What is the initial treatment for sacroiliitis?

Initial Treatment for Sacroiliitis

In patients with active sacroiliitis, treatment with a nonsteroidal anti-inflammatory drug (NSAID) is strongly recommended as the initial therapy over no treatment with an NSAID. 1, 2

First-Line Treatment: NSAIDs

• NSAIDs are the cornerstone of initial therapy for sacroiliitis due to their established analgesic effects and demonstrated benefit in both pediatric and adult populations 1, 2
• The American College of Rheumatology recommends at least a 1-month trial of NSAIDs before considering treatment failure 2
• For patients at high risk of gastrointestinal adverse events, selective COX-2 inhibitors are recommended when available 2
• Studies have shown that NSAIDs can significantly reduce pain and morning stiffness in patients with sacroiliitis 3

Second-Line Treatment: When NSAIDs Fail

• For patients with active sacroiliitis despite NSAID treatment, adding a tumor necrosis factor inhibitor (TNFi) is strongly recommended over continued NSAID monotherapy 1, 2
• This recommendation is based on both pediatric data and evidence from adult spondyloarthritis, including randomized controlled trials showing benefit 1
• No particular TNFi is recommended as the preferred choice 2

Alternative Second-Line Options

• For patients who have contraindications to TNFi or have failed TNFi therapy:
  • Sulfasalazine is conditionally recommended, particularly for patients with peripheral arthritis 1
  • IL-17 inhibitors (secukinumab or ixekizumab) may be considered in adults 2
• Methotrexate monotherapy is strongly recommended against for the treatment of sacroiliitis 1
  • However, methotrexate may have utility as adjunct therapy in patients with concomitant peripheral polyarthritis or to prevent anti-drug antibodies against monoclonal TNFis 1

Adjunctive Treatments

Glucocorticoids

• Bridging therapy with a limited course of oral glucocorticoids (<3 months) during initiation or escalation of therapy is conditionally recommended 1
• This approach may be most useful in settings of high disease activity, limited mobility, and/or significant symptoms 1
• Intra-articular glucocorticoid injections of the sacroiliac joints as adjunct therapy are conditionally recommended 1, 4
• Recent studies show that ultrasound-guided sacroiliac joint injections can provide significant pain reduction for up to 6 months 4
• Intra-articular steroid injections have been shown to be superior to NSAIDs in patients with sacroiliitis, history of lumbar surgery, and pain lasting more than 30 days 5

Physical Therapy

• Physical therapy is conditionally recommended for patients with sacroiliitis who have or are at risk for functional limitations 1, 2
• PT may help identify and reduce mechanical factors contributing to microtrauma and repetitive stress that could potentially contribute to disease activity 1
• Active physical therapy interventions (supervised exercise) are conditionally recommended over passive interventions 2

Treatment Algorithm for Sacroiliitis

1. Initial therapy: NSAIDs for at least 1 month 1, 2
2. If inadequate response to NSAIDs:
   • Add TNFi therapy 1, 2
   • Consider bridging with oral glucocorticoids (<3 months) during initiation of TNFi 1
   • Consider intra-articular glucocorticoid injections 1, 4
3. If TNFi contraindicated or failed:
   • Consider sulfasalazine (especially with peripheral arthritis) 1
   • In adults, consider IL-17 inhibitors 2
4. Throughout treatment course:
   • Incorporate physical therapy 1, 2
   • Avoid methotrexate monotherapy 1

Pitfalls and Caveats

• Misdiagnosis is possible - accessory sacroiliac joints with arthritic changes can mimic ankylosing spondylitis with sacroiliitis 6
• Additional imaging studies beyond conventional X-ray or MRI may be required for accurate diagnosis in complex cases 6
• Systemic glucocorticoids are not recommended for long-term management of axial disease 2
• For patients receiving biologic therapy, continuing the biologic alone is conditionally recommended over continuing both biologic and NSAID or conventional DMARD therapy 2
• Discontinuation or tapering of biologic therapy is conditionally not recommended as a standard approach 2