What is the treatment for enthesitis?

From the Guidelines

Treatment for enthesitis should start with non-steroidal anti-inflammatory drugs (NSAIDs) and local glucocorticoid injections, and in cases of insufficient response, therapy with a biologic disease-modifying antirheumatic drug (bDMARD) should be considered. According to the most recent guidelines 1, the initial approach to managing enthesitis involves reducing inflammation and pain with NSAIDs, such as ibuprofen or naproxen, and using local glucocorticoid injections for more severe cases.

Key Considerations

• NSAIDs are the first-line treatment for enthesitis to reduce inflammation and pain.
• Local glucocorticoid injections can be used as adjunctive therapy for more severe cases.
• In cases of insufficient response to NSAIDs or local glucocorticoid injections, bDMARDs, which include TNF inhibitors, IL-17 inhibitors, or IL-12/23 inhibitors, should be considered 1.
• The choice of bDMARD may depend on the presence of other manifestations, such as skin involvement, where an IL-17 inhibitor or IL-12/23 inhibitor may be preferred 1.

Treatment Approach

• Rest and activity modification are recommended to reduce stress on the affected areas.
• Physical therapy, focusing on gentle stretching and strengthening exercises, helps maintain mobility and prevent stiffness.
• For cases associated with conditions like psoriatic arthritis or ankylosing spondylitis, disease-modifying antirheumatic drugs (DMARDs) such as methotrexate or biologic agents may be necessary to address the underlying autoimmune process 1.
• Hot and cold therapy can provide symptomatic relief, and proper footwear and orthotics may help when lower limb entheses are affected.

Decision Making

The decision to proceed with bDMARDs should be based on the presence of unequivocal enthesitis and an insufficient response to first-line treatments, considering the potential benefits and risks of these therapies for each individual patient 1. The treatment approach should be tailored to the severity and underlying cause of enthesitis, with the goal of achieving remission or low disease activity and improving quality of life.

From the Research

Treatment for Enthesitis

The treatment for enthesitis, a hallmark feature of spondyloarthropathies (SpA), involves various approaches.

• Non-steroidal anti-inflammatory drugs (NSAIDs) are recommended as a first-line treatment for ankylosing spondylitis (AS), a type of SpA characterized by enthesitis, as they have been shown to be effective in reducing pain severity and improving disease activity 2.
• Targeted and biologic disease-modifying antirheumatic drugs (DMARDs) have also been found to be efficacious in treating enthesitis, with preliminary data suggesting that targeting IL-17 or IL-12/23 may be more effective than TNF inhibition 3.
• Cytokine-blocking agents, such as those targeting IL-17A, IL-22, and TNF, have been summarized as current treatment possibilities for enthesitis based on pathophysiological concepts 4.
• Anti-TNF and anti-IL-17 agents, as well as Janus kinase inhibitors, have shown moderate responsiveness for enthesitis, although the data for IL-23 targeting is contradictory 5.
• The use of imaging, such as MRI and ultrasound, has been supported for diagnosis and monitoring of enthesitis due to its higher sensitivity and specificity compared to clinical examination 3, 6.

Treatment Options

Treatment options for enthesitis include:

• Synthetic DMARDs, although there is limited information about their efficacy 3
• Biologic DMARDs, which have shown efficacy in treating enthesitis compared to placebo 3
• NSAIDs, which are effective in reducing pain severity and improving disease activity in AS patients with enthesitis 2
• Cytokine-blocking agents, which have been summarized as current treatment possibilities for enthesitis based on pathophysiological concepts 4