What is the initial treatment for sacroiliac (SI) joint arthritis?

Initial Treatment for Sacroiliac (SI) Joint Arthritis

The initial treatment for sacroiliac joint arthritis should begin with nonsteroidal anti-inflammatory drugs (NSAIDs) as adjunct therapy, along with physical therapy, while disease-modifying antirheumatic drugs (DMARDs) are strongly recommended as the primary treatment over NSAID monotherapy. 1

Diagnosis and Assessment

Before initiating treatment, proper diagnosis is essential:

• Confirm sacroiliitis through:
  • MRI findings consistent with sacroiliitis
  • Clinical examination findings (pain with direct palpation of SI joints)
  • Patient-reported symptoms of inflammatory back pain 1
• Assess disease activity using validated measures like joint counts, ESR, and CRP 2

Treatment Algorithm

First-Line Treatment

1. DMARDs as Primary Therapy

   • Methotrexate is conditionally recommended over leflunomide or sulfasalazine 1
   • Starting dose: 7.5-15 mg weekly, escalating to 20-25 mg weekly as needed 2
   • Subcutaneous administration is conditionally recommended over oral route 1
   • An optimal trial of methotrexate is considered to be 3 months; however, if minimal response after 6-8 weeks, consider changing or adding therapy 1

2. NSAIDs as Adjunct Therapy

   • Use full anti-inflammatory doses for symptomatic relief 2
   • Use lowest effective dose for shortest time possible 2
   • Conditionally recommended as adjunctive therapy, not as monotherapy 1

3. Physical Therapy

   • Conditionally recommended for patients who have or are at risk for functional limitations 1
   • Focus on specific exercises to strengthen muscles, improve range of motion, and joint protection techniques 2

Additional First-Line Options

1. Intra-articular Glucocorticoid Injections

   • Conditionally recommended as adjunct therapy 1
   • Triamcinolone hexacetonide is strongly recommended over triamcinolone acetonide 1
   • Particularly useful for localized SI joint pain 3

2. Short-term Oral Glucocorticoids

   • Bridging therapy (< 3 months) during initiation or escalation of therapy is conditionally recommended for moderate/high disease activity 1
   • Most useful in settings of limited mobility and/or significant symptoms 1
   • Avoid chronic low-dose glucocorticoids (strongly recommended against) 1

Treatment Escalation

If inadequate response to initial therapy:

1. For patients on DMARD monotherapy with continued moderate/high disease activity:

   • Adding a biologic to original DMARD is conditionally recommended over changing to a second DMARD 1
   • Adding a biologic is conditionally recommended over changing to triple DMARD therapy 1

2. For patients with low disease activity despite DMARD therapy:

   • Escalating therapy is conditionally recommended over no escalation 1
   • Options include: intra-articular glucocorticoid injections, optimizing DMARD dose, or adding/changing biologic 1

Common Pitfalls to Avoid

1. Relying solely on NSAIDs without DMARDs

   • NSAIDs alone are insufficient for disease modification and prevention of joint damage 1

2. Delaying DMARD initiation

   • Early DMARD therapy is crucial to prevent permanent joint damage 2

3. Inadequate monitoring

   • Regular assessment of disease activity every 3-6 months is essential 2
   • Adjust interventions based on response 2

4. Chronic glucocorticoid use

   • Strongly recommended against adding chronic low-dose glucocorticoids, regardless of risk factors or disease activity 1

5. Overlooking non-pharmacological approaches

   • Physical therapy is an important component of treatment 1, 3
   • Patient education on self-management techniques is crucial 2

For patients who fail conservative management, minimally invasive procedures may be considered as second-line therapy, including radiofrequency nerve ablation or SI joint fusion in appropriate cases 3, 4.