What is the recommended treatment for a patient with sacroilitis?

Treatment of Sacroiliitis

Initial Pharmacological Management

NSAIDs are strongly recommended as first-line treatment for active sacroiliitis, with a trial of at least 1 month (two different NSAIDs for 15 days each) before considering treatment failure. 1, 2

• No specific NSAID is preferred over another, though selective COX-2 inhibitors should be used in patients at high risk of gastrointestinal adverse events 1, 2
• For patients with active disease, continuous NSAID use is conditionally recommended to control symptoms, while on-demand treatment is strongly recommended for those with stable disease 1
• Maximum therapeutic effect typically occurs within 2-4 weeks of continuous use 1
• Important caveat: Consider a 1-2 week NSAID washout before MRI imaging, as NSAIDs can mask active sacroiliitis in approximately 20% of patients, potentially leading to false-negative results 3

Second-Line Treatment: Biologic Therapy

For patients with active sacroiliitis despite adequate NSAID trial, adding a TNF inhibitor (etanercept, adalimumab, infliximab, or golimumab) is strongly recommended over continued NSAID monotherapy. 1, 2, 4

• No particular TNF inhibitor is preferred as first choice 2
• This recommendation is based on strong evidence from both adult and pediatric randomized controlled trials demonstrating significant benefit 1, 4

Algorithm for TNF Inhibitor Failure:

Primary non-response (never worked):

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

Secondary non-response (initially worked, then stopped):

• Switch to a different TNF inhibitor conditionally recommended 2
• Do NOT switch to a biosimilar of the same ineffective TNF inhibitor 2

Local Glucocorticoid Therapy

For isolated active sacroiliitis despite NSAIDs, intra-articular glucocorticoid injections are conditionally recommended as adjunct therapy. 1, 2, 4

• Injections should be performed in experienced specialist centers, preferably with imaging guidance (ultrasound or CT) 1, 2
• Both guided and unguided injections may be used by trained providers, though guided injections may be more efficacious and less painful 1
• Short-term oral glucocorticoids (<3 months) may be conditionally used as bridging therapy during initiation or escalation of other treatments, particularly with high disease activity, limited mobility, or significant symptoms 1, 2, 4

Physical Therapy

Physical therapy is strongly recommended for all patients with sacroiliitis, particularly those with or at risk for functional limitations. 1, 2, 4

• Active supervised exercise programs focusing on pelvic girdle stabilization are conditionally recommended over passive interventions (massage, ultrasound, heat) 2
• Land-based therapy is conditionally recommended over aquatic therapy 2
• PT should identify and reduce mechanical factors contributing to microtrauma and repetitive stress 1

Treatments Strongly Recommended AGAINST

The following treatments should NOT be used for sacroiliitis:

• Long-term systemic glucocorticoids are strongly recommended against for axial disease 1, 2
• Methotrexate monotherapy is strongly recommended against, as adult data shows lack of effectiveness 1, 2, 4
  • Exception: Methotrexate may be useful as adjunct therapy in patients with concomitant peripheral polyarthritis or to prevent anti-drug antibodies against monoclonal TNF inhibitors 1, 4
• Conventional DMARDs (sulfasalazine, methotrexate, leflunomide) are strongly recommended against for purely axial involvement 1, 2
  • Exception: Sulfasalazine is conditionally recommended only for patients with contraindications to TNF inhibitors or who have failed more than one TNF inhibitor 1, 2, 4

Treatment Algorithm Summary

1. Start with NSAIDs (continuous use for active disease, on-demand for stable disease) for 1 month 1, 2
2. If inadequate response: Add TNF inhibitor 1, 2, 4
3. If primary TNF inhibitor failure: Switch to IL-17 inhibitor 2
4. If secondary TNF inhibitor failure: Switch to different TNF inhibitor 2
5. Adjunctive options throughout: Intra-articular glucocorticoid injections and physical therapy 1, 2
6. Bridging only: Short-term oral glucocorticoids (<3 months) during treatment transitions if severe symptoms 1, 2, 4

Special Considerations

• Once biologic therapy is initiated, continuing the 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 a standard approach 2
• For patients receiving TNF inhibitors, avoid peritendinous injections of the Achilles, patellar, and quadriceps tendons 1