What is the recommended management for a patient with sacroileitis?

Management of Sacroiliitis

Start with NSAIDs as first-line therapy for at least 1 month, and if inadequate response occurs, escalate directly to TNF inhibitors rather than trying conventional DMARDs, which are ineffective for axial disease. 1, 2

Initial Pharmacological Management

NSAIDs are strongly recommended as the initial treatment for active sacroiliitis. 1, 2

• No specific NSAID is preferred over another—choose based on patient tolerance and cardiovascular/gastrointestinal risk profile 1
• For patients at high gastrointestinal risk, use selective COX-2 inhibitors when available 1, 2
• Consider NSAID failure after 1 month of continuous use (at least two different NSAIDs for 15 days each) 1
• For patients with stable disease, on-demand NSAID use is strongly recommended over continuous treatment 1, 2
• For patients with active disease, continuous NSAID use is conditionally recommended to control symptoms (not to prevent structural damage) 1

Escalation to Biologic Therapy

For active sacroiliitis despite adequate NSAID trial, add TNF inhibitor therapy—this is strongly recommended over continuing NSAID monotherapy. 1, 2

• No particular TNF inhibitor is preferred as first choice 2
• Do not use conventional DMARDs (methotrexate, sulfasalazine, leflunomide) for purely axial disease—they are ineffective 1, 2
• Methotrexate monotherapy is strongly recommended against for sacroiliitis 1, 2

Managing Inadequate Response to First TNF Inhibitor

The approach differs based on type of failure:

For primary non-response (never worked):

• Switch to IL-17 inhibitors (secukinumab or ixekizumab) conditionally recommended 2

For secondary non-response (initially worked, then lost efficacy):

• Switch to a different TNF inhibitor conditionally recommended 2
• Do not switch to a biosimilar of the same TNF inhibitor that failed 2

For patients with contraindications to TNF inhibitors:

• IL-17 inhibitors (secukinumab or ixekizumab) are conditionally recommended 2
• Sulfasalazine may be considered only if contraindications to all biologics exist 1, 2

Local Glucocorticoid Therapy

For isolated active sacroiliitis despite NSAIDs, intra-articular glucocorticoid injections are conditionally recommended. 1, 2

• This procedure should be performed in experienced specialist centers 1
• Image guidance (ultrasound or CT) is preferred when available 1, 2
• Both guided and unguided injections may be used by trained providers 1

Bridging Therapy

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

• Most useful in settings of high disease activity, limited mobility, or significant symptoms 1
• Long-term systemic glucocorticoids are strongly recommended against for axial disease 1, 2

Physical Therapy

Physical therapy is strongly recommended for all patients with sacroiliitis. 2

• Active supervised exercise programs are conditionally recommended over passive interventions (massage, ultrasound, heat) 2
• Land-based therapy is conditionally recommended over aquatic therapy 2
• Focus should be on pelvic girdle stabilization with targeted stretching 3

Common Pitfalls to Avoid

• Do not waste time with methotrexate or sulfasalazine for purely axial disease—these are only potentially useful if concomitant peripheral arthritis exists 1, 2
• Do not use systemic glucocorticoids for ongoing management—only as short-term bridging 1, 2
• Do not delay escalation to biologics if NSAIDs fail after 1 month—conventional DMARDs will not help 1, 2
• Ensure adequate NSAID trial (1 month, at least two different agents) before declaring failure 1

Continuation and De-escalation Considerations

For patients achieving good control on biologic therapy:

• Continuing biologic alone is conditionally recommended over continuing both biologic and NSAID or conventional DMARD 2
• Discontinuation or tapering of biologic therapy is conditionally not recommended as standard approach 2