Pharmacotherapy of Xerostomia in Primary Sjogren's Syndrome

Geoffrey C. Wall, Pharm.D., Michelle L. Magarity, Pharm.D., Jeffrey W. Jundt, M.D.

Disclosures

Pharmacotherapy. 2002;22(5) 

In This Article

Treatment Guidelines

Frequent dental check-ups are required to prevent increased oral infections and accelerated tooth decay. Supplemental prescription fluoride rinses should be added to oral care regimens, and chlorhexidine rinses may be necessary to prevent periodontal disease.[36] Specially developed toothpastes such as Peridex (fluorine-based) may be used but has been associated with stained tooth enamel. Chlorine-based Retardex (Rowpar Pharmaceuticals, Scottsdale, AZ) reportedly has not been linked with staining.[37] Toothpastes containing lactoperoxidase such as Biotene may help reduce bacterial overgrowth.

Oral candidiasis is common in patients with SJS, and aggressive treatment with topical antifungals such as nystatin or clotrimazole is often necessary. Some clinicians recommend nystatin vaginal tablets orally in patients without complete dentures because the high sucrose content in other topical antifungals may contribute to dental caries. Treatment may last weeks or months. Unfortunately systemic antifungal therapy often fails because the decrease in salivary function impairs achievement of therapeutic levels in affected areas. However, reports do describe success with oral fluconazole treatment.[38,39] Angular cheilitis can be treated with topical nystatin or triazoles. Frequent recurrence of candidiasis may require maintenance therapy with topical antifungals.

Proper treatment of xerostomia requires more than pharmacotherapy to replace saliva. Oral and dental manifestations often require measures for both prevention and treatment. As mentioned, oral candidiasis, often characterized by angular cheilitis and acute erythematous disease rather than simple thrush, can occur in up to 65% of patients with SJS.[40] Thus appropriate and aggressive oral hygiene techniques are crucial. Fluoride therapy and chlorhexidine solution complement these prevention strategies.[13] Dental caries and tooth loss are also common. Patients should be encouraged and educated regarding the necessity of maintaining optimal oral hygiene.

Mild-to-moderate disease should be treated with saliva substitutes. Several products are available, and a trial-and-error approach may be required to find an agent that meets the patient's expectations of efficacy and tolerability. Patients in whom saliva substitutes are not tolerated or do not help may be advanced to sialogogue therapy. Either pilocarpine or cevimeline may be given first (average wholesale price $114.50/100 Salagen 5 mg, $103.64/100 Evoxac 30 mg).[41] Again, if one drug is not effective or is not well tolerated, the other may be tried. Patients refractory to these measures may require referral to investigators engaged in clinical trials.

An approach to treating SJS xerostomia is as follows[42]:

  • Avoid contributing cofactors

    • Environmental irritants such as smoking and low humidity

    • Drugs[41]

      • Central nervous system agents

        • Tricyclic antidepressants, selective serotonin reuptake inhibitors, venlafaxine, trazodone, nefazodone, bupropion, mirtazapine, doxepin

        • Phenothiazines, olanzapine, quetiapine, clozapine, risperidone

        • Baclofen, cyproheptadine, cyclobenza-prine, tizanidine

        • Entacapone, amantadine, dopamine agonists, selegiline

        • Sibutramine, amphetamines, phentermine

        • Gabapentin, vigabatrin, lithium, modafinil

        • Ondansetron, selective serotonin 5-HT (1B/1D) receptor agonists

        • Fentanyl, morphine, tramadol

      • Cardiovascular agents

        • Central a2 agonists, dexmedetomidine

        • Disopyramide, mexiletine, sotalol, flecainide

      • Anticholinergics, antimuscarinics

        • Histamine[1] receptor antagonists, benztropine, trihexyphenidyl, dicyclomine, hyoscyamine, scopolamine, propantheline, oxybutynin, tolterodine

        • Ipratropium

      • Other agents

        • Acitretin, isotretinoin

        • Mesalamine

        • Albendazole, didanosine, foscarnet, ganciclovir, griseofulvin

  • Maintain optimal oral hygiene

    • Frequent dental visits

    • Fluoride treatments

    • Frequent toothbrushing

      • Biotene

      • Retardex

  • Aggressive treatment of infections

    • Bacterial parotiditis

    • Oral candidiasis

  • Saliva substitutes

    • Start with a carboxymethylcellulose-containing agent, applying ad lib for dry mouth symptoms.

    • If not effective or not well tolerated, switch to a different agent, or add a muscarinic agent.

  • Muscarinic agents

    • Start pilocarpine 5 mg orally 4 times/day.

    • If compliance is an issue, consider starting cevimeline 30 mg 3 times/day.

    • If one agent is not tolerated or effective at therapeutic dosages, switch to alternative agent.

    • If neither agent is well tolerated or effective, consider immunosuppressive agents.

  • Immunosuppressive agents

    • Consider low-dosage corticosteroids or methotrexate (refer to SJS specialist).

    • Consider referral to clinical trials if above strategies are unsuccessful.

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