Treatment of Sacroiliitis in Adults

First-Line Treatment

The American College of Rheumatology recommends NSAIDs as initial therapy for active sacroiliitis, with at least a 1-month trial before considering treatment failure 3
On-demand NSAID treatment is conditionally recommended over continuous treatment for patients with stable disease, according to the American College of Rheumatology 1, 4
For patients at high risk of gastrointestinal adverse events, selective COX-2 inhibitors are recommended when available, as suggested by the European League Against Rheumatism 3

For patients with active sacroiliitis despite NSAID treatment, TNFi therapy is strongly recommended over continued NSAID monotherapy, according to the American College of Rheumatology 2, 5, 6
No particular TNFi is recommended as the preferred choice, as stated by the American College of Rheumatology 2, 4
In patients who have contraindications to TNFi or have failed TNFi therapy, IL-17 inhibitors (secukinumab or ixekizumab) are conditionally recommended, as suggested by the American College of Rheumatology 1, 2, 4

For patients with primary non-response to the first TNFi, switching to secukinumab or ixekizumab is conditionally recommended, according to the American College of Rheumatology 1, 4
For patients with secondary non-response to the first TNFi, switching to a different TNFi is conditionally recommended, as stated by the American College of Rheumatology 1, 4
Strongly recommended against switching to the biosimilar of the first TNFi if that TNFi was ineffective, as suggested by the American College of Rheumatology 1, 4

For isolated active sacroiliitis despite NSAID treatment, locally administered glucocorticoid injections are conditionally recommended, according to the American College of Rheumatology 1, 2, 7
Intra-articular corticosteroid injections should ideally be performed in experienced centers, preferably with imaging guidance (ultrasound or CT), as suggested by the European League Against Rheumatism 3

Physical therapy is strongly recommended for all patients with sacroiliitis, according to the American College of Rheumatology 1, 2
Active physical therapy interventions (supervised exercise) are conditionally recommended over passive interventions (massage, ultrasound, heat), as stated by the American College of Rheumatology 1, 2
Land-based physical therapy is conditionally recommended over aquatic therapy, according to the American College of Rheumatology 1, 2

Strongly recommended against systemic glucocorticoids for the treatment of axial disease, as suggested by the American College of Rheumatology 1, 2, 3, 7
Strongly recommended against methotrexate monotherapy for sacroiliitis, according to the American College of Rheumatology 5, 8, 6
Conventional DMARDs (sulfasalazine, methotrexate, leflunomide) are not recommended for purely axial disease, as stated by the European League Against Rheumatism 3

Short-term oral glucocorticoids (<3 months) may be conditionally considered as bridging therapy during initiation or escalation of other treatments in cases of high disease activity, limited mobility, or significant symptoms, according to the American College of Rheumatology 5, 8, 6
Sulfasalazine may be considered for patients with peripheral arthritis or those who have contraindications to biologics, as suggested by the American College of Rheumatology 9, 6
For patients receiving biologic therapy, continuing the biologic alone is conditionally recommended over continuing both biologic and NSAID or conventional DMARD therapy, according to the American College of Rheumatology 1, 4
Discontinuation or tapering of biologic therapy is conditionally not recommended as a standard approach, as stated by the American College of Rheumatology 1, 4