New guidelines for management of Sjögren’s disease prepare the way for new treatments

Physicians of all specialties who care for patients with Sjögren’s disease now have new guidelines on how to manage the disease thanks to the British Society for Rheumatology.The guidelines cover current research for both adult and juvenile onset of Sjögren’s disease. The chronic autoimmune disease often features fatigue and dryness in the eyes, mouth and other mucosal features, which means that a wide variety of specialists encounter these patients. “I think that there are multiple specialties looking after Sjögren’s disease—ophthalmologists, rheumatologists, dentists, ENT specialists—and a lot of them are not aware of the therapeutic options available to them,” said Dr. Arthur Bookman, when asked to comment on the guidelines. Dr. Bookman is the director of the multidisciplinary Sjögren’s Clinic at University Health Network’s Schroeder Arthritis Clinic in Toronto. “It’s worthwhile for everybody to read these guidelines if they have any interest in Sjögren’s disease,” he said. DiagnosisThe guidelines outline new evidence on the utility of biomarkers in diagnosing Sjögren’s disease. Clinicians can measure antinuclear antibody (ANA) as a screening antibody in people who have clinical indications of Sjögren’s disease or connective tissue disease. If ANA is negative and there’s a high index of suspicion of Sjögren’s disease, screen with extractable nuclear antigen antibodies (ENA). A salivary gland ultrasound screening can also give useful information for diagnosis, but other imaging (i.e., MRI, PET) isn’t recommended in routine assessment. Consider a minor labial salivary gland biopsy when a diagnosis can’t be made through other means.Physicians should screen for other conditions that are often present with Sjögren’s disease, the guidelines note. Common comorbidities include thyroid disease, hypertension, osteoporosis and osteoarthritis.Read: Be aware that lisinopril or other ACE inhibitors may cause burning mouth syndromeDr. Bookman recommended that physicians measure the degree of eye dryness in the clinic with a Schirmer’s test and the amount of saliva produced with unstimulated salivary flow test.“Those measures really tell you the degree to which patients are suffering with dryness and how aggressive you need to be with topical measures for dry eyes and dry mouth,” he said.“The tests also enable a degree of certainty if a patient really has Sjögren’s disease or not, rather than guessing when a patient says they have dry eyes or dry mouth.”Dry eyesThe guideline’s review of clinically effective eye drops is particularly important for physicians treating people with Sjögren’s disease. Dr. Bookman said some of his patients are treated like regular dry eye patients, “with no considerations for the options advancing management and, in many cases, they can be doing a lot more.” The guidelines recommend regular use of preservative-free lubricating eye drop and for physicians to consider autologous or allogeneic eye drops for those patients with ongoing symptoms. Offer topical steroid eye drops or topical cyclosporin eye drops for the short term for patients who have ongoing inflammation, but be sure to read the full review in the guidelines. There are detailed recommendations for people with meibomian gland dysfunction or blepharitis. For a systematic treatment, consider a trial of pilocarpine for patients who have dryness and residual glandular function.Dry mouthThe guidelines suggest using saliva substitutes to help patients with oral dryness. For a systemic approach, try a trial of pilocarpine.Vaginal drynessAdvise patients that they can use topical non-hormonal vaginal moisturizers plus estrogen creams if they have significant vaginal dryness.Read: A link between rheumatoid arthritis and Parkinson's disease?Systemic diseaseThe guidelines outline possible treatments, which include short-term use of hydroxychloroquine for people with significant fatigue. While they can be used for specific indications, steroids or conventional immunosuppressive drugs shouldn’t be routinely used for Sjögren’s disease.The authors provide a review of a number of biologics that are currently being investigated for the treatment of Sjögren’s disease. Some, like a novel Bruton’s tyrosine kinase inhibitor (LOU064), are currently in phase III clinical trials.“We’re at the cusp of getting some drugs specific for the treatment of Sjögren’s disease,” Dr. Bookman said. The hope is that new medications will provide symptom relief. “The thing with Sjögren’s disease is it’s very hard to affect an adequate response with treatment so that patients actually feel the difference, that they feel better,” Dr. Bookman explained.“There are a lot of these drugs in the pipeline that you can show are having an effect on the amount of inflammation that’s happening in the disease, the various markers of how inflamed these people are and how active the disease is in their bodies, but patients don’t seem to recognize that improvement in terms of symptomatic improvement.”Non-pharmaceutical treatments include a hot compress for dry eyes and lifestyle modifications for fatigue. Exercise is safe and potentially beneficial for people with Sjögren’s disease, the guidelines state. Studies suggest the quality-of-life impacts of Sjögren’s disease are of the same magnitude as those with rheumatoid arthritis. Physicians should make sure patients have access to appropriate resources and support networks. The guidelines were published in Rheumatology.Read: Pregnancy outcomes generally favorable for women with Sjögren’s syndrome

New guidelines for management of Sjögren’s disease prepare the way for new treatments

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