Sjögren’s syndrome ‘not curable, but certainly treatable’ with available therapies
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DESTIN, Fla. — Although not currently curable, the symptoms of Sjögren’s syndrome, like dry eyes and dry mouth, can be effectively managed using a variety of therapies, said a speaker said at the Congress of Clinical Rheumatology East 2022 meeting.
“There are no curative therapies, but we certainly have the tools to palliate these symptoms and prevent complications,” Frederick B. Vivino, MD, MS, of Penn Presbyterian Medical Center, in Philadelphia, said in his presentation.
Vivino noted that although dry eyes and mouth are consistently the most important issues reported by patients, there are options to treat the full range of Sjögren’s manifestations, including lung disease.
Regarding the “all-important” dry eyes, Vivino suggested that multiple options are available, depending on the severity of the complication. These include anti-inflammatory drops, omega-3 fatty acids, punctal plugs and moisture chamber glasses. Steroid eye drops may also be used in certain cases.
“But, of course, after a month, the incidence of glaucoma and cataracts caused by steroids tends to go up,” Vivino said.
Autologous serum tears created from the patient’s own blood are available in severe cases.
“Sometimes that provides the best relief of all,” Vivino said. However, he noted that most insurance companies will not pay for this treatment.
When patients develop eye infections, azithromycin drops may be used, along with antibiotic ointments such as 0.5% erythromycin ocular ointment or oral doxycycline.
“The issue here is that because Sjögren’s is a chronic condition, these infections may recur,” Vivino said.
There can be many causes of Sjögren’s-associated dry mouth, but Vivino stressed that many medications can also cause this complication.
“Sometimes a common-sense approach is to work with primary care and other clinicians to eliminate as many drugs as possible,” he said.
For patients with mild dry mouth, gustatory or masticatory stimulus with sugar-free lozenges is a “perfectly adequate” approach, according to Vivino. As severity increases, secretagogues are an effective option.
“The most important thing is to ignore the manufacturers’ directions for dosing secretagogues,” Vivino said, noting that these recommendations are often too aggressive. “Start low and go slow.”
For still more severe cases, pilocarpine 5 mg or cevimeline 30 mg after dinner may have utility, he added.
“When you try this therapeutic approach, make sure you try both [drugs] before you give up,” Vivino said.
Turning to systemic manifestations of Sjögren’s syndrome, Vivino noted that interstitial lung disease can warrant immediate attention.
“Over the last several years, it has become apparent that ILD has become a source of not only morbidity, but mortality in Sjögren’s,” he said.
That said, there is hope.
“ILD in Sjögren’s is treatable and even curable,” Vivino said. “I would like you to remember that.”
Steroids are the first-line therapy for these patients.
“Patients are almost always steroid responsive, which is very gratifying,” Vivino said.
Next in line are mycophenolate mofetil or azathioprine. If these drugs fail and reassessment is necessary, rituximab (Rituxan, Genentech) or a calcineurin inhibitor is recommended.
“If it is in the fibrotic stage, it is nintedanib (Ofev, Boehringer Ingelheim),” he said.
Vivino urged clinicians to research the full spectrum of complications that can occur in patients with this condition.
“Sjögren’s syndrome, unfortunately, is not curable but it is certainly treatable,” he said. “These patients have syndromes that are worthy of your time and effort as rheumatologists.”
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