What are the treatment options for intervertebral disc inflammation beyond Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)?

Medical Treatment for Intervertebral Disc Inflammation Beyond NSAIDs

For intervertebral disc inflammation refractory to NSAIDs, initiate TNF inhibitors (infliximab, adalimumab, etanercept, golimumab, or certolizumab) as the preferred second-line therapy, with IL-17 inhibitors (secukinumab or ixekizumab) as alternative options if TNF inhibitors are contraindicated or ineffective. 1

Treatment Algorithm After NSAID Failure

Second-Line Biologic Therapy

• TNF inhibitors are strongly recommended as the primary second-line treatment for active inflammatory disc disease despite adequate NSAID therapy 1
• The American College of Rheumatology provides high-quality evidence supporting TNF inhibitor use in axial inflammatory conditions, with approximately 50% of patients achieving at least 50% improvement in disease activity 1
• Patients with disease duration less than 10 years show superior response rates (72% achieving ≥50% improvement) compared to those with longer disease duration 1

Alternative Biologic Options

• IL-17 inhibitors (secukinumab or ixekizumab) are conditionally recommended when TNF inhibitors are contraindicated or in cases of primary non-response to the first TNF inhibitor 1
• For patients with contraindications to TNF inhibitors, IL-17 inhibitors are preferred over conventional DMARDs (sulfasalazine, methotrexate) or tofacitinib 1

Local Corticosteroid Injections

• Epidural or intradiscal corticosteroid injections provide effective short-term relief for isolated inflammatory disc disease 1
• These injections are conditionally recommended for localized sacroiliitis or inflammatory disc lesions despite NSAID treatment 1
• Patients with inflammatory end-plate changes (Modic Type 1) on MRI demonstrate significantly better response to intradiscal steroid injections compared to those without inflammatory changes 2
• Both particulate (triamcinolone) and non-particulate (dexamethasone) corticosteroids show comparable effectiveness for radicular pain from disc herniation 3

Important Caveats for Corticosteroid Use

• Systemic glucocorticoids are strongly contraindicated for axial inflammatory conditions and should be avoided 1
• Local injections should be used as bridging therapy while awaiting biologic effect, not as long-term monotherapy 1
• Avoid peri-tendon injections near Achilles, patellar, and quadriceps tendons due to rupture risk 1

Conventional DMARDs (Limited Role)

• Sulfasalazine, methotrexate, and tofacitinib have minimal efficacy for axial inflammatory disc disease and are only conditionally recommended 1
• These agents are generally ineffective or only marginally effective for axial symptoms, though sulfasalazine may provide modest benefit for peripheral arthritis 1
• The American College of Rheumatology conditionally recommends against adding sulfasalazine or methotrexate to failed TNF inhibitor therapy, favoring switching to a different biologic instead 1

Physical Therapy (Essential Adjunct)

• Intensive physical therapy is strongly recommended as a foundational treatment component regardless of pharmacologic therapy 1
• Active supervised exercise programs are preferred over passive modalities (massage, ultrasound, heat) 1
• Land-based exercises are conditionally preferred over aquatic therapy 1

Treatment Sequencing for Biologic Failure

After First TNF Inhibitor Failure

• For primary non-response (never achieved adequate response): Switch to IL-17 inhibitors (secukinumab or ixekizumab) over trying a different TNF inhibitor 1
• For secondary non-response (initial response followed by loss of efficacy): Switch to a different TNF inhibitor over switching to non-TNF biologics 1
• Do not switch to a biosimilar of the same TNF inhibitor that failed 1

Emerging Small Molecule Therapies

• Small molecule treatments targeting anti-inflammatory, anti-apoptotic, and anti-oxidative pathways are under investigation but remain experimental 4
• Diclofenac administered intradiscally has shown promise in animal models for modulating inflammatory responses, though this remains investigational 5

Treatment Response Monitoring

• Evaluate treatment response at 2-4 weeks for local injections and 12 weeks for biologic therapy 1
• Regular monitoring with validated disease activity measures and inflammatory markers (CRP, ESR) is conditionally recommended 1
• Consider advancing therapy if insufficient response is documented rather than prolonging ineffective treatment 1