Tips for Safe Steroid Use in Sjögren Syndrome

December 31, 2006

When corticosteroids are no longer a viable option for management of Sjögrensyndrome in a particular patient and GI symptoms preclude NSAID use, whatother treatments can be tried?

When corticosteroids are no longer a viable option for management of Sjgrensyndrome in a particular patient and GI symptoms preclude NSAID use, whatother treatments can be tried? Also, how much physical activity do yourecommend for patients with Sjgren syndrome?
---- R. E. Nordling, MD
Bryson City, NC
Corticosteroids are highly effective in the managementof Sjgren syndrome. They are thetreatment of choice, especially when NSAIDsare not tolerated. However, the potential foradverse effects--which increases with higherdosages and longer regimens--makes treatment withcorticosteroids problematic.As in all patients with autoimmune disease, the keyquestions are:

  • Is corticosteroid use indicated?
  • What is the minimal dosage that will be effective?
  • Is it possible to treat the underlying problem and thuseliminate the need for corticosteroids?

In Sjgren syndrome, the indications for corticosteroiduse are similar to those in systemic lupus erythematosus(SLE). Corticosteroids have long been used totreat the rheumatologic, dermatologic, renal, cardiac,and pulmonary manifestations of both SLE and Sjgrensyndrome; they work quickly and are effective.The initial dosage depends on the severity ofthe patient's condition. Because of a past tendency tooveruse these agents, they are now sometimes underutilized.However, problems such as diabetes, glaucoma,osteoporosis, and other conditions attributable to corticosteroiduse are generally the result of too high a dosagecontinued for too long. While every patient's responseto corticosteroids is distinct, prednisone dosages of10 mg/d or higher are more likely to result in adverseeffects, while dosages of 5 mg/d or lower are much lessso. If a patient requires a prednisone dosage of 7.5 mg/dor higher, you can often taper the dose by using anantimalarial (hydroxychloroquine, up to 7 mg/kg/d) ormethotrexate (a weekly dosage of 7.5 to 15 mg takenorally or, if that upsets the patient's stomach, by injection).Even with dosages of 7.5 mg/d or less, it is still necessaryto take appropriate precautions against the standardrisks associated with corticosteroid use (eg, diabetes,glaucoma, and osteoporosis), as well as the increased riskof periodontal complications associated with use of theseagents in patients with Sjgren syndrome.I am a strong advocate of daily aerobic exercise toprevent deconditioning in patients with Sjgren syndrome.Use the "2-hour rule" to determine an appropriate initiallevel of exercise: if the patient feels worse 2 hours afterexercising--or worse at the same time the next day--heor she did too much. Have the patient gradually increaseactivity; the goal is to maintain a pulse rate of 120 to 130beats per minute for a half hour a day. A trainer can oftenbe helpful in this process.

---- Robert I. Fox, MD, PhD
Rheumatology Clinic
Scripps Institute for Medical Research
La Jolla, Calif