Treatment Approach for Achilles Tendinitis and Bilateral Sacroiliitis in CKD Stage 3B
Avoid NSAIDs entirely in this patient and prioritize eccentric exercise therapy for Achilles tendinitis, low-dose colchicine or intra-articular/oral glucocorticoids for sacroiliitis, and initiate statin therapy for cardiovascular risk reduction given the CKD stage 3B.
Critical Medication Considerations in CKD Stage 3B
NSAIDs Must Be Avoided
- NSAIDs are contraindicated in this patient with CKD stage 3B due to nephrotoxicity risk and potential for acute kidney injury 1.
- The KDIGO 2024 guidelines explicitly state that for symptomatic inflammatory conditions in CKD, low-dose colchicine or glucocorticoids are preferable to NSAIDs 1.
Statin Therapy is Mandatory
- This 70-year-old patient with CKD stage 3B (eGFR <60 ml/min per 1.73 m²) requires statin or statin/ezetimibe combination therapy for cardiovascular risk reduction 2.
- Start with rosuvastatin 5 mg once daily, not exceeding 10 mg once daily given the severe renal impairment 2.
Management of Achilles Tendinitis
First-Line Conservative Treatment
- Eccentric exercise training is the gold standard and most evidence-based conservative treatment for Achilles tendinopathy 3.
- Physical therapy should emphasize supervised active exercise interventions over passive modalities like massage, ultrasound, or heat 1.
- Land-based physical therapy is preferred over aquatic therapy 1.
Pharmacologic Options (NSAID-Free)
- Low-dose colchicine is the preferred pharmacologic option given the CKD and NSAID contraindication 1.
- Oral glucocorticoids (short course, low dose) can be considered for acute symptom control 1.
- Avoid peri-tendon injections around the Achilles tendon as these carry rupture risk 1.
Treatment Timeline
- Conservative management should continue for at least 6 months before considering surgical options 4.
- If symptoms persist despite eccentric exercises, consider shock wave therapy or nitric oxide patches as second-line options 4.
Management of Bilateral Sacroiliitis
Pharmacologic Management
- Low-dose colchicine or oral glucocorticoids are the preferred systemic anti-inflammatory options given the CKD 1.
- For isolated active sacroiliitis, intra-articular glucocorticoid injections are conditionally recommended over no local treatment 1.
- Systemic glucocorticoids should be used cautiously and for short durations only 1.
Physical Therapy
- Strongly recommend physical therapy as it improves outcomes in axial spondyloarthropathies 1.
- Active supervised exercise programs are superior to passive interventions 1.
Biologic Considerations
- If symptoms remain active despite the above measures and NSAIDs cannot be used, consider TNF inhibitors as first-line biologic therapy 1.
- Secukinumab or ixekizumab are alternative biologics if TNF inhibitors are contraindicated 1.
Additional CKD Management Priorities
Cardiovascular Risk Reduction
- Initiate statin therapy immediately (rosuvastatin 5 mg daily, maximum 10 mg daily) 2.
- Consider plant-based Mediterranean-style diet to complement lipid-lowering therapy 1, 2.
- Estimate 10-year cardiovascular risk using a validated tool 1.
Dietary Modifications
- Limit alcohol, meats, and high-fructose corn syrup intake as these may contribute to inflammatory conditions 1.
- Individualized dietary counseling through a renal dietitian is advisable for CKD stage 3B 1.
Critical Pitfalls to Avoid
- Never prescribe NSAIDs in CKD stage 3B, even for short-term use, as this significantly increases risk of acute kidney injury and CKD progression 1.
- Avoid peritendinous injections around the Achilles tendon (patellar, quadriceps, Achilles) due to rupture risk 1.
- Do not use systemic glucocorticoids long-term for axial spondyloarthropathy; they are strongly recommended against for chronic use 1.
- Do not overlook statin therapy as cardiovascular disease is the leading cause of mortality in CKD patients 2.