EVALUATE THE PATIENT FOR DISORDERS ASSOCIATED WITH SJOGREN SYNDROME LIKE:
- ACQUIRED IMMUNODEFICIENCY SYNDROME
- RHEUMATOID ARTHRITIS
- SLE
- SCLERODERMA
- POLYMYOSITIS
- PRIMARY BILIARY CIRHOSIS
- THYROIDITIS
- CHRONIC ACTIVE HEPATITIS
- MIXED CRYOGLOBULINEMIA
Medical Care:
" Dry eyes
o Artificial tears should be applied liberally.
" Patients may need to apply artificial tears more often if they enter an environment with low humidity (ie, air conditioning, airplanes).
" Artificial tears with hydroxymethylcellulose or dextran are more viscous and can last longer before reapplication is needed. Encourage patients to try various preparations to determine what works best for them.
" If artificial tears burn when they are instilled, the preservative in the artificial tears is likely irritating the eye. If artificial tears are used more often than every 4 hours, patients should use a preservative-free preparation to avoid eye irritation from the preservatives.
" If patients wake up in the morning with severe matting in the eyes, then they should use a more viscous preparation, such as Lacri-Lube, at night. While the more viscous preparations can be applied less often, they can make patients' vision filmy. Therefore, they are best used at night.
" The more viscous preparations can occasionally lead to blepharitis, which can exacerbate sicca symptoms.
o Temporary plugging of the lacrimal puncta can increase the amount of tears that remain in the eyes. Electrocautery and other techniques can be used for permanent punctal occlusion.
o Patients should avoid medications with anticholinergic and antihistamine effects.
o The use of humidifiers may help. If living in an area with hard water, using distilled water is best.
o Glasses fitted with moisture shields can decrease evaporation.
" Dry mouth
o Patients can liberally drink sips of water and take bottled water with them on trips. They can also place a glass of water at their bedside for nighttime use as needed.
o Sugar-free lemon drops can also be used as needed to stimulate salivary secretion.
o Artificial saliva can be used as needed, although patient tolerance is variable. Preparations include Salivart, Saliment, Saliva Substitute, MouthKote, and Xero-Lube.
o Patients should be seen regularly by a dentist, who might advise fluoride treatments. Toothpaste without detergents can reduce mouth irritation in patients with SS. Brands include Biotene toothpaste, Biotene mouth rinse, Dental Care toothpaste, and Oral Balance gel.
o Patients should avoid medications with anticholinergic and antihistamine effects.
o Watch for and treat oral candidiasis and angular cheilitis with topical antifungal agents, such as nystatin troches. Oral fluconazole may be needed occasionally. Patients also need to be sure to disinfect their dentures.
o Sinusitis and sinus blockade should be treated because these problems may contribute to mouth breathing. Emphasize the use of isotonic sodium chloride solution nasal sprays to avoid using antihistamines.
o Use of humidifiers may help. For patients living in an area with hard water, using distilled water is best.
o Pilocarpine or cevimeline tablets are options. Some small studies suggest that interferon alfa may be a useful therapy in the future.
" Skin and vaginal dryness
o Patients should use skin creams, such as Eucerin, or skin lotions, such as Lubriderm, to help with dry skin.
o Patients should use vaginal lubricants, such as Replens, for vaginal dryness. Vaginal estrogen creams can be considered in postmenopausal women. Watch for and treat vaginal yeast infections.
" Arthralgias and arthritis
o Acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) can be taken for arthralgias.
o Consider hydroxychloroquine if NSAIDs are not sufficient for the synovitis occasionally associated with primary SS. This medication, however, does not relieve sicca symptoms.
o Patients with RA associated with SS likely require other disease-modifying agents.
" Other
o In patients with major organ involvement, such as lymphocytic interstitial lung disease, consider therapy with steroids and immunosuppressive agents, such as cyclophosphamide.
o While cyclophosphamide and similar agents may be helpful to treat serious manifestations of SS or disorders associated with SS, clinicians should understand that these agents are also associated with the development of lymphomas.
" Anticoagulation: Long-term anticoagulation may be needed in those patients with vascular thrombosis related to antiphospholipid antibody syndrome.
Surgical Care:
" Perform a minor salivary gland biopsy for diagnostic purposes.
" Perform a biopsy on the parotid gland if malignancy is suggested.
" Perform a biopsy on an enlarged lymph node to help rule out pseudolymphoma or lymphoma.
" Occlusion of the lacrimal puncta can be corrected surgically. Electrocautery and other techniques can be used for permanent punctal occlusion.
" During surgery, the anesthesiologist should use as little anticholinergic medications as possible and use humidified oxygen to help avoid inspissation of pulmonary secretions. Good postoperative respiratory therapy should also be provided. Patients are at higher risk for corneal abrasions, so ocular lubricants should be considered.
Activity: Encourage patients to be active.