tract. People with untreated RA are particularly at risk. 
“With advancements in treatment and early diagnosis, problems related to RA specifically involving the GI tract are less common,” says Dr. Cappelli. “But it is incredibly important to remember we still do not have a cure for RA — it is a disease that can flare up at any time even if it has been quiet for a while.”

6. It was your stomach all along.

It is still unclear why some individuals develop RA and others do not. But a growing area of research suggests that the stomach, which houses a lot of good bacteria and immune tissue, may play some role. 
“The GI tract is a spot where there is a lot of interaction between the environment, in terms of what you ingest, and the immune system. The thought is that this microbiome might become perturbed and be related to the development of RA or other immune system problems,” says Dr. Cappelli. “There are no large-scale studies yet but it is something we are very interested in continuing to explore.”


Craig E and Cappelli LC. Gastrointestinal and Hepatic Disease in Rheumatoid Arthritis.  

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. 
Asai S, et al. Influence of methotrexate on gastrointestinal symptoms in patients with rheumatoid arthritis. 
Gist AC, et al. Fibromyalgia remains a significant burden in rheumatoid arthritis patients in Australia.

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