What is the treatment for a young patient with spinal arthritis?

Treatment for Young Patients with Spinal Arthritis

Young patients with spinal arthritis (sacroiliitis) should start treatment with NSAIDs at anti-inflammatory doses, and if disease remains active after 2-4 weeks, a TNF inhibitor should be added rather than continuing NSAID monotherapy alone. 1

Initial Treatment Approach

• NSAIDs are strongly recommended as first-line therapy for active sacroiliitis in children and adolescents, providing both analgesic and anti-inflammatory effects to control sacroiliac joint inflammation 1, 2
• Treatment should be initiated at optimal anti-inflammatory doses (not just as-needed dosing) and continued for 2-4 weeks to assess response 2
• This recommendation is based on established utility in adult spondyloarthritis and analgesic effects demonstrated in children with other forms of arthritis 1

Escalation to Biologic Therapy

If disease activity persists despite NSAIDs, adding a TNF inhibitor is strongly recommended over continuing NSAID monotherapy alone. 1, 2

• Common TNF inhibitors used include adalimumab, etanercept, infliximab, and golimumab 2, 3
• This recommendation is supported by both pediatric data and randomized controlled trials in adult spondyloarthritis showing significant benefit 1
• TNF inhibitors can be used alone or in combination with methotrexate, though methotrexate may be added primarily to prevent anti-drug antibody formation against monoclonal TNF inhibitors 1

What NOT to Use

Methotrexate monotherapy is strongly recommended against for treating sacroiliitis, as data from adult spondyloarthritis demonstrates lack of effectiveness for axial disease 1

• Methotrexate may only have utility as adjunct therapy in patients with concomitant peripheral polyarthritis or to prevent anti-drug antibodies against monoclonal TNF inhibitors 1

Alternative Options for Special Circumstances

• Sulfasalazine is conditionally recommended only for patients who have contraindications to TNF inhibitors or have failed more than one TNF inhibitor 1, 2
• This recommendation is conditional due to relatively limited efficacy demonstrated in randomized controlled trials of juvenile spondyloarthritis 1

Adjunctive Therapies

Bridging glucocorticoids (oral or intraarticular):

• A limited course of oral glucocorticoids (<3 months) is conditionally recommended during initiation or escalation of therapy, particularly with high disease activity, limited mobility, or significant symptoms 1, 2
• Intraarticular glucocorticoid injections of the sacroiliac joints are conditionally recommended as adjunct therapy 1, 2

Physical therapy:

• Conditionally recommended for patients with sacroiliitis who have or are at risk for functional limitations to maintain range of motion and strengthen periarticular muscles 1, 2
• May help identify and reduce mechanical factors contributing to microtrauma and repetitive stress 1

Treatment Algorithm Summary

1. Start with NSAIDs at anti-inflammatory doses 1, 2
2. Evaluate response after 2-4 weeks 2
3. Add TNF inhibitor if inadequate response rather than continuing NSAID monotherapy 1, 2
4. Consider bridging glucocorticoids if high disease activity, limited mobility, or significant symptoms 1, 2
5. Add physical therapy for those with or at risk for functional limitations 1, 2

Critical Pitfalls to Avoid

• Do not use methotrexate monotherapy for axial disease—it is ineffective for sacroiliitis 1
• Do not delay TNF inhibitor therapy if NSAIDs fail—early biologic intervention prevents long-term joint damage and improves outcomes 4, 2
• Do not use sulfasalazine as first-line therapy—reserve it only for patients with contraindications to TNF inhibitors or after multiple TNF inhibitor failures 1, 2
• Do not continue NSAID monotherapy indefinitely if disease remains active—this leads to suboptimal outcomes 1