Diagnostic considerations, management of dry mouth and a promising new treatment were covered across various sessions at ACR.
Sjögren’s syndrome and sicca symptoms may not be the sexiest topic, and some may think it’s pretty dry (haha).
When you’re in clinic trying to address manifestations such as interstitial lung disease, painful peripheral neuropathies or inflammatory arthritis, asking about sicca symptoms may turn into a checkbox.
We can recommend some Biotene, olive oil and a visit to the dentist, but considering sicca symptoms are the most common symptom and have significant impact on quality of life and overall health, should we be doing more to assess and counsel our Sjögren’s patients?
This year’s ACR Convergence started off with a series of lectures on Sjögren’s syndrome and a focus on the identification and management of xerostomia.
First up, Dr Sara McCoy took us through Sjögren’s syndrome and mimics and reviewed the diagnostic work up of patients with xerostomia (11F101. Review Course – Sjögren’s and Sjögren’s Mimics). As always, the clinical history is the key to first identifying xerostomia symptoms and manifestations of Sjögren’s disease.
During physical examinations, I admit that I have never attempted to do an unstimulated whole salivary flow measurement in clinic, but a thorough look inside the mouth can provide a lot of information by examining dentition, salivary pooling and the appearance of the tongue.
Investigation with biopsy of minor salivary glands may be slightly invasive but can provide a more definitive diagnosis. Histopathology can differentiate between Sjögren’s mimics such as sarcoidosis, IgG4 disease, eosinophilic sialodochitis and viral infections (Hepatitis C and HIV) which have management and prognostic importance.
Later, Dr Mike Brennan (Diagnosis of Dry Mouth in Clinical Practice) highlighted the clinical importance of assessing severity of salivary flow and clinical measures including the xerostomia-specific questionnaire.
Dr Athena Papas (Prevention of Dry Mouth Complications) took us through the importance of saliva. Water is a poor substitute and stimulated salivary flow (chewing gum or mechanical stimulation) or sialogogue are a better alternative.
But what happens when even stimulated salivary flow is reduced? Substitutes to ensure a good oral health include baking soda rinses, olive oil and coconut oil. Please remember to avoid sour food/drinks, as even though sour foods can stimulate saliva secretion, as the acidity will accelerate dental erosions.
Lastly, Dr Leslie Laing (Management of Dry Mouth Complications) a prosthodontist and immunologist, shows some examples of, albeit confronting, clinical cases of when severe xerostomia impacts on quality of life. A simple take away message for me was that both dentures and dental implants, apart from their aesthetic and functional purposes, can also provide mechanical stimulation to increase salivary flow.
In terms of new disease modifying treatments on the horizon, Dr Thomas Dorner introduced the phase II clinical trial investigating the safety and efficacy of remibrutinib (a Bruton’s tyrosine kinase inhibitor) in moderate to severe Sjögren’s syndrome as part of the LOUiSSe study.
After 24 weeks of treatment, the primary endpoint was ESSDAI score demonstrated a significant improvement (−2.86, P=0.003), increased unstimulated salivary flow and reduced immunoglobulins at 24 weeks. Unfortunately, more subjective patient outcomes measured by the ESSPARI (dryness, pain and fatigue) did not demonstrate any improvement compared to placebo.
Regardless, this is a promising step.
Sessions include:
- 11F101. Review Course – Sjögren’s and Sjögren’s Mimics
- 12S118. Recognition, Prevention, and Management of Oral Dryness Complications
- 1113. Remibrutinib (LOU064) in Sjögren’s Syndrome: Safety and Efficacy Results from a 24‑Week Placebo-controlled Proof-of-Concept Study [in Plenary II]
Dr Bonnia Liu is a rheumatology fellow and nuclear medicine advanced trainee at Austin Health in Melbourne.
