What is the treatment for sacroilitis?

Treatment for Sacroiliitis

For patients with active sacroiliitis, the recommended treatment approach begins with NSAIDs, followed by TNF inhibitors if symptoms persist, with adjunctive therapies including physical therapy and limited courses of glucocorticoids as needed. 1

Initial Treatment

First-Line Therapy

• NSAIDs are strongly recommended as initial treatment for active sacroiliitis over no treatment 1
• NSAIDs provide both analgesic effects and anti-inflammatory benefits in controlling sacroiliac joint inflammation 2
• Treatment should be initiated promptly to reduce pain, stiffness, and prevent long-term joint damage 1

Second-Line Therapy

• For patients with active sacroiliitis despite NSAID treatment, adding a TNF inhibitor (TNFi) is strongly recommended over continued NSAID monotherapy 1
• TNFi therapy has demonstrated significant benefit in both pediatric data and adult spondyloarthritis randomized controlled trials 1
• Common TNF inhibitors used include etanercept, adalimumab, infliximab, and golimumab 1

Alternative Second-Line Options

• Sulfasalazine is conditionally recommended for patients who have contraindications to TNFi or have failed more than one TNFi 1
• Methotrexate monotherapy is strongly recommended against for sacroiliitis treatment 1
  • However, methotrexate may be useful as adjunct therapy for patients with concomitant peripheral polyarthritis or to prevent anti-drug antibody formation against monoclonal TNFi 1

Adjunctive Therapies

Glucocorticoids

• Bridging therapy with a limited course of oral glucocorticoids (<3 months) is conditionally recommended during initiation or escalation of therapy 1
  • Most beneficial in settings of high disease activity, limited mobility, or significant symptoms 1
• Intraarticular glucocorticoid injections of the sacroiliac joints are conditionally recommended as adjunct therapy 1
  • Ultrasound or fluoroscopy-guided sacroiliac joint steroid injections can provide rapid pain relief, particularly in the initial treatment phase 3, 4
  • Studies show significant reduction in pain scores within 24 hours post-injection, with benefits lasting up to 6 months 3

Physical Therapy

• Physical therapy is conditionally recommended for patients with sacroiliitis who have or are at risk for functional limitations 1
• PT can help identify and reduce mechanical factors contributing to microtrauma and repetitive stress that may contribute to disease activity 1
• Goals include maintaining range of motion and strengthening periarticular muscles 5

Treatment Algorithm

1. Initial Approach:

   • Start with NSAIDs at optimal anti-inflammatory doses 1, 2
   • Evaluate response after 2-4 weeks of consistent therapy 1

2. If inadequate response to NSAIDs:

   • Add TNF inhibitor therapy 1
   • Consider short-term oral glucocorticoids (<3 months) as bridging therapy during TNFi initiation 1
   • Consider sacroiliac joint injections for rapid symptom relief 3, 4

3. If TNFi contraindicated or failed:

   • Consider sulfasalazine as alternative therapy 1
   • Avoid methotrexate monotherapy 1

4. Throughout treatment course:

   • Incorporate physical therapy to maintain function and joint mobility 1, 5
   • Monitor disease activity and treatment response regularly 1

Common Pitfalls and Caveats

• Misdiagnosis is common as sacroiliac joint pain can mimic other causes of lower back pain 6
• Diagnostic confirmation may require imaging (MRI is more sensitive for early changes) and sometimes diagnostic blocks 6
• Methotrexate should not be used as monotherapy for sacroiliitis but may have utility as adjunct therapy in specific cases 1
• While intraarticular steroid injections provide rapid relief, they may not affect long-term disease activity 4
• Regular assessment of treatment response is essential to guide therapeutic decisions 1