What is the best medication for sacroiliac (SI) joint pain?

Best Medication for Sacroiliac (SI) Joint Pain

NSAIDs are the first-line medication for sacroiliac joint pain, used continuously for 2-4 weeks to evaluate response, with options including naproxen, ibuprofen, diclofenac, or COX-2 inhibitors. 1

Stepwise Medication Approach

First-Line Therapy

• NSAIDs:
  • Use continuously for 2-4 weeks to properly evaluate response 1
  • Options include naproxen, ibuprofen, diclofenac, or COX-2 inhibitors
  • For patients with increased gastrointestinal risk: Use either selective COX-2 inhibitors or non-selective NSAIDs with gastroprotective agents 1
  • NSAIDs should be used as adjunct therapy, not as monotherapy for chronic, persistent synovitis 2

Second-Line Therapy (for inadequate NSAID response)

• Corticosteroid Injections:
  • Conditionally recommended for isolated active sacroiliitis 1
  • Should be image-guided when available
  • Can provide pain relief for over 3 months in some patients 3
  • Local injections directed to the site of musculoskeletal inflammation 2

Third-Line Therapy (for refractory cases)

• Biologics:
  • TNF inhibitors (first-line biologics): etanercept, adalimumab, golimumab 1
  • IL-17 inhibitors (for TNF inhibitor failures): secukinumab, ixekizumab 1
  • Anti-TNF therapy should be given to patients with persistently high disease activity despite conventional treatments 2

Fourth-Line Therapy

• JAK inhibitors: Strongly recommended when biologics are contraindicated or unavailable 1

Other Medication Options

• Analgesics:
  • Paracetamol (acetaminophen) and opioid-like drugs might be considered for residual pain after previously recommended treatments have failed 2
  • Should be used only after other options have been exhausted

Medications to Avoid or Use with Caution

• Systemic glucocorticoids: Not supported by evidence for axial disease 2, 1
• DMARDs (Disease-modifying antirheumatic drugs):
  • No evidence for efficacy in axial disease, including methotrexate 2
  • Sulfasalazine may be considered only if peripheral arthritis is present 2, 1

Interventional Procedures for Medication-Refractory Cases

• Radiofrequency ablation (RFA):

  • Consider for patients who fail medication management 3
  • Cooled RFA may provide longer-lasting relief 1
  • Extensive lesioning strategies have the strongest evidence 3

• SI joint fusion:

  • Reserved for patients with:
    • Positive response to SI injection with >75% relief
    • Failure of all nonsurgical treatments
    • Continued or recurrent SIJ pain 1, 4

Important Clinical Considerations

• Use standardized measures like ASDAS to monitor disease activity and treatment response 1
• Assess treatment response after 2-4 weeks of NSAID therapy 1
• If a significant change in disease course occurs, consider causes other than inflammation, such as spinal fracture 2
• Diagnostic SI joint blocks with local anesthetic can confirm the SI joint as pain source 1

Pitfalls to Avoid

• Don't rely solely on imaging findings, as MRI findings may not always correlate with the location of pain 1
• Avoid long-term systemic glucocorticoid use due to adverse effects 1
• Don't use DMARDs for isolated SI joint pain without peripheral symptoms 2, 1
• Avoid using NSAIDs as monotherapy for chronic, persistent synovitis 2

By following this stepwise medication approach, most patients with SI joint pain can achieve significant pain relief and improved function.