What is the management approach for enthesopathy?

Management Approach for Enthesopathy

For patients with enthesopathy, first-line treatment should include NSAIDs and local glucocorticoid injections, with biological DMARDs (bDMARDs) considered for those with unequivocal enthesitis who have insufficient response to first-line therapy. 1

Initial Assessment and Diagnosis

• Enthesopathy refers to pathological changes at the insertion sites of tendons, ligaments, and joint capsules to bone, which can be inflammatory (enthesitis) or non-inflammatory 2
• Diagnosis should focus on distinguishing true inflammatory enthesitis from mechanical enthesopathy or widespread pain syndromes 1
• Clinical examination should evaluate:
  • Number and pattern of painful entheses (asymmetrical pattern suggests inflammatory enthesitis) 1
  • Presence of clinical swelling 1
  • Common sites include calcaneus (Achilles tendon insertion), plantar fascia, patellar tendon, tibial tuberosity, and greater trochanter 2, 3
• Imaging with ultrasound or MRI can confirm diagnosis but clinical examination is usually sufficient 1, 4

Treatment Algorithm

First-Line Therapy

• NSAIDs are the initial pharmacological treatment of choice for enthesopathy 1

  • Should be used as first-line treatment for pain and inflammation 1
  • Consider GI risk profile when selecting specific NSAID 1

• Local glucocorticoid injections directed to the site of inflammation 1

  • Particularly effective for accessible entheseal sites 1
  • Use with caution due to potential risk of tendon rupture 1

• Non-pharmacological approaches 1

  • Physical therapy and regular exercise 1
  • Patient education about the condition 1

Second-Line Therapy

• Conventional synthetic DMARDs (csDMARDs) 1
  • Limited efficacy specifically for enthesitis 1
  • Sulfasalazine may be considered for peripheral enthesitis but evidence shows inconsistent results 1

Third-Line Therapy (for unequivocal enthesitis with insufficient response)

• Biological DMARDs (bDMARDs) should be considered when NSAIDs and local injections are insufficient 1

  • All bDMARDs have similar efficacy for enthesitis 1
  • Options include:
    • TNF inhibitors (infliximab, etanercept, adalimumab) 1
    • IL-17 inhibitors 1
    • IL-12/23 inhibitors 1

• Apremilast may be considered for mild disease or when bDMARDs are contraindicated 1

  • Most appropriate for patients with oligoarticular disease (≤4 joints) and limited skin involvement 1

Special Considerations

• Differentiate inflammatory vs. mechanical enthesopathy 1, 5

  • Inflammatory enthesitis is characteristic of spondyloarthropathies 2, 6
  • Mechanical enthesopathy may be due to repetitive stress or trauma 3, 5

• Concomitant fibromyalgia can complicate assessment 6

  • May cause overestimation of disease severity 6
  • Term "unequivocal enthesitis" is used to avoid overtreating trigger-point pain from other causes 1

• Impact on quality of life

  • Enthesitis significantly impacts function and quality of life 6
  • Treatment should aim to improve both symptoms and functional outcomes 6

Treatment Based on Specific Clinical Context

• For enthesopathy in psoriatic arthritis:

  • Follow the treatment ladder from NSAIDs to bDMARDs 1
  • Consider IL-17 inhibitors when there is significant skin involvement 1

• For enthesopathy in ankylosing spondylitis:

  • NSAIDs are first-line therapy 1
  • TNF inhibitors are recommended for inadequate response to NSAIDs 1

• For mechanical/degenerative enthesopathy:

  • Focus on physical therapy and NSAIDs 4
  • Local injections for symptomatic relief 1