What is the recommended treatment for sacroiliac (SI) joint pain?

Management of Sacroiliac Joint Pain

NSAIDs should be used as the first-line treatment for sacroiliac (SI) joint pain, administered continuously for 2-4 weeks to evaluate response before transitioning to on-demand use. 1

Initial Treatment Approach

First-Line Therapy

• NSAIDs:
  • Start with continuous use for 2-4 weeks to evaluate response
  • If effective, transition to on-demand use
  • Consider gastroprotective agents for patients with increased GI risk
  • NSAID failure is defined as inadequate response after 1 month of continuous use 1

Non-Pharmacological Interventions (to be used concurrently)

• Physical therapy and exercise:
  • Focus on pelvic girdle stabilization exercises
  • Active supervised exercise programs
  • Regular exercise throughout the disease course 1
• Patient education about the condition and self-management strategies

Second-Line Interventions (for inadequate NSAID response)

Intra-articular Injections

• Corticosteroid injections:
  • Conditionally recommended for isolated active sacroiliitis 1, 2
  • Imaging guidance preferred when available
  • Can provide relief for up to 8 weeks 1
  • Should be performed in experienced specialist centers

Systemic Medications

• Short-course oral glucocorticoids:
  • May be used as bridging therapy
  • Long-term systemic glucocorticoid use is strongly recommended against due to adverse effects 2, 1
• Sulfasalazine:
  • Consider only if peripheral arthritis accompanies SI joint pain
  • Not effective for isolated axial disease 1
• Other analgesics:
  • Acetaminophen and limited opioids may be considered when NSAIDs are contraindicated or poorly tolerated 1

Third-Line Interventions (for failure of above treatments)

Biologic DMARDs

• TNF inhibitors (etanercept, adalimumab, golimumab):
  • Strongly recommended for patients with inadequate response to NSAIDs 2, 1
  • Monitor response using standardized measures like ASDAS
• IL-17 inhibitors (secukinumab, ixekizumab):
  • Strongly recommended for patients who fail TNF inhibitors 2, 1
• JAK inhibitors:
  • Strongly recommended when biologics are contraindicated or unavailable 2

Interventional Procedures

• Radiofrequency ablation:
  • Consider for patients who fail pharmacological management 3
  • Cooled radiofrequency ablation shows strongest evidence 3
• SI joint fusion:
  • Consider only after failure of all conservative and minimally invasive interventions 4, 5
  • Should be reserved for carefully selected patients with persistent, severe pain

Treatment Algorithm Based on Disease Severity

Mild to Moderate Pain

1. NSAIDs + physical therapy/exercise
2. Intra-articular corticosteroid injections if NSAIDs inadequate
3. Consider radiofrequency ablation if above fails

Severe Pain with Inadequate Response to Conservative Treatment

1. TNF inhibitors or IL-17 inhibitors
2. Switch mechanism of action if primary failure occurs
3. Consider SI joint fusion for refractory cases

Important Caveats

• Conventional DMARDs (methotrexate, leflunomide) are not recommended for isolated SI joint pain 2, 1
• Treatment response should be monitored using standardized measures
• Combination therapy with biologics plus conventional DMARDs is strongly recommended against for patients in remission 2
• When biologics are indicated, biosimilars are also strongly recommended as therapeutic options 2

The evidence supports a stepwise approach to SI joint pain management, starting with NSAIDs and physical therapy, progressing to injections and biologics for refractory cases, with surgical options reserved for those with persistent severe pain despite comprehensive medical management.