Neuropathic pain in Sjögren’s patients should be treated symptomatically with gabapentin or pregabalin, opioid agonists, or tricyclic or serotonin and norepinephrine reuptake inhibitors, such as nortriptyline, desipramine, duloxetine, or venlaxafine. For those with an inadequate response, the physician may try systemic treatments, such as corticosteroids, intravenous immunoglobulin (IVIg), or rituximab. Dr. Baer cited a clinical series of 19 patients with primary Sjögren’s whose neuropathy was treated with IVIg.3 The researchers noted clinical improvement in 42% of the patients and clinical stability in 52%. They concluded that IVIg may be useful in treating Sjögren’s-associated sensorimotor neuropathies or nonataxic sensory neuropathy.
“Unfortunately, the outcomes of most controlled trials of systemic immunomodulatory therapy in Sjögren’s have not been positive,” Dr. Baer said. Subjective improvement has been demonstrated with cyclosporine and alternate-day prednisone, although neither resulted in objective improvements. Neither subjective nor objective improvements have been demonstrated with azathioprine, infliximab, etanercept, interferon-gamma lozenges, or hydroxychloroquine. Despite the negative clinical trials with hydroxychloroquine, Dr. Baer noted that he still uses it because he thinks it can help, particularly with fatigue, and that is worth a six-month trial. Thalidomide therapy resulted in intolerable side effects.
With rituximab, the three placebo-controlled trials to date have had different outcome measures, with none achieving significant improvement in the primary outcome measure at the trial conclusion. However, there has been evidence of benefit either at intermediate time points or for some of the secondary measures, Dr. Baer said. “There is hope that belimumab may be beneficial in Sjögren’s,” Dr. Baer said. In a recent open label study of belimumab presented at the ACR Annual Meeting, 19 out of 30 patients reached the primary endpoint.4
In the end, establishing a positive diagnosis and treating “patients in whom the symptoms are driven by an ongoing autoimmune process” is the best way to realize the promise of biologic therapies down the road, Dr. Baer said, adding, “I am optimistic that we will see progress.”
Kimberly J. Retzlaff is a medical journalist based in Denver.
References
- Shiboski SC, Shiboski CH, Criswell LA, et al. American College of Rheumatology classification criteria for Sjögren’s syndrome: A data-driven, expert consensus approach in the Sjögren’s international collaborative clinical alliance cohort. Arthritis Care Res (Hoboken). 2012;64:475-487.
- Segal BM, Pogatchnik B, Henn L, Rudser K, Sivils KM. Pain severity and neuropathic pain symptoms in primary Sjogren’s syndrome: A comparison study of seropositive and seronegative Sjogren’s syndrome. Arthritis Care Res. 2013 Jan 17. [Epub ahead of print]
- Rist S, Sellam J, Hachulla E, et al. Experience of intravenous immunoglobulin therapy in neuropathy associated with primary Sjögren’s syndrome: A national multicentric retrospective study. Arthritis Care Res. 2011;63:1339-1344.
- Mariette X, Quartuccio L, Seror R, et al. Results of the Beliss study, the first open phase 2 study of belimumab in primary Sjogren’s syndrome. Arthritis Rheum. 2012;64(10 Suppl.):S1079.
