Recommendations for the treatment of Sjögren's syndrome

The recommendations proposed by the Sjögren's Syndrome Committee of the Brazilian Society of Rheumatology for the treatment of Sjögren's syndrome were based on a systematic review of literature in Medline (PubMed) and the Cochrane databases until October 2014 and on expert opinion in the absence of studies on the subject. 131 articles classified according to Oxford & Grade were included. These recommendations were developed in order to guide the management and facilitate the access to treatment for those patients with an appropriate indication, considering the Brazilian socioeconomic context and pharmacological agents available in this country.

Keywords:
Sjögren's syndrome; Treatment; Recommendations; Guidelines; Systematic review

Authorship

Valéria Valim ^**Corresponding author. E-mail: val.valim@gmail.com (V. Valim).

Hospital Universitário Cassiano Antônio de Moraes (HUCAM), Empresa Brasileira de Serviços Hospitalares (EBSERH), Department of Internal Medicine, Health Sciences Center, Universidade Federal do Espírito Santo (UFES), Vitória, ES, BrazilUniversidade Federal do Espírito SantoBrazilVitória, ES, BrazilHospital Universitário Cassiano Antônio de Moraes (HUCAM), Empresa Brasileira de Serviços Hospitalares (EBSERH), Department of Internal Medicine, Health Sciences Center, Universidade Federal do Espírito Santo (UFES), Vitória, ES, Brazil

Virgínia Fernandes Moça Trevisani

Department of Internal Medicine, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, BrazilUniversidade Federal de São PauloBrazilSão Paulo, SP, BrazilDepartment of Internal Medicine, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brazil

Discipline of Rheumatology, Universidade de Santo Amaro (Unisa), São Paulo, SP, BrazilUniversidade de Santo AmaroBrazilSão Paulo, SP, BrazilDiscipline of Rheumatology, Universidade de Santo Amaro (Unisa), São Paulo, SP, Brazil

Sandra Gofinet Pasoto

Hospital das Clínicas, Medicine School, Department of Internal Medicine, Division of Rheumatology, Universidade de São Paulo (USP), São Paulo, SP, BrazilUniversidade de São PauloBrazilSão Paulo, SP, BrazilHospital das Clínicas, Medicine School, Department of Internal Medicine, Division of Rheumatology, Universidade de São Paulo (USP), São Paulo, SP, Brazil

Erica Vieira Serrano

Hospital Universitário Cassiano Antônio de Moraes (HUCAM), Empresa Brasileira de Serviços Hospitalares (EBSERH), Universidade Federal do Espírito Santo (UFES), Vitória, ES, BrazilUniversidade Federal do Espírito SantoBrazilVitória, ES, BrazilHospital Universitário Cassiano Antônio de Moraes (HUCAM), Empresa Brasileira de Serviços Hospitalares (EBSERH), Universidade Federal do Espírito Santo (UFES), Vitória, ES, Brazil

Escola Superior de Ciências da Santa Casa de Misericórdia de Vitória (EMESCAM), Vitória, ES, BrazilEscola Superior de Ciências da Santa Casa de Misericórdia de VitóriaBrazilVitória, ES, BrazilEscola Superior de Ciências da Santa Casa de Misericórdia de Vitória (EMESCAM), Vitória, ES, Brazil

Sandra Lúcia Euzébio Ribeiro

Department of Internal Medicine/Rheumatology, Universidade Federal do Amazonas (UFAM), Manaus, AM, BrazilUniversidade Federal do AmazonasBrazilManaus, AM, BrazilDepartment of Internal Medicine/Rheumatology, Universidade Federal do Amazonas (UFAM), Manaus, AM, Brazil

Tania Sales de Alencar Fidelix

Verônica Silva Vilela

Discipline of Rheumatology, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ, BrazilUniversidade do Estado do Rio de JaneiroBrazilRio de Janeiro, RJ, BrazilDiscipline of Rheumatology, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ, Brazil

Leandro Lara do Prado

Leandro Augusto Tanure

Department of Locomotor System, Hospital das Clínicas, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, BrazilUniversidade Federal de Minas GeraisBrazilBelo Horizonte, MG, BrazilDepartment of Locomotor System, Hospital das Clínicas, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil

Tatiana Nayara Libório-Kimura

Department of Pathology and Forensic Medicine, Medicine School, Universidade Federal do Amazonas (UFAM), Manaus, AM, BrazilUniversidade Federal do AmazonasBrazilManaus, AM, BrazilDepartment of Pathology and Forensic Medicine, Medicine School, Universidade Federal do Amazonas (UFAM), Manaus, AM, Brazil

Odvaldo Honor de Brito Filho

Dentist and Periodontist, BrazilDentist and PeriodontistBrazilBrazilDentist and Periodontist, Brazil

Liliana Aparecida Pimenta de Barros

Department of Dental Clinic, Health Sciences Center, Universidade Federal do Espírito Santo (UFES), Vitória, ES, BrazilUniversidade Federal do Espírito SantoBrazilVitória, ES, BrazilDepartment of Dental Clinic, Health Sciences Center, Universidade Federal do Espírito Santo (UFES), Vitória, ES, Brazil

Samira Tatiyama Miyamoto

Department of Health Care Education, Universidade Federal do Espírito Santo (UFES), Vitória, ES, BrazilUniversidade Federal do Espírito SantoBrazilVitória, ES, BrazilDepartment of Health Care Education, Universidade Federal do Espírito Santo (UFES), Vitória, ES, Brazil

Silvia Vanessa Lourenço

Discipline of General Pathology, Dental School, Universidade de São Paulo (USP), São Paulo, SP, BrazilUniversidade de São PauloBrazilSão Paulo, SP, BrazilDiscipline of General Pathology, Dental School, Universidade de São Paulo (USP), São Paulo, SP, Brazil

Maria Carmen Lopes Ferreira Silva Santos

Department of Pathology, Health Sciences Center, Universidade Federal do Espírito Santo (UFES), Vitória, ES, BrazilUniversidade Federal do Espírito SantoBrazilVitória, ES, BrazilDepartment of Pathology, Health Sciences Center, Universidade Federal do Espírito Santo (UFES), Vitória, ES, Brazil

Luis Antonio Vieira

Department of Ophthalmology, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, BrazilUniversidade Federal de São PauloBrazilSão Paulo, SP, BrazilDepartment of Ophthalmology, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brazil

Consuelo Bueno Diniz Adán

Wanderley Marques Bernardo

Project Guidelines, Associação Médica Brasileira (AMB), São Paulo, SP, BrazilAssociação Médica BrasileiraBrazilSão Paulo, SP, BrazilProject Guidelines, Associação Médica Brasileira (AMB), São Paulo, SP, Brazil

*Corresponding author. E-mail: val.valim@gmail.com (V. Valim).

Conflicts of interest

The authors declare no conflicts of interest.

SCIMAGO INSTITUTIONS RANKINGS

Dentist and Periodontist, BrazilDentist and PeriodontistBrazilBrazilDentist and Periodontist, Brazil

Figures | Tables

Figures (5)
Tables (1)

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Fig. 1
Flow diagram of the selection of evidence for Sjögren's syndrome treatment.

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Fig. 2
Flowchart for the symptomatic treatment of dryness of SS.

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Fig. 3
Flowchart for the treatment of musculoskeletal symptoms. NSAIDs, non-steroidal anti-inflammatory drugs; GC, glucocorticoids.

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Fig. 4
Flowchart for the treatment of neurological systemic manifestations. PN, peripheral polyneuropathy; CNS, central nervous system; MS, multiple sclerosis; GC, glucocorticoids; MP, methylprednisolone; CYC, cyclophosphamide.

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Fig. 5
Flowchart for the treatment of systemic kidney, lung and vasculitis manifestations. GN, glomerulonephritis; TIN, tubulointerstitial nephritis; GC, glucocorticoids; MP, methylprednisolone; CYC, cyclophosphamide.

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Table 1
Patient education: measures for hygiene and hydration of mucous membranes.

Fig. 1 Flow diagram of the selection of evidence for Sjögren's syndrome treatment.

Fig. 2 Flowchart for the symptomatic treatment of dryness of SS.

Fig. 3 Flowchart for the treatment of musculoskeletal symptoms. NSAIDs, non-steroidal anti-inflammatory drugs; GC, glucocorticoids.

Fig. 4 Flowchart for the treatment of neurological systemic manifestations. PN, peripheral polyneuropathy; CNS, central nervous system; MS, multiple sclerosis; GC, glucocorticoids; MP, methylprednisolone; CYC, cyclophosphamide.

Fig. 5 Flowchart for the treatment of systemic kidney, lung and vasculitis manifestations. GN, glomerulonephritis; TIN, tubulointerstitial nephritis; GC, glucocorticoids; MP, methylprednisolone; CYC, cyclophosphamide.

Table 1 Patient education: measures for hygiene and hydration of mucous membranes.

SS patients should be encouraged to drink fluids frequently, preferably water.

SS patients should be informed that tobacco, caffeine and various medications such as diuretics, beta blockers, antidepressants and anxiolytics, are known causes of dryness and can worsen the glandular symptoms.

To prevent tear evaporation, the patient must avoid dry environments, air conditioning, wind, and also activities that decrease eye blinking, such as using the computer or reading for a long period of time.

Patients with symptomatic dry eye should use environment humidifiers, and glasses with side shields during exposure to wind or when practicing outdoor sports.

Preventive measures for oral health aim to control biofilm, caries, loss of teeth and oral candidiasis. For this purpose, it is important to maintain a good oral hygiene, keeping intraoral pH (basic) with the use of buffers and restricting consumption of sugar.

Careful oral hygiene includes the same recommendations for the general population, with special attention to prosthesis hygiene and choosing less abrasive products, avoiding products that increase dryness of the mucosa, for example, toothpastes containing sodium lauryl sulfate and the use of alcohol-containing mouth rinse.

Removable total dental prosthesis users should daily cleaned their dentures using a dental brush with stiff bristles with toothpaste, switching to a soft bristles brush for oral mucosa cleaning. Once a week, the prosthesis must be immersed in an aqueous solution containing 1% sodium hypochlorite solution during 30 min; then the prosthesis should be rinsed in running water. One can obtain this concentration of sodium hypochlorite by diluting a tablespoon of chlorine bleach in a glass containing 300 mL of filtered water.

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Sociedade Brasileira de Reumatologia Av Brigadeiro Luiz Antonio, 2466 - Cj 93., 01402-000 São Paulo - SP, Tel./Fax: 55 11 3289 7165 - São Paulo - SP - Brazil
E-mail: sbre@terra.com.br

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