What is the treatment for bilateral sacroiliitis?

Treatment for Bilateral Sacroiliitis

For bilateral sacroiliitis, the recommended treatment approach begins with NSAIDs as first-line therapy, followed by TNF inhibitors for inadequate response, with adjunctive therapies including short-course glucocorticoids, intraarticular injections, and physical therapy as needed. 1

Initial Treatment

• NSAIDs are strongly recommended as first-line therapy for active sacroiliitis over no treatment, providing both analgesic effects and anti-inflammatory benefits 2, 1
• Treatment should be initiated promptly to reduce pain, stiffness, and prevent long-term joint damage 1, 3
• NSAIDs should be administered at optimal anti-inflammatory doses with response evaluation after 2-4 weeks 1, 4

Second-Line Therapy

• For patients with active sacroiliitis despite NSAID treatment, adding a TNF inhibitor (TNFi) is strongly recommended over continued NSAID monotherapy 2, 1
• Common TNF inhibitors used include etanercept, adalimumab, infliximab, and golimumab 1
• This recommendation is based on both pediatric data and adult spondyloarthritis randomized controlled trials showing significant benefit 2

Alternative Second-Line Options

• Sulfasalazine is conditionally recommended for patients who have contraindications to TNFi or have failed more than one TNFi 2, 1
• This recommendation is based on low quality evidence, particularly the relatively limited efficacy of sulfasalazine demonstrated in clinical trials 2
• Methotrexate monotherapy is strongly recommended against for sacroiliitis treatment 2, 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 2, 1

Adjunctive Therapies

• Bridging therapy with a limited course of oral glucocorticoids (<3 months) is conditionally recommended during initiation or escalation of therapy 2, 1
• This approach is particularly useful in settings of high disease activity, limited mobility, or significant symptoms 2
• Intraarticular glucocorticoid injections of the sacroiliac joints are conditionally recommended as adjunct therapy 2, 1
• This recommendation is conditional based on very low quality of evidence and varying patient preferences regarding the procedure 2
• Physical therapy is conditionally recommended for patients with sacroiliitis who have or are at risk for functional limitations 2, 1
• PT may help identify and reduce mechanical factors contributing to microtrauma and repetitive stress that could potentially contribute to disease activity 2

Treatment Algorithm

1. Start with NSAIDs at optimal anti-inflammatory doses 1, 4
2. Evaluate response after 2-4 weeks of NSAID therapy 1
3. For inadequate response to NSAIDs, add TNF inhibitor therapy 2, 1
4. Consider short-course oral glucocorticoids (<3 months) as bridging therapy during initiation of TNFi 2
5. Consider intraarticular glucocorticoid injections as adjunctive therapy 2, 5
6. For patients who cannot use TNFi or have failed multiple TNFi, consider sulfasalazine 2, 1
7. Incorporate physical therapy throughout treatment course to maintain function 2, 1

Treatment for Refractory Cases

• For patients with persistent pain despite conservative and pharmacologic management, interventional procedures may be considered 3, 5
• These include radiofrequency ablation of sacroiliac joint nerves 6, 5
• In severe cases unresponsive to other treatments, sacroiliac joint fusion surgery may be considered 3, 4
• Surgical treatment is typically indicated for patients with a positive response to an SI injection with >75% relief, failure of nonsurgical treatment, and continued or recurrent SIJ pain 4

Common Pitfalls and Caveats

• Sacroiliitis can be difficult to diagnose due to the complex anatomy and overlapping symptoms with other causes of low back pain 3
• Methotrexate monotherapy should be avoided for isolated sacroiliitis, though it may be beneficial for patients with concomitant peripheral arthritis 2
• Regular assessment of treatment response is essential to guide therapeutic decisions 1
• Bilateral sacroiliitis may be a manifestation of systemic inflammatory conditions beyond typical spondyloarthropathies, such as sarcoidosis, requiring consideration of the underlying etiology 7