Xylitol and Cardiovascular Risk for Sjögren's Patients
You might be aware of a recent study in the media on xylitol and cardiovascular (CV) risks that have you questioning your use of the many oral health products containing xylitol and that you’re using to treat your dry mouth due to Sjögren’s. As soon as this study was released, the Sjögren’s Foundation started talking to our top experts to obtain their input, and we are and will stay on top of this issue!
The study was carried out at the Cleveland Clinic with over 3,300 adults in the U.S. and Europe over a 3-year period and was led by Dr. Stanley Hazen, MD, PhD. Dr. Hazen’s team found that high levels of xylitol raised platelet activity, increasing the potential for CV events, including blood clots (thrombosis), heart attacks, and strokes. A similar link was found between another sugar alcohol, erythritol, and CV risk in a 2023 study.
Most of the data to-date has focused on the dental benefits of xylitol, including its ability to help fight cavities. As a result of this benefit, xylitol is frequently used in oral health products for dry mouth. Xylitol also is one of several sugar alcohols used as a sweetener and often found in foods labeled as “sugar free” or “diabetes- or keto-friendly.”
So, what does this mean for Sjögren’s patients?
We talked with key Sjögren’s experts in rheumatology, oral medicine, and cardiology about this study to see what advice they had for Sjögren’s patients. Rheumatologist Donald Thomas, MD, FACP, FACR, of Arthritis and Pain Associates of Prince Georges County Maryland and Clinical Associate Professor of Medicine, Uniformed Services University of the Health Sciences in Bethesda, tells us:
“Some subjects in the Cleveland Clinic study consumed 30 grams of xylitol all at once. This is markedly more than the amount Sjögren’s patients consume from saliva-stimulating products. For example, two Xylimelts® used while sleeping is only 1 gram and is consumed very slowly. Most over-the-counter xylitol-containing candies (such as Ice Chips) have 1-2 grams per serving and also enter the intestinal track very slowly. In fact, the majority of xylitol is not absorbed but is excreted in the feces.
The study unfortunately did not assess how much xylitol was consumed by the subjects. For example, many diabetics eat sugar-free and keto diet foods which can contain more than 30 grams of xylitol per serving. As a result, we need further studies to assess the issue.
In the meantime, I would recommend that anyone who has had a CV event strongly consider avoiding products containing xylitol until more is known. It is important to realize that Sjögren’s increases the risk of developing CV events. Therefore, Sjögren’s patients who have other risk factors for CV events (such as diabetes, high blood pressure, high cholesterol, are overweight, smokers, and those with a strong family history of CV events) might want to strongly consider avoiding xylitol-containing products, with the exception of toothpastes and mouthwashes, until further studies are done.
If you are engaging in other measures to help your dry mouth (such as taking cevimeline, pilocarpine, or bethanechol) and find that you still need to use xylitol-containing products to help your quality of life, the potential benefits of using these products may outweigh the unknown risk for CV events, since it is not proven that the level contained in these products are linked to CV events. Bottom line is to discuss your specific situation with your physician.”
The Sjögren’s Foundation summarizes key points by suggesting that Sjögren’s patients:
- Who have additional CV risk factors avoid products and foods containing xylitol until further studies are done
- Who do NOT have additional CV risk factors note that oral health products contain much less than study participants ingested and, as such, CV risks are of much less concern (for example, a Salese oral lozenge contains only 0.03 grams of xylitol and is released slowly)
- Remember that small amounts, if any, are swallowed from toothpastes and mouthwashes
- Consider adding up the approximate amount of xylitol you ingest in an average day and, if nearing or surpassing the 30-gram level, discuss with your doctor and find ways to cut your consumption level
- Check company websites to find out how much xylitol is in an item that you use or ingest
- Discuss with your healthcare providers if there is any question or if you are at increased risk of CV!
In addition to rheumatologist Donald Thomas, MD, the Sjögren’s Foundation thanks oral medicine expert Vidya Sankar, DMD, MHS, Associate Professor and Division Director for Oral Medicine at Tufts University School of Medicine, and cardiologist Dr. Waqas Haider, of Medstar Washington Hospital Center and Georgetown University Hospital, for their review and input.
References:
- Witkowski M, Nemet I, Li XS, et al. Xylitol is prothrombotic and associated with cardiovascular risk. Eur Heart J. 2024;45(27):2439-2452. doi:10.1093/eurheartj/ehae244
- Witkowski M, Nemet I, Alamri H, et al. The artificial sweetener erythritol and cardiovascular event risk. Nat Med. 2023;29(3):710-718. doi:10.1038/s41591-023-02223-9
Xylitol and Cardiovascular Risk for Sjögren's Patients
You might be aware of a recent study in the media on xylitol and cardiovascular (CV) risks that have you questioning your use of the many oral health products containing xylitol and that you’re using to treat your dry mouth due to Sjögren’s. As soon as this study was released, the Sjögren’s Foundation started talking to our top experts to obtain their input, and we are and will stay on top of this issue!
The study was carried out at the Cleveland Clinic with over 3,300 adults in the U.S. and Europe over a 3-year period and was led by Dr. Stanley Hazen, MD, PhD. Dr. Hazen’s team found that high levels of xylitol raised platelet activity, increasing the potential for CV events, including blood clots (thrombosis), heart attacks, and strokes. A similar link was found between another sugar alcohol, erythritol, and CV risk in a 2023 study.
Most of the data to-date has focused on the dental benefits of xylitol, including its ability to help fight cavities. As a result of this benefit, xylitol is frequently used in oral health products for dry mouth. Xylitol also is one of several sugar alcohols used as a sweetener and often found in foods labeled as “sugar free” or “diabetes- or keto-friendly.”
So, what does this mean for Sjögren’s patients?
We talked with key Sjögren’s experts in rheumatology, oral medicine, and cardiology about this study to see what advice they had for Sjögren’s patients. Rheumatologist Donald Thomas, MD, FACP, FACR, of Arthritis and Pain Associates of Prince Georges County Maryland and Clinical Associate Professor of Medicine, Uniformed Services University of the Health Sciences in Bethesda, tells us:
“Some subjects in the Cleveland Clinic study consumed 30 grams of xylitol all at once. This is markedly more than the amount Sjögren’s patients consume from saliva-stimulating products. For example, two Xylimelts® used while sleeping is only 1 gram and is consumed very slowly. Most over-the-counter xylitol-containing candies (such as Ice Chips) have 1-2 grams per serving and also enter the intestinal track very slowly. In fact, the majority of xylitol is not absorbed but is excreted in the feces.
The study unfortunately did not assess how much xylitol was consumed by the subjects. For example, many diabetics eat sugar-free and keto diet foods which can contain more than 30 grams of xylitol per serving. As a result, we need further studies to assess the issue.
In the meantime, I would recommend that anyone who has had a CV event strongly consider avoiding products containing xylitol until more is known. It is important to realize that Sjögren’s increases the risk of developing CV events. Therefore, Sjögren’s patients who have other risk factors for CV events (such as diabetes, high blood pressure, high cholesterol, are overweight, smokers, and those with a strong family history of CV events) might want to strongly consider avoiding xylitol-containing products, with the exception of toothpastes and mouthwashes, until further studies are done.
If you are engaging in other measures to help your dry mouth (such as taking cevimeline, pilocarpine, or bethanechol) and find that you still need to use xylitol-containing products to help your quality of life, the potential benefits of using these products may outweigh the unknown risk for CV events, since it is not proven that the level contained in these products are linked to CV events. Bottom line is to discuss your specific situation with your physician.”
The Sjögren’s Foundation summarizes key points by suggesting that Sjögren’s patients:
In addition to rheumatologist Donald Thomas, MD, the Sjögren’s Foundation thanks oral medicine expert Vidya Sankar, DMD, MHS, Associate Professor and Division Director for Oral Medicine at Tufts University School of Medicine, and cardiologist Dr. Waqas Haider, of Medstar Washington Hospital Center and Georgetown University Hospital, for their review and input.
References: