Management Approach for Enthesopathy

Initial Assessment and Diagnosis

• The European League Against Rheumatism recommends that diagnosis should focus on distinguishing true inflammatory enthesitis from mechanical enthesopathy or widespread pain syndromes 1, 2
• Clinical examination should evaluate the number and pattern of painful entheses, with an asymmetrical pattern suggesting inflammatory enthesitis 1, 2
• The presence of clinical swelling should also be evaluated 1

Treatment Algorithm

First-Line Therapy

• The American College of Rheumatology recommends NSAIDs as the initial pharmacological treatment of choice for enthesopathy 1, 2, 3
• Local glucocorticoid injections directed to the site of inflammation are also recommended 1, 2, 3
• Non-pharmacological approaches, including physical therapy and regular exercise, should also be considered 3, 5

Second-Line Therapy

• Conventional synthetic DMARDs (csDMARDs) have limited efficacy specifically for enthesitis 1, 2, 3
• Sulfasalazine may be considered for peripheral enthesitis, but evidence shows inconsistent results 3

Third-Line Therapy

• Biological DMARDs (bDMARDs) should be considered when NSAIDs and local injections are insufficient 1, 2
• All bDMARDs have similar efficacy for enthesitis 1, 2
• Options include TNF inhibitors (infliximab, etanercept, adalimumab) 1, 2, 3, IL-17 inhibitors 1, 2, and IL-12/23 inhibitors 1, 2

Special Considerations

• The Assessment of SpondyloArthritis international Society recommends differentiating inflammatory vs. mechanical enthesopathy 1, 2
• Concomitant fibromyalgia can complicate assessment and may cause overestimation of disease severity 1, 2

Treatment Based on Specific Clinical Context

• For enthesopathy in psoriatic arthritis, the treatment ladder from NSAIDs to bDMARDs should be followed 1, 2, 3
• For enthesopathy in ankylosing spondylitis, NSAIDs are first-line therapy, and TNF inhibitors are recommended for inadequate response to NSAIDs 4, 5, 6