What are the treatment options for symmetric sacroiliitis?

From the Guidelines

Treatment for symmetric sacroiliitis should prioritize non-pharmacological approaches and non-steroidal anti-inflammatory drugs (NSAIDs) as first-line treatments, with biological agents such as TNF inhibitors or IL-17 inhibitors considered for more severe cases or those associated with conditions like ankylosing spondylitis. According to the 2017 update of the ASAS-EULAR management recommendations for axial spondyloarthritis 1, NSAIDs are the first-line drug in axSpA, and physical therapy is an essential aspect of management. For patients who do not respond adequately to NSAIDs, disease-modifying antirheumatic drugs (DMARDs) or biological agents may be prescribed. The 2019 American College of Rheumatology guideline for the treatment of juvenile idiopathic arthritis also recommends treatment with an NSAID as the initial approach for sacroiliitis, with the addition of a TNF inhibitor for those who do not respond to NSAIDs alone 1.

Non-Pharmacological Approaches

• Physical therapy focusing on core strengthening, flexibility, and proper body mechanics is essential for long-term management.
• Heat therapy, gentle stretching, and maintaining proper posture can help manage daily symptoms.

Pharmacological Approaches

• Non-steroidal anti-inflammatory drugs (NSAIDs) like naproxen (500mg twice daily), ibuprofen (400-800mg three times daily), or celecoxib (200mg daily) are typically first-line treatments to reduce inflammation and pain.
• For patients who don't respond adequately to NSAIDs, disease-modifying antirheumatic drugs (DMARDs) such as sulfasalazine or biological agents including TNF inhibitors (e.g., adalimumab, etanercept) or IL-17 inhibitors (e.g., secukinumab) can be considered.
• Local corticosteroid injections directly into the sacroiliac joints may provide temporary relief.

Considerations for Treatment

• Treatment should be tailored to the underlying cause of sacroiliitis, as symmetric involvement often suggests a systemic inflammatory condition rather than mechanical or infectious causes.
• The use of biological agents should be based on the severity of the disease and the presence of specific conditions such as ankylosing spondylitis.
• Cost considerations and the potential for tapering biological agents should also be taken into account, as recommended by the ASAS-EULAR management recommendations 1.

From the Research

Treatment Options for Symmetric Sacroiliitis

• Nonsurgical modalities are the initial phase of treatment, including:
  • Activity modification
  • Use of a sacroiliac (SI) belt
  • NSAIDs
  • Physical therapy 2
• Other potential therapeutic modalities include:
  • Prolotherapy
  • Radiofrequency ablation, although limited data support their use as a primary treatment modality 2
• Surgical treatment is indicated for patients with:
  • A positive response to an SI injection with >75% relief
  • Failure of nonsurgical treatment
  • Continued or recurrent SIJ pain 2
• Surgical options include:
  • Percutaneous SI arthrodesis, which may be recommended as a first-line surgical treatment due to its improved safety profile compared with open arthrodesis 2
  • Open arthrodesis, which should be performed in cases of revision surgery, nonunion, and aberrant anatomy 2
• For patients with ankylosing spondylitis, which can cause symmetric sacroiliitis, treatment options include:
  • Anti-tumor necrosis factor biological agents, such as etanercept and adalimumab, which have been shown to be effective in reducing disease activity 3