Therapeutic Recommendations for the Management of Older Adult Patients with Sjögren’s Syndrome

Abstract

Primary Sjögren's syndrome (SjS) is a systemic autoimmune disease most commonly diagnosed in middle-aged women. Although the disease can occur at all ages, it is diagnosed between 30 and 60 years of age in two-thirds of patients. In more than 20% of cases, the people are older than 65 years. In this review, we focus on the therapeutic management of primary SjS in older patients, following the recently published 2020 European League Against Rheumatism (EULAR) recommendations for the management of the disease with topical and systemic therapies. These recommendations are applicable to all patients with primary SjS regardless of age at diagnosis, although the therapeutic management in older patients requires additional considerations. Older patients are more likely to have pulmonary, liver, kidney, or heart-related comorbidities (even cognitive disturbances); caution is required when most drugs are used, including muscarinic agents, systemic corticosteroids and synthetic immunosuppressants. It is also important to monitor the use of eye drops containing steroids due to the increased risk of developing cataracts, a frequent ocular complication in the older population. In contrast, the majority of drugs that can be used topically (pilocarpine rinses, eye drops containing topical non-steroidal anti-inflammatory drugs (NSAIDs) or cyclosporine A, topical dermal formulations of NSAIDs) have shown an acceptable safety profile in older patients, as well as rituximab. A rigorous evaluation of the medical history of older patients is essential when drugs included in the EULAR guidelines are prescribed, with special attention to factors frequently related to ageing, such as polypharmacy, the existence of organ-specific comorbidities, or the enhanced susceptibility to infections.

Influence of the age at diagnosis in the disease expression of primary Sjögren syndrome. Analysis of 12,753 patients from the Sjögren Big Data Consortium

“…Clinical (15): studies in non-autoimmune populations have shown that the frequency of oral dryness is much higher in older people (16)(17)(18)(19)(20). This has been linked to progressive glandular ageing, and especially with the greater use of drugs in older people which has been closely associated with reduced salivary flow rates (19), especially in patients receiving ≥2 hyposalivatory drugs ( 21) and those with coexisting diabetes mellitus (22).…”

Practical diagnostic tips for the Sjögren Clinic: pearls, myths and mistakes

“…In more than 20% of cases, SS is diagnosed in people aged ≥65 years (11). When the disease is diagnosed at older ages, the frequency of dryness symptoms and abnormal diagnostic tests (parotid sialography, ocular tests, minor salivary gland biopsy) is similar to that reported in middle-aged people (12).…”

Potential mechanisms and drug prediction of Rheumatoid Arthritis and primary Sjögren’s Syndrome: A public databases-based study

“…Cyclosporine is a traditional immunosuppressant, initially used in organ transplantation, that is now widely used in treating various autoimmune diseases, such as RA and pSS [ 51 ]. The 2020 European League Against Rheumatism recommendations for the management of pSS by topical and systemic therapy stated that cyclosporine showed acceptable safety as a drug that could be used topically [ 52 ]. Zidovudine and stavudine, thymidine analogues, are antiretroviral drugs that inhibit retroviral replication by disrupting viral reverse transcriptase and extending viral DNA strands [ 53 ].…”