Treatment of Juvenile Idiopathic Arthritis with Sacroiliac Joint Involvement
For children and adolescents with JIA and active sacroiliitis, initiate treatment with scheduled NSAIDs immediately, and if inadequate response occurs, add a TNF inhibitor rather than continuing NSAID monotherapy alone. 1
Initial Therapy Approach
First-Line Treatment: NSAIDs
- NSAIDs are strongly recommended as initial therapy for active sacroiliitis in children and adolescents with JIA, despite very low quality evidence supporting this recommendation. 1
- Scheduled (not as-needed) NSAID dosing should be used to provide consistent anti-inflammatory coverage. 1
- Continue NSAIDs as adjunctive therapy even when escalating to additional agents. 1
Physical Therapy
- Physical therapy is conditionally recommended for children with sacroiliitis who have or are at risk for functional limitations, focusing on maintaining range of motion and preventing deconditioning. 1
Treatment Escalation for Inadequate NSAID Response
Second-Line: TNF Inhibitors
- Adding a TNF inhibitor (etanercept, adalimumab, infliximab, or golimumab) is strongly recommended over continuing NSAID monotherapy when sacroiliitis persists despite adequate NSAID trial (low quality evidence). 1
- TNF inhibitors should be initiated promptly rather than delaying with prolonged NSAID trials, as early aggressive treatment prevents permanent joint damage. 1
Alternative DMARD Options
- Sulfasalazine is conditionally recommended only for patients who have contraindications to TNF inhibitors or have failed TNF inhibitor therapy (low quality evidence). 1
- Methotrexate monotherapy is strongly recommended against for sacroiliitis, as it lacks efficacy for axial disease (very low quality evidence). 1
Adjunctive Glucocorticoid Therapy
Bridging Oral Glucocorticoids
- A limited course of oral glucocorticoids (<3 months) is conditionally recommended as bridging therapy during initiation or escalation of other treatments, particularly useful with high disease activity, limited mobility, or significant symptoms. 1
- This bridging approach controls symptoms quickly while waiting for DMARDs or biologics to achieve therapeutic effect. 1
Intraarticular Glucocorticoid Injections
- Intraarticular glucocorticoid injection of the sacroiliac joints is conditionally recommended as adjunct therapy (very low quality evidence). 1
- These injections require image guidance (fluoroscopy or CT) for accurate placement given the deep location of the sacroiliac joints. 1
Critical Treatment Principles
Risk Stratification
- Consider poor prognostic features including sacroiliac joint involvement itself, which indicates higher risk for progressive disease requiring earlier biologic therapy. 1
- Other high-risk features include hip, wrist, or cervical spine involvement, erosive disease, elevated inflammatory markers, and symmetric disease. 1
Disease Activity Monitoring
- Use validated disease activity measures to guide treatment decisions and facilitate treat-to-target approaches, escalating therapy when disease activity remains moderate to high. 1
Common Pitfalls to Avoid
- Never use prolonged oral glucocorticoids as monotherapy—they should only serve as short-term bridging therapy (<3 months) during initiation of definitive treatment. 1
- Do not delay TNF inhibitor initiation with prolonged trials of ineffective conventional DMARDs like methotrexate, which lacks efficacy for axial disease. 1
- Avoid dismissing sacroiliac pain as mechanical without ruling out inflammatory arthritis, as early DMARD/biologic therapy is crucial to prevent permanent joint damage and disability. 1
- Do not use methotrexate monotherapy for sacroiliitis—it is strongly recommended against for this manifestation. 1