Background <p>Spondyloarthritis (SpA) is a prevalent extraintestinal symptom of inflammatory bowel disease (IBD), impacting up to 20% of patients and considerably contributing to the disease burden. The coexistence of inflammatory bowel disease and spondyloarthritis poses therapeutic problems due to the necessity for simultaneous management of intestinal and musculoskeletal inflammation.</p> Objective <p>To conduct a comprehensive review and synthesis of the current evidence regarding pharmacological treatments for IBD-associated SpA. This review will assess the efficacy of these treatments on both gut and joint symptoms, as well as their safety profiles and therapeutic positioning.</p> Methods <p>A thorough search of PubMed, Scopus, and the Cochrane Library was performed till May 2025. Studies were included if they focused on adult patients with concurrent IBD and SpA, and assessed pharmacological treatments. Data extraction adhered to PRISMA criteria. The risk of bias was evaluated via the Newcastle–Ottawa Scale, SANRA, and qualitative assessment for expert consensus.</p> Results <p>Thirteen studies were included, comprising observational cohorts, narrative reviews, and expert consensus guidelines. Tumour necrosis factor inhibitors (TNFi), including infliximab and adalimumab, consistently demonstrated dual efficacy in improving gastrointestinal and musculoskeletal outcomes, notably reducing disease activity indices such as BASDAI, ASDAS, and CDAI. Conventional synthetic DMARDs, such as methotrexate and sulfasalazine, provided modest benefit in peripheral arthritis but lacked efficacy for axial SpA and intestinal inflammation. Emerging therapies—particularly ustekinumab (IL-12/23 inhibitor) and vedolizumab (gut-selective anti-integrin)—were considered valuable options in TNFi-refractory patients. However, their impact on axial symptoms remains uncertain, and guidelines advise caution in such phenotypes. Janus kinase inhibitors (e.g., tofacitinib, upadacitinib) have shown promise in both ulcerative colitis and axial SpA, but require further validation in IBD-SpA overlap populations. IL-23 blockers and TYK2 inhibitors are under investigation, particularly for gut-dominant disease, though evidence in SpA is limited. IL-17 inhibitors, while effective in SpA, are generally contraindicated in IBD due to risk of intestinal flares. Combination strategies, including dual-biologic therapies or biologic–DMARD regimens, are increasingly explored for complex or refractory cases, with observational data suggesting clinical benefit and acceptable safety under close monitoring.</p> Conclusion <p>TNFi remains to be the cornerstone treatment for IBD-associated SpA. Biologic alternatives like ustekinumab and vedolizumab provide targeted options for specific individuals; nevertheless, additional data is required regarding axial involvement. An individualised, multidisciplinary therapy approach is crucial. Future research should focus on head-to-head trials, long-term safety assessments, and prediction biomarkers to enhance personalised treatment in this dual disease scenario.</p> Prospero registration ID <p>1,084,370.</p>