The management of enthesitis in clinical practice

Enthesitis is a hallmark feature of the spondyloarthropathies (SpA). This review provides an overview of recent insights on diagnosis and management of enthesitis.

Recent studies support the use of imaging for diagnosis because of its higher sensitivity and specificity compared with clinical examination. Several new MRI and ultrasound scoring systems have been developed for enthesitis, which may facilitate the use of imaging in research. Enthesitis has been evaluated as a primary study outcome mainly in psoriatic arthritis (PsA); however, the use of different indices and definitions of improvement limits comparison across studies. There is very limited information about the efficacy of synthetic disease modifying antirheumatic drugs (DMARDs) for the treatment of enthesitis. In contrast, targeted and biologic DMARDs have all shown efficacy in treating enthesitis compared with placebo. There have been only a few head-to-head trials that compared two different cytokine inhibitors for the treatment of enthesitis. Preliminary data suggest that targeting IL-17 or IL12/23 may be more efficacious for controlling enthesitis than TNF inhibition.

Emerging data suggest interleukin-17 and 12/23 inhibitors may be the first choice in PsA patients with enthesitis. Further head-to-head studies are needed before making definitive recommendations.