Treatment of Sacroiliitis in Adults
For adults with active sacroiliitis, the first-line treatment is nonsteroidal anti-inflammatory drugs (NSAIDs), followed by tumor necrosis factor inhibitors (TNFi) if NSAIDs fail to control symptoms. 1
First-Line Treatment
- NSAIDs should be used as initial therapy for active sacroiliitis, with at least a 1-month trial (trying at least two different NSAIDs for 15 days each) before considering treatment failure 1
- On-demand NSAID treatment is conditionally recommended over continuous treatment for patients with stable disease 1
- No specific NSAID is recommended over others, though phenylbutazone has historically been considered the NSAID of choice for ankylosing spondylitis 2
- For patients at high risk of gastrointestinal adverse events, selective COX-2 inhibitors are recommended when available 1
Second-Line Treatment
- For patients with active sacroiliitis despite NSAID treatment, TNFi therapy is strongly recommended over continued NSAID monotherapy 1
- No particular TNFi is recommended as the preferred choice 1
- In patients who have contraindications to TNFi or have failed TNFi therapy, IL-17 inhibitors (secukinumab or ixekizumab) are conditionally recommended 1
Treatment Algorithm for Inadequate Response to Initial TNFi
- For patients with primary non-response to the first TNFi, switching to secukinumab or ixekizumab is conditionally recommended 1
- For patients with secondary non-response to the first TNFi, switching to a different TNFi is conditionally recommended 1
- Strongly recommended against switching to the biosimilar of the first TNFi if that TNFi was ineffective 1
Local Treatments
- For isolated active sacroiliitis despite NSAID treatment, locally administered glucocorticoid injections are conditionally recommended 1
- Ultrasound-guided sacroiliac joint injections with corticosteroids can provide significant pain reduction for up to 6 months 3
- Intra-articular corticosteroid injections should ideally be performed in experienced centers, preferably with imaging guidance (ultrasound or CT) 1, 3
Physical Therapy
- Physical therapy is strongly recommended for all patients with sacroiliitis 1
- Active physical therapy interventions (supervised exercise) are conditionally recommended over passive interventions (massage, ultrasound, heat) 1
- Land-based physical therapy is conditionally recommended over aquatic therapy 1
Treatments NOT Recommended
- Strongly recommended against systemic glucocorticoids for the treatment of axial disease 1
- Strongly recommended against methotrexate monotherapy for sacroiliitis 1
- Conventional DMARDs (sulfasalazine, methotrexate, leflunomide) are not recommended for purely axial disease 1
Special Considerations
- Short-term oral glucocorticoids (<3 months) may be conditionally considered as bridging therapy during initiation or escalation of other treatments in cases of high disease activity, limited mobility, or significant symptoms 1
- Sulfasalazine may be considered for patients with peripheral arthritis or those who have contraindications to biologics 1
- For patients receiving biologic therapy, continuing the biologic alone is conditionally recommended over continuing both biologic and NSAID or conventional DMARD therapy 1
- Discontinuation or tapering of biologic therapy is conditionally not recommended as a standard approach 1