How do you treat celiac disease associated inflammatory arthritis refractory to gluten free diet?

There is no good evidence based answer to this great question. In general, if celiac patients have persistent symptoms and exam findings of inflammatory arthritis or enthesitis, I offer non-biologic DMARDs depending on the severity of symptoms. If very mild, we can use hydroxychloroquine and escalate to methotrexate or sulfasalazine, as needed. Few patients with celiac disease despite remaining gluten free (with negative TTG Ab) had evidence of acute on chronic sacroiliitis (HLA-B27 negative). I...