What is the treatment for sacroiliac (SI) joint inflammation?

Treatment for Sacroiliac Joint Inflammation

The treatment of sacroiliac (SI) joint inflammation should follow a stepwise approach, starting with NSAIDs for 2-4 weeks continuously, followed by biologics (TNF inhibitors or IL-17 inhibitors) for inadequate responders, with corticosteroid injections as an adjunctive therapy for isolated active sacroiliitis. 1

First-Line Treatment

NSAIDs

• NSAIDs should be used as first-line therapy for SI joint inflammation
• Options include naproxen, ibuprofen, diclofenac, or COX-2 inhibitors 1
• Must be used continuously for 2-4 weeks to properly evaluate response
• For patients with increased gastrointestinal risk:
  • Use non-selective NSAIDs plus gastroprotective agent OR
  • Use selective COX-2 inhibitors 1
• NSAID failure is defined after 1 month of continuous use 1

Physical Therapy and Exercise

• Focus on pelvic girdle stabilization exercises
• Active supervised exercise programs are recommended alongside medication 1
• Pelvic belts may be beneficial, particularly in postpartum patients 2

Second-Line Treatment

Corticosteroid Injections

• Conditionally recommended for isolated active sacroiliitis 1
• Should be performed with imaging guidance when available
• Can be both diagnostic and therapeutic 3
• Short-course oral glucocorticoids can be used as bridging therapy during initiation of biologics 1
• Long-term systemic glucocorticoid use is strongly recommended against due to adverse effects 1

Biologic Therapy

For patients with inadequate response to NSAIDs:

1. TNF inhibitors (first-line biologics):

   • Options include etanercept, adalimumab, or golimumab 1
   • Monitor response using standardized measures like ASDAS

2. IL-17 inhibitors (for TNF inhibitor failures):

   • Options include secukinumab and ixekizumab 1

3. JAK inhibitors:

   • Strongly recommended when biologics are contraindicated or unavailable 1

DMARDs

• Conventional DMARDs (methotrexate, leflunomide) are not recommended for isolated SI joint pain 1
• Sulfasalazine may be considered only in patients with peripheral arthritis accompanying SI joint pain 1

Advanced Interventions for Refractory Cases

Radiofrequency Ablation

• Consider for patients who fail conservative management and injections 4, 2
• Cooled radiofrequency ablation may provide longer-lasting relief 2

Surgical Management

• SI joint fusion should be reserved for patients with:
  • Positive response to SI injection with >75% relief
  • Failure of all nonsurgical treatments
  • Continued or recurrent SIJ pain 3
• Percutaneous SI arthrodesis is preferred over open arthrodesis due to improved safety profile 3

Monitoring and Disease Assessment

• Treatment response should be assessed after 2-4 weeks of NSAID therapy 1
• Use standardized measures like ASDAS to monitor disease activity 5, 1
• Disease monitoring should include:
  • Patient-reported outcomes
  • Clinical findings
  • Laboratory tests (including CRP)
  • Imaging when appropriate 5

Important Considerations

• SI joint pain accounts for 15-25% of reported back pain and significantly impacts quality of life 4
• MRI findings may not always correlate with the location of pain 1
• Biosimilars are strongly recommended as therapeutic options when biologics are indicated 1
• Cost considerations should be weighed when choosing between equally effective treatments 1

Diagnostic Challenges

• SI joint dysfunction can be difficult to diagnose through physical examination alone 3
• Positive responses to at least three physical provocation tests suggest SI joint dysfunction 2
• Diagnostic SI joint blocks with local anesthetic can confirm the SI joint as the pain source 6, 2