Robert I. Fox, MD, PhD

Disclosures

May 27, 2009

Question

What are the treatment options for Sjögren's syndrome in an individual unable to tolerate steroids or sulfa?

Response from Robert I. Fox, MD, PhD
Professor and Member, Scripps Memorial Hospital and Research Foundation; Rheumatologist, Scripps Memorial Hospital, La Jolla, California

The effective treatment of Sjögren's syndrome generally encompasses 3 separate aspects:

  • Topical treatment of dry eyes and dry mouth as well as other mucosal surfaces (skin, nasal, and vaginal dryness). Agents may include nonsteroidal and nonsulfa compounds, such as artificial tears and saliva, and also secretagogues such as cevimeline and pilocarpine.

  • Treatment of extraglandular systemic manifestations ranging from rash to lymphoproliferative disorders. The approach to these conditions is generally similar to that in patients with systemic lupus erythematosus, but some therapeutic alterations may be needed to accommodate lymphocytic aggressive infiltration of tissues (ie, interstitial pneumonitis or interstitial nephritis) as well as intolerance to medications with cholinergic side effects.

  • Treatment of poorly defined symptoms associated with fibromyalgia, such as cognitive and myalgia symptoms and fatigue that do not correlate closely with markers of systemic inflammation. The choice of medications for fibromyalgia, including those recently approved by the US Food and Drug Administration, may include nonsteroidal and nonsulfa agents such as duloxetine, milnaciprin, and pregabalin. Newer nonsteroidal agents such as oxybate may help fibromyalgia by normalizing sleep patterns.

In general, we try to avoid or limit the use of steroids in patients with Sjögren's syndrome because of the usual undesirable steroid side effects, and also because they may accelerate dental complications. A sulfa allergy may be important in later choice of antibiotics, but unlike the treatment of some patients with Wegener's granulomatosis, a sulfa allergy has not been shown to affect the therapy of Sjögren's syndrome.

A general overview of Sjögren's syndrome treatment is available in many review articles.[1,2,3,4,5,6] Interested readers are invited to visit the author's blog, Rheum With a View, which provides useful information regarding topical and systemic therapies for patients with Sjögren's syndrome, as well as links to other resources.

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