by Donald Thomas, MD
Sjögren’s Foundation Board Chair
There are many over-the-counter and prescription drugs that can help Sjögren’s patients feel better. I will not discuss the numerous over the counter medications used for pain and moisture nor the prescription pain medications, but will concentrate on the prescription drugs used to increase moisture and to calm down the immune system. The following descriptions are brief. For complete information, ask your doctor or pharmacist.
Salagen (pilocarpine) and Evoxac (cevimeline): These two drugs are approved by the U.S. Food and Drug Administration (FDA) to increase saliva in the treatment of dry mouth. They are prescribed when other dry mouth treatments (such as xylitol gum, xylitol lozenges, and artificial saliva) do not provide enough mouth moisture. Although FDA-approved to treat dry mouth, some people find that they also help other dry areas such as the eyes, nasal passages, and skin. They can help reduce cough when it is due to a dry windpipe from Sjögren’s, and they can improve heartburn (gastroesophageal reflux) by improving the flow of saliva down the esophagus. The most common side effect is excessive sweating. A downside of these drugs is that they need to be taken three to four times a day for full effectiveness.
Plaquenil (hydroxychloroquine, HCQ): Since Sjögren’s is an autoimmune disease where the immune system is overactive, medications that calm down the immune system are sometimes needed. Plaquenil is one of the safest drugs used to treat Sjögren’s. It can especially be helpful for Sjögren’s arthritis, fatigue, and rashes. It is important to get two eye tests done every year to make sure that it doesn’t cause any eye problems. It is best to get both a visual field 10-2 and an SD-OCT test done yearly. If you are of Asian ancestry, you need three tests yearly (the preceding two tests plus a VF 24-2 or a VF 30-2). If your doctor cannot do an SD-OCT or VF 10-2 it is OK to substitute one of these with an FAF or a mfERG test.1 Make sure to show your eye doctor this paragraph to ensure you are getting the correct tests performed (you should be your own best health advocate to ensure you are getting the proper exams).
Immunosuppressant drugs: These are stronger than Plaquenil and actually decrease (or suppress) immune system activity rather than just calm it down. These medicines are called immunosuppressants. They include methotrexate, mycophenolate mofetil, azathioprine, and cyclophosphamide. These are the most common immunosuppressants used for Sjögren’s. Since they suppress the immune system, they can increase the risk of developing infections, so they should not be used during any periods of active infection. They also require blood counts and liver enzymes to be measured regularly to ensure that they are not causing any problems in the bone marrow (that is where blood cells are made) and liver.
Corticosteroids (steroids): Steroids such as prednisone and Medrol (methylprednisolone) also suppress the immune system. Steroids work much faster than the preceding drugs. Unfortunately, most people get side effects from them. We like to use the lowest doses possible and to get our patients off steroids as soon as possible. Common side effects include weight gain, broken bones from osteoporosis, making diabetes worse, moodiness, cataracts and insomnia.
B-cell depletors: A type of white blood cell called B-cells is overactive in Sjögren’s. Some patients may benefit by using medications that calm down these B-cells. You may see this referred to as “B-cell depletion” when reading the Sjögren’s medical literature. The two drugs used are RITUXAN® (rituximab) and Benlysta (belimumab). They are both liquids requiring infusion into a vein (IV), or by self-injection under the skin (SQ).
References: 1 Marmor MF, et al. Recommendations on screening for chloroquine and hydroxychloroquine retinopathy (2016 revision).
This article was first printed in the Foundation's patient newsletter for members.