What is the treatment for sacroilitis?

Treatment of Sacroiliitis

Start with NSAIDs as first-line therapy, and if inadequate response occurs after 2-4 weeks at optimal anti-inflammatory doses, add a TNF inhibitor rather than continuing NSAID monotherapy alone. 1, 2, 3

First-Line Treatment: NSAIDs

• NSAIDs are strongly recommended as initial therapy for active sacroiliitis, providing both analgesic and anti-inflammatory effects to control sacroiliac joint inflammation. 1, 2, 3

• Evaluate treatment response after 2-4 weeks of optimal anti-inflammatory dosing before declaring treatment failure. 2, 3

• For patients with stable disease, on-demand NSAID use is conditionally recommended over continuous daily treatment. 3

• In patients at high gastrointestinal risk, selective COX-2 inhibitors should be preferred when available. 3

Second-Line Treatment: TNF Inhibitors

For patients with persistent active sacroiliitis despite adequate NSAID trial, adding TNF inhibitor therapy is strongly recommended over continuing NSAID monotherapy. 1, 2, 3

• This recommendation is based on both pediatric data and adult spondyloarthritis randomized controlled trials demonstrating significant benefit. 1

• Common TNF inhibitors include etanercept, adalimumab, infliximab, and golimumab—no particular agent is preferred as first choice. 2, 3

• The strength of this recommendation reflects the superior efficacy of TNF inhibitors in controlling inflammation and preventing long-term joint damage. 2

Alternative Second-Line Options (Limited Role)

• Sulfasalazine is conditionally recommended only for patients with contraindications to TNF inhibitors or those who have failed more than one TNF inhibitor. 1, 3

• The conditional nature reflects limited efficacy demonstrated in randomized controlled trials of juvenile spondyloarthritis. 1

• Sulfasalazine may also be considered for patients with concomitant peripheral arthritis. 3

What NOT to Use

Methotrexate monotherapy is strongly recommended against for sacroiliitis treatment, based on adult spondyloarthritis data showing lack of effectiveness. 1, 3

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

• Systemic glucocorticoids are strongly recommended against for axial disease treatment. 3

Third-Line Treatment: IL-17 Inhibitors

• For patients with contraindications to TNF inhibitors or who have failed TNF inhibitor therapy, IL-17 inhibitors (secukinumab or ixekizumab) are conditionally recommended. 3

• For primary non-response to the first TNF inhibitor, switching to an IL-17 inhibitor is conditionally recommended. 3

• For secondary non-response (loss of efficacy over time), switching to a different TNF inhibitor is conditionally recommended. 3

Adjunctive Therapies

Physical Therapy

• Physical therapy is strongly recommended for all patients with sacroiliitis to maintain range of motion and strengthen periarticular muscles. 2, 3

• Active supervised exercise is conditionally recommended over passive interventions like massage, ultrasound, or heat. 3

• Land-based therapy is conditionally recommended over aquatic therapy. 3

Bridging Glucocorticoids

• Short-term oral glucocorticoids (less than 3 months) are conditionally recommended as bridging therapy during initiation or escalation of other treatments. 1, 2, 3

• This approach has most utility in settings of high disease activity, limited mobility, or significant symptoms. 1, 2

Intra-articular Glucocorticoid Injections

• Intra-articular glucocorticoid injections of the sacroiliac joints are conditionally recommended as adjunct therapy for isolated active sacroiliitis. 1, 2, 3

• These injections should ideally be performed in experienced centers with imaging guidance (fluoroscopy, ultrasound, or CT). 3, 4

• MR imaging-guided steroid injection has been shown to effectively reduce sacroiliac inflammatory activity and may prevent disease progression. 4

Treatment Algorithm Summary

1. Start with NSAIDs at optimal anti-inflammatory doses 2, 3
2. Evaluate response after 2-4 weeks 2
3. If inadequate response, add TNF inhibitor (do not continue NSAID monotherapy) 1, 2, 3
4. If TNF inhibitor fails:
   • Primary non-response: switch to IL-17 inhibitor 3
   • Secondary non-response: switch to different TNF inhibitor 3
5. Consider adjunctive therapies throughout: physical therapy (strongly recommended), intra-articular injections (conditional), bridging oral glucocorticoids (conditional, <3 months) 2, 3

Common Pitfalls to Avoid

• Do not use methotrexate monotherapy for sacroiliitis—it lacks efficacy for axial disease. 1, 3

• Do not use systemic glucocorticoids as standard treatment for axial manifestations. 3

• Do not continue NSAID monotherapy indefinitely if inadequate response occurs—escalate to TNF inhibitor. 1, 2, 3

• Do not switch to a biosimilar of the same TNF inhibitor if the original was ineffective. 3