What is the initial treatment for enthesopathy?

Initial Treatment for Enthesopathy

NSAIDs are strongly recommended as the first-line treatment for enthesopathy, based on clinical guidelines from the American College of Rheumatology. 1

Treatment Algorithm for Enthesopathy

First-Line Treatment

• NSAIDs: First choice for all patients with active enthesitis
  • Examples: Ibuprofen, naproxen, diclofenac
  • Dosing should be at anti-inflammatory levels
  • Monitor for gastrointestinal, renal, and cardiovascular side effects

Second-Line Treatment (for patients with inadequate response to NSAIDs)

1. Physical therapy 1

   • Particularly important for patients with functional limitations
   • Focus on maintaining range of motion and strengthening

2. Local corticosteroid injections 1

   • For persistent, localized entheseal pain
   • Ultrasound guidance improves accuracy and outcomes
   • Caution: avoid repeated injections at the same site due to risk of tendon weakening

3. Short-course oral corticosteroids 1

   • Consider as bridging therapy (< 3 months) during initiation of other treatments
   • Most useful in cases with high disease activity, limited mobility, or significant symptoms
   • Typical regimen: Prednisone at moderate doses with tapering schedule

Third-Line Treatment (for moderate to severe disease despite above treatments)

1. TNF inhibitors (TNFi) 1

   • Conditionally recommended over methotrexate or sulfasalazine
   • Examples: etanercept, adalimumab, infliximab, golimumab
   • Most effective biologic option for enthesitis

2. Disease-modifying antirheumatic drugs (DMARDs) 1

   • Consider for patients with contraindications to TNFi
   • Options include:
     • Sulfasalazine: May be effective in mild enthesitis
     • Methotrexate: Particularly if concomitant peripheral arthritis is present

3. IL-17 inhibitors 1

   • Consider if patient has contraindications to TNFi or has severe psoriasis
   • Examples: secukinumab, ixekizumab

Special Considerations

Diagnosis

• Enthesopathy refers to pathology at attachment sites of tendons, ligaments, joint capsules to bone 2
• Common sites: heel (Achilles tendon, plantar fascia), greater trochanter, patella, elbow (epicondyles)
• Diagnosis is primarily clinical but can be confirmed with ultrasound or MRI 3
• Ultrasound findings may include:
  • Thickening of the enthesis
  • Hypoechogenicity
  • Erosions at insertion sites
  • Power Doppler signal indicating inflammation

Underlying Causes

• Always identify and address underlying causes:
  • Inflammatory (spondyloarthropathies)
  • Mechanical/overuse
  • Metabolic (diabetes, gout)
  • Drug-induced (retinoids, fluoroquinolones) 4
  • Degenerative

Pitfalls to Avoid

1. Delayed diagnosis: Enthesopathy can be overlooked or misdiagnosed as simple tendinitis
2. Inadequate treatment duration: NSAIDs may require 2-4 weeks for full effect
3. Failure to address biomechanical factors: Orthoses and activity modification are important adjuncts
4. Overuse of corticosteroid injections: Can lead to tendon weakening and rupture
5. Missing underlying systemic disease: Enthesitis may be the first sign of spondyloarthropathy

Monitoring and Follow-up

• Assess response to treatment after 4-6 weeks
• If inadequate response to NSAIDs after 2-4 weeks, consider escalation to second-line therapy
• For patients on biologics, monitor for infections and other adverse effects
• Regular ultrasound assessment can help monitor disease activity and treatment response

By following this treatment algorithm and addressing both the symptoms and underlying causes of enthesopathy, clinicians can effectively manage this condition and prevent long-term morbidity.