For most people with Sjogren’s syndrome, treating dry eye and dry mouth are enough to enhance the quality of their lives. But in those who develop joint pain, fatigue, nerve dysfunction, or fibromyalgia, symptoms can be treated with mild medications.
A small percentage of people with Sjogren’s develop more severe inflammation, involving organs such as the kidneys, lungs, intestines, or brain. For these people, NYU Langone doctors may prescribe more aggressive medications.
Your doctor may recommend artificial tears to ease the discomfort of dry eye syndrome. These over-the-counter eye drops replace or supplement the tears the body produces. Available in varying strengths, the drops are typically used two to four times a day.
If you wear contact lenses, your doctor may recommend artificial tears designed for contact lens use that lubricate the eyes and prevent the lenses from drying out. Your doctor can recommend specific brands and dosing information based on your symptoms.
For severe dry eye syndrome, your ophthalmologist may prescribe cyclosporine eye drops twice a day. Commonly known as Restasis®, these drops decrease inflammation in the lacrimal glands, which produce tears, and can be used long term. It can take weeks or months for cyclosporine to alleviate dryness.
Cholinergic agonists help to stimulate secretions in the body. For dry eye and dry mouth, doctors may prescribe pilocarpine hydrochloride or cevimeline, both of which stimulate the lacrimal glands to produce more tears and the salivary glands to create more saliva. Both medications are taken by mouth three times a day. After about two weeks, people usually start to feel some relief. Those who have glaucoma—a condition involving damage to the optic nerve—should talk with their ophthalmologist before taking cevimeline.
If cholinergic agonists don’t provide enough relief from dry eyes, you may want to talk to your ophthalmologist about punctal plugs—tiny plugs placed in the tear ducts to block the drainage of tears and increase lubrication in the eyes. Inserting the plugs is a painless procedure that takes only a few minutes, and can be done in your ophthalmologist’s office.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are sometimes recommended to ease joint pain caused by Sjogren’s syndrome. NSAIDs such as ibuprofen and naproxen, which are available without a prescription, may be more effective in relieving pain when combined with other medications that treat Sjogren’s syndrome, such as immunosuppressive medications.
Taking large doses of NSAIDs for long periods can increase the risk of heartburn, gastrointestinal bleeding, high blood pressure, kidney disease, and heart disease.
If you have fibromyalgia in addition to Sjogren’s syndrome, your doctor may treat the chronic, widespread pain with an anticonvulsant, such as pregabalin, sold as Lyrica®, which is thought to calm overactive nerve cells that send pain signals throughout the body.
Your doctor may prescribe a serotonin–norepinephrine reuptake inhibitor (SNRI), such as duloxetine, sold as Cymbalta®, which increases levels of two neurotransmitters—serotonin and epinephrine—in the brain. These neurotransmitters are believed to dampen pain signals.
For moderate joint pain, your doctor may prescribe an immunosuppressant. These medications work by curbing an overactive immune system, thereby decreasing inflammation. Your doctor may prescribe a mild medication first, such as hydroxychloroquine, sold as Plaquenil®.
This medication was originally formulated to prevent and treat malaria, but is now also classified as a disease-modifying antirheumatic drug, or DMARD, which means it treats the underlying disease rather than its symptoms. It’s used in people with Sjogren’s syndrome, rheumatoid arthritis, and lupus to relieve joint pain, fatigue, and rashes. It may take up to 12 weeks for you to notice the effects of hydroxychloroquine.
Hydroxychloroquine is safe, even for pregnant women with Sjogren’s syndrome. Rarely, it can accumulate in the retina, the tissue at the back of the eye that helps to create images to be processed by the brain. Deposits on the retina can lead to vision changes. If you’re taking hydroxychloroquine, it’s recommended that you have a vision test every 6 to 12 months to ensure your eyes are not affected.
If joint pain is severe and does not respond to hydroxychloroquine, your doctor may prescribe methotrexate. This medication is effective in treating joint inflammation in conditions such as rheumatoid arthritis. It is generally well tolerated but requires monitoring by your rheumatologist. Side effects may include liver damage. Unlike hydroxychloroquine, it should not be used by women who are pregnant or by women who are planning to get pregnant in the next few months.
If severe Sjogren’s syndrome affects other major organs, such as the lungs, brain, or kidneys, doctors may prescribe more powerful medications that suppress the immune response, including cyclophosphamide, rituximab, and azathioprine. Taking these medications requires close monitoring because of potential side effects, such as lowered numbers of blood cells, abnormalities in the kidneys and liver, and infections.
Corticosteroid medications, commonly known as steroids, decrease inflammation by suppressing the immune response. Doctors typically use steroids to treat flare-ups, when symptoms such as joint pain and rashes come on suddenly. Steroids such as prednisone or methylprednisolone are taken by mouth, and your doctor determines the dosage based on the severity of your symptoms.
While steroids are effective at decreasing inflammation, they also have potentially serious side effects in higher doses and with long-term use. These include cataracts, osteoporosis, weight gain and fat redistribution, high blood pressure, and high blood sugar or diabetes. Doctors recommend that steroids be used with caution and under close medical supervision.
Some people with Sjogren’s syndrome develop a yeast infection in the mouth called oral candidiasis, commonly known as thrush. With this infection, white lesions coat the inside of your mouth and tongue.
If you develop signs and symptoms of thrush, your doctor can prescribe antifungal medication or mouthwash and give you tips on how to prevent the infection from recurring.
If you are a woman with Sjogren’s syndrome and are experiencing vaginal dryness, you may want to speak with your gynecologist about vaginal moisturizers available over the counter. Sexual activity may be more comfortable with the use of a water-based lubricant.
In women who are postmenopausal, dryness may be due to vaginal atrophy in addition to—or instead of—Sjogren’s syndrome. Prescription estrogen, in the form of a tablet, cream, or ring that you can insert into the vagina, may make you more comfortable.