Sjögren's syndrome: current therapies remain inadequate for a common disease

Efficacy of Intense Pulsed Light Treatment in Patients with Sjögren’s Syndrome Associated with Meibomian Gland Dysfunction

Purpose: To investigate the efficacy of intense pulsed light (IPL) treatment in patients with meibomian gland dysfunction (MGD) associated with Sjögren’s syndrome.Methods: This study included 43 patients with MGD and Sjögren’s syndrome. Patients received either IPL with meibomian gland expression (IPL/MGX) (n = 22) or MGX only (n = 21). Treatments were administered three times at a 3-week interval. Patients were followed up 6 weeks after the end of the treatment. Ocular Surface Disease Index (OSDI), tear film breakup time with fluorescein dye (FBUT), non-invasive tear breakup time, tear meniscus height (TMH), Schirmer test, SICCA ocular surface staining score, meibum quality score (MQS), and meibum expression score (MES) were evaluated at each visit. Meibomian gland dropouts (meiboscore) and tear film lipid layer grade were measured using keratography.Results: OSDI, FBUT, corneal surface staining score, MQS, meiboscore, and tear film lipid layer grade improved after IPL/MGX treatment (p < 0.05). In both treatment groups, MES significantly improved (p < 0.01 and p < 0.05 for IPL/MGX and MGX groups, respectively). The Schirmer test score, conjunctival surface staining score, and TMH after treatment were not significantly different between the groups. After treatment, the IPL/MGX group had significantly lower OSDI, FBUT, corneal staining score, MQS, and MES, but higher FBUT, compared with the MGX group (p < 0.05).Conclusions: IPL treatment effectively improved tear film, ocular surface parameters, meibomian gland function, and lipid layer grade in patients with Sjögren’s syndrome and MGD.

Emerging targets of inflammation and tear secretion in dry eye disease

The underlying mechanisms of dry eye are thought to be part of a vicious circle involving a hyperosmolarity-triggered inflammatory cascade, resulting in loss of goblet cells and glycocalyx mucin and observed corneal and conjunctival epithelial cell damage. This damage leads to increased tear film instability, further hyperosmolarity and hence perpetuating of a vicious circle. The aim of dry eye management is to restore the homeostasis of the tear film and break the perpetuation of this vicious circle. Despite the plethora of treatment options available, many of these are largely palliative, short-lived and require repeated instillations. Two emerging areas in dry eye therapy aim to promote tear secretion and to safely manage dry eye-associated inflammation and are the focus of this review.

Meibomian gland dysfunction patients with novel Sjögren's syndrome biomarkers benefit significantly from a single vectored thermal pulsation procedure: a retrospective analysis

Purpose

To measure the effects from a single vectored thermal pulsation treatment of the meibomian glands on dry eye signs and symptoms in patients who tested positively versus negatively for novel Sjögren’s syndrome (SS) biomarkers.

Methods

The retrospective study included the deidentified data of 102 eyes of 59 patients with dry eye and meibomian gland dysfunction (MGD), who were also tested for novel biomarkers for SS and underwent a single 12-minute LipiFlow thermal pulsation procedure. All patients were already being treated with individualized dry eye therapy but remained symptomatic. Meibomian gland secretion (MGS) scores, Standard Patient Evaluation of Eye Dryness (SPEED) questionnaire scores and tear breakup times (TBUTs) before and 8 weeks after thermal pulsation treatment were analyzed.

Results

Twenty-three patients tested positive for novel biomarkers of SS and 36 patients tested negative. At baseline, MGS, SPEED and TBUT of both SS-positive and SS-negative patients were equivalent. At 8 weeks’ post-treatment, mean MGS score, SPEED and TBUT were 13.0±7.8, 12.5±6.8 and 9.6±4.6, respectively, in SS-positive patients and 15.9±7.9, 10.0±6.3 and 8.3±4.6, respectively, in SS-negative patients (P<0.001). While the post-treatment MGS was significantly better in SS-negative patients than SS-positive (P=0.021), no significant difference between post-treatment SPEED and TBUT was observed between the two groups (P>0.05).

Conclusion

LipiFlow treatment in MGD patients who were SS-positive for novel biomarkers of SS demonstrated improvement in signs and symptoms of dry eye. While improvement in MGS scores in SS-negative patients was higher than that observed in SS-positive patients, SPEED and TBUT were equivalent between these two groups.

Emerging biotherapies for Sjögren's syndrome

IMPORTANCE OF THE FIELD

Sjögren's syndrome (SS) is an autoimmune epithelitis. This exocrinopathy is frequently associated with extraglandular complications, and the patients are at risk of developing B cell lymphoma. Given the lack of disease-modifying drugs, and the fact that SS is a quintessential B-cell mediated disease, attention has recently been focused on biotherapies.

AREAS COVERED IN THIS REVIEW

Despite negative grounds, TNF-alpha antagonists have been tested in the disease, and proven not be efficient. However, B-cell depleting therapy using anti-CD20 antibodies such as rituximab, which is a chimeric mAb, has shown promise in the field, while anti-CD22 mAb seems to be less active.

WHAT THE READER WILL GAIN

New treatments against the B-cell activating factor of the TNF family are about to be tested, or replaced by receptor immunoglobulin decay protein.

TAKE HOME MESSAGE

B-cell depleting therapies seem promising in SS, but no data are, thus far, available on treatments targeting B-cell activating factor of the TNF family.

Discrimination between Sjögren's and non-Sjögren's sicca syndrome by sialoscintigraphy and antibodies against alpha-fodrin and Ro/La autoantigens

Both Sjögren's syndrome (SS) and non-Sjögren's syndrome (NSS) can present with the sicca symptoms of dry eyes and a dry mouth but they are distinct pathological entities that require diagnostic discrimination. This study included 82 sicca syndrome patients and examined the ability of sialoscintigraphy and antibodies against the autoantigens alpha-fodrin, Ro and La to discriminate between SS and NSS. A total of 30.8% of SS patients compared with 58.8% of NSS patients were alpha-fodrin positive. The prevalence of Ro positivity was 69.4% for SS patients compared with 0% for NSS patients. The prevalence of La positivity was 52.4% for SS compared with 0% for NSS patients. Sialoscintigraphy showed that more NSS patients had grade III salivary gland impairment compared with SS patients (64.7% versus 19.4%). These data suggest that using sialoscintigraphy in combination with measuring the levels of serum alpha-fodrin, Ro and La might be useful for SS and NSS discrimination.

Altered expression of genes functioning in lipid homeostasis is associated with lipid deposition in NOD mouse lacrimal gland

Functional atrophy and accompanying lymphocytic infiltration and destruction of the lacrimal gland (LG) are characteristics of Sjögren's Syndrome (SjS). The male NOD mouse is an experimental model for the autoimmune exocrinopathy that develops in the LG of SjS patients. Acinar cells in LG of male NOD mice aged 3-4 months were previously shown to accumulate lipid droplets. In the current study, analysis of lipid components revealed that the accumulated lipids were mostly cholesteryl esters (CE). Gene expression microarray analysis followed by real-time RT-PCR revealed alterations in the expression of several genes involved in lipid homeostasis in LG of 12-week-old male NOD mice relative to matched BALB/c controls. A series of upregulated genes including apolipoprotein E, apolipoprotein F, hepatic lipase, phosphomevalonate kinase, ATP-binding cassette D1 and ATP-binding cassette G1 were identified. Comparison of liver mRNAs to LG mRNAs in BALB/c and NOD mice revealed that the differential expressions were LG-specific. Gene expression profiles were also characterized in LGs of female mice, younger mice and immune-incompetent NOD SCID mice. Investigation of the cellular distribution of Apo-E and Apo-F proteins suggested that these proteins normally coordinate to mediate lipid efflux from the acinar cells but that dysfunction of these processes due to missorting of Apo-F may contribute to CE deposition. Finally, the initiation and extent of lipid deposition were correlated with lymphocytic infiltration in the LG of male NOD mice. We propose that impaired lipid efflux contributes to lipid deposition, an event that may contribute to the development and/or progression of dacryoadenitis in the male NOD mouse.

Transduced viral IL-10 is exocytosed from lacrimal acinar secretory vesicles in a myosin-dependent manner in response to carbachol

The purpose of this study was to determine the intracellular trafficking and release pathways for the therapeutic protein, viral IL-10 (vIL-10), from transduced acinar epithelial cells from rabbit lacrimal gland. Primary cultured rabbit lacrimal gland acinar cells (LGACs) were transduced with adenovirus serotype 5 containing viral interleukin-10 (AdvIL-10). The distribution of vIL-10 was assessed by confocal fluorescence microscopy. Carbachol (CCH)-stimulated release of vIL-10 was quantified by ELISA. vIL-10 localization and exocytosis was probed in response to treatments with agents modulating actin- and myosin-based transport. vIL-10 immunoreactivity was detected in large intracellular vesicles in transduced LGAC. vIL-10 was partially co-localized with biosynthetic but not endosomal compartment markers. vIL-10 release was sensitive to CCH, and the kinetics of release showed an initial burst phase that was similar but not identical to that of the secretory protein, beta-hexosaminidase. Disassembly of actin filaments with latrunculin B significantly increased CCH-stimulated vIL-10 secretion, suggesting that vIL-10 was released from stores sequestered beneath the subapical actin barrier. That release required the activity of actin-dependent myosin motors previously implicated in secretory vesicle exocytosis was confirmed by findings that CCH-stimulated vIL-10 release was reduced by inhibition of non-muscle myosin 2 and myosin 5c function, using ML-7 and overexpression of dominant negative myosin 5c, respectively. These results suggest that the majority of vIL-10 transgene product is packaged into a subpopulation of secretory vesicles that utilize actin-dependent myosin motors for aspects of actin coat assembly, compound fusion and exocytosis at the apical plasma membrane in response to CCH stimulation.

Scleroderma: considerations for dental hygienists

Scleroderma, the general name of a group of progressive diseases affecting the connective tissues is the most deadly of the varying connective tissue disorders. Characterized by abnormal thickening of the skin, this collagen-vascular disease is associated with immune dysfunction. Hallmark signs of scleroderma include fibrosis, vascular instability and initial inflammation resulting from excessive collagen deposition. Oral facial involvement is considerable, necessitating adaptations in patient oral self-care and influencing oral hygiene. Appropriate dental hygiene management of patients with this autoimmune disorder requires an understanding of clinical characteristics, the recognition of oral facial involvement, treatment considerations and pharmacological interventions. With this information, dental hygienists will be better prepared to provide compassionate, safe and effective dental hygiene management and care to patients with scleroderma.

Sjogrens syndrome as failed local immunohomeostasis: prospects for cell-based therapy

Sjogrens syndrome has been estimated to affect between 0.2% and 2% or more of the population. It is an autoimmune disease with the hallmark histopathology of focal, periductal, and perivascular CD4(+) cell infiltration of the lacrimal and salivary glands. The immunohistopathology is typically associated with severe lacrimal and salivary dysfunctions, which contribute to debilitating ocular surface and oral symptoms. The quality of life of patients with Sjogrens syndrome often is degraded further by serious, multisystemic manifestations, and they are subject to a forty-fold increased risk of developing B cell lymphomas. In normal lacrimal glands, secretory epithelial cells, autoimmune effector lymphocytes, and regulatory lymphocytes can be seen as collaborating to maintain a local immunohomeostasis. The epithelium contributes by secreting immunomodulatory paracrine factors and also by continuously exposing autoantigens, which thereby become available for uptake by professional antigen presenting cells (APCs). Local or systemic perturbations may initiate autoimmune pathophysiology by impairing the replacement of normally-turning-over regulatory cells, by altering epithelial production of immunomodulatory paracrine factors, by inducing intact epithelial cells to begin secreting previously cryptic epitopes (epitopes that previously were not available to bind to major histocompatibility complex (MHC) molecules and so could not be recognized by T cell antigen receptors), and by inducing epithelial cells to begin expressing MHC Class II molecules and presenting formerly cryptic epitopes directly to CD4(+) cells. This process has been modeled ex vivo with mixed cell reactions comprised of isolated epithelial cells and autologous lymphocytes. This development has occurred as studies of anterior chamber-associated immune deviation (ACAID) and other immunoregulatory phenomena have elucidated the origins and functions of several different kinds of regulatory lymphocytes and shown that regulatory lymphocytes can be generated ex vivo. It now is possible to envision strategies for exploiting each possible mode of epithelial autoantigen exposure to produce therapeutic regulatory cells that might be capable of re-establishing normal immunohomeostasis. Consideration of the hypothetical therapies identifies a number of basic questions that warrant investigation.

Vaskulitische Ulcera cruris bei primärem Sjögren-Syndrom

Sjögren syndrome is a rare chronic systemic autoimmune disease characterized by progressive dryness of the mucous membranes. There are many variable clinical manifestations. A 40-year-old woman presented with painful leg ulcers refractory to various therapies. She had a history of xerostomia and xerophthalmia for several years. Based on clinical, serologic and histopathologic findings, we diagnosed leg ulcers in primary Sjögren syndrome. Combing immunosuppressive therapy with phase-adapted modern wound-therapy resulted in a complete healing of the ulcers. In the case of clinically atypical leg ulcers, Sjögren syndrome should be considered as a rare differential diagnostic possibility.

Sjögren's syndrome in dermatology

Sjogren's Syndrome (SS) is a systemic autoimmune disease characterized by dry eyes (keratoconjunctivis sicca) and dry mouth (xerostomia). To fulfill diagnostic criteria, patients must have objective signs of dryness on examination and laboratory confirmation of an autoimmune process as evidenced by a positive autoantibody to SS-A antigen or a characteristic lip biopsy. SS may exist as a primary condition or in association with other systemic autoimmune disorders (termed secondary SS) such as rheumatoid arthritis, systemic lupus erythematous (SLE), progressive systemic sclerosis (scleroderma), or dermatomyositis. Exclusions to the diagnosis include pre-existing lymphoma, hepatitis C or HIV infection. Pathogenesis involves both genetic (especially HLA-DR) and environmental factors. Both T-cells and B-cells are involved in the generation of cytokines and chemokines within the glands. The epithelial cells of the glands also play a role in pathogenesis. The dermatologic manifestations range from drynessness (sicca) and its complications to vasculitis. There is a significant overlap in the clinical manifestations, as well as treatment, of SS and SLE. However, SS patients require special attention to the complications of ocular dryness (keratocojunctivitis sicca and blepharitis) and oral dryness (rapid tooth loss and oral candidiasis) SS patients have a markedly increased risk of lymphoma and enlarged lymph nodes or persistently enlarged parotid/submandibular glands that require further evaluation.

Effect of inflammation on lacrimal gland function

The lacrimal gland is the main contributor to the aqueous layer of the tear film. It secretes proteins, electrolytes and water, which helps to nourish and protect the ocular surface. Lacrimal gland secretion is primarily under neural control, which is achieved through a neural reflex arc. Stimuli to the ocular surface activate afferent sensory nerves in the cornea and conjunctiva. This in turn activates efferent parasympathetic and sympathetic nerves in the lacrimal gland to stimulate secretion. Sex steroid hormones are also important regulators of lacrimal gland functions. A decrease or lack of lacrimal gland secretion is the leading cause of aqueous tear deficient dry eye syndrome (DES). It has been suggested that DES is an inflammatory disorder that affects the ocular surface and the lacrimal gland. In several pathological instances, the lacrimal gland can become a target of the immune system and show signs of inflammation. This can result from autoimmune diseases (Sjögren's syndrome), organ transplantation (graft versus host disease), or simply as a result of aging. The hallmarks of lacrimal gland inflammation are the presence of focal lymphocytic infiltrates and increased production of proinflammatory cytokines. The mechanisms leading to lacrimal gland dysfunction are still poorly understood. Apoptosis, production of autoantibodies, hormonal imbalance, alterations in signaling molecules, neural dysfunction, and increased levels of proinflammatory cytokines have been proposed as possible mediators of lacrimal gland insufficiency in disease states.

Sjögren's syndrome

Sjögren's syndrome is a chronic autoimmune disorder of the exocrine glands with associated lymphocytic infiltrates of the affected glands. Dryness of the mouth and eyes results from involvement of the salivary and lacrimal glands. The accessibility of these glands to biopsy enables study of the molecular biology of a tissue-specific autoimmune process. The exocrinopathy can be encountered alone (primary Sjögren's syndrome) or in the presence of another autoimmune disorder such as rheumatoid arthritis, systemic lupus erythematosus, or progressive systemic sclerosis. A new international consensus for diagnosis requires objective signs and symptoms of dryness including a characteristic appearance of a biopsy sample from a minor salivary gland or autoantibody such as anti-SS-A. Exclusions to the diagnosis include infections with HIV, human T-lymphotropic virus type I, or hepatitis C virus. Therapy includes topical agents to improve moisture and decrease inflammation. Systemic therapy includes steroidal and non-steroidal anti-inflammatory agents, disease-modifying agents, and cytotoxic agents to address the extraglandular manifestations involving skin, lung, heart, kidneys, and nervous system (peripheral and central) and haematological and lymphoproliferative disorders. The most difficult challenge in diagnosis and therapy is patients with symptoms of fibromyalgia (arthralgia, myalgia, fatigue) and oral and ocular dryness in the presence of circulating antinuclear antibodies.

Therapeutic effect of cevimeline on dry eye in patients with Sjögren's syndrome: a randomized, double-blind clinical study

PURPOSE

Sjögren's syndrome (SS) is a systemic autoimmune disease characterized by salivary and lacrimal glandular destruction leading to symptoms of dry mouth and dry eye. Dryness can also occur in the absence of glandular destruction. Patients with SS have autoantibodies that bind to muscarinic acetylcholine receptors in the exocrine glands. Recently, a muscarinic acetylcholine receptor agonist, cevimeline, has been approved for use against symptoms of dry mouth in patients with SS. In this study, the efficacy of cevimeline in improving symptoms of dry eye was examined.

DESIGN

Prospective, randomized, double-blind, multi-center clinical study.

METHODS

Sixty patients were randomly assigned to three groups-placebo; cevimeline, 20 mg three times daily; or cevimeline, 30 mg three times daily-and received treatment for 4 weeks. Patients were evaluated before treatment, at week 2, at the end of treatment, and at the end of a 2- to 4-week follow-up period.

RESULTS

Compared with the placebo, statistically significant differences were seen with cevimeline, 20 mg three times daily, in subjective symptoms, tear dynamics, condition of the corneoconjunctival epithelium, and global improvement rating. No difference was found among the three groups regarding the safe use of the drug.

CONCLUSIONS

These results indicate that cevimeline, 20 mg three times daily, is safe and effective in improving symptoms of dry eye in patients with SS. Additional studies, with larger patient populations, are needed to further assess the effectiveness of cevimeline for dry eye.

An update of the etiology and management of xerostomia

Salivary gland disease gives rise to salivary gland enlargement, pain, and prolonged xerostomia (dry mouth). Xerostomia is the most common long-standing problem for the majority of affected patients. There are many causes of dry mouth, with long-standing xerostomia being a particular problem in Sjögren's syndrome and after radiation to the head and neck region. Xerostomia is usually managed with saliva substitutes, but a large number of potential systemic therapies of long-standing xerostomia now exist. Some-particularly immunosuppressants-are of fundamental interest for the potential reduction of gland damage in Sjögren's syndrome but as yet are of limited clinical usefulness. Others, particularly pilocarpine and cevimeline, are, or have the potential to be, clinically useful in stimulating salivation by virtue of their action on cholinergic receptors.

Sjogren's syndrome: evolving therapies

Sjogren's syndrome (keratoconjunctivis sicca) is a relatively common disorder with incidence of approximately 0.5% of adult women. It has both local (ocular and oral) features as well as systemic manifestations. There has been recent FDA approval of agents to stimulate salivation (pilocarpine and cevimeline) and studies are in progress to determine their role in the treatment of dry eye. New therapies are in clinical trials for ocular manifestations with the most interest focused on topical cyclosporin A and purinogenic receptor agonists. In oral therapy, topical human interferon has reported encouraging results in short-term studies. However, the high placebo response (probably reflecting the beneficial response of mechanical stimulation of the buccal mucosa by the lozenge) and the response to much cheaper therapies (such as acid maltose lozenges) may offer safer and cheaper alternatives. For systemic disease, there is interest in tumour necrosis factor inhibitors. However, the cost-effectiveness and safety of biological agents needs longer term follow up, as they appear much less dramatic in their effect on systemic lupus erythematosus or Sjogren's syndrome than in rheumatoid arthritis.

Achieving and maintaining cognitive vitality with aging

Cognitive vitality is essential to quality of life and survival in old age. With normal aging, cognitive changes such as slowed speed of processing are common, but there is substantial interindividual variability, and cognitive decline is clearly not inevitable. In this review, we focus on recent research investigating the association of various lifestyle factors and medical comorbidities with cognitive aging. Most of these factors are potentially modifiable or manageable, and some are protective. For example, animal and human studies suggest that lifelong learning, mental and physical exercise, continuing social engagement, stress reduction, and proper nutrition may be important factors in promoting cognitive vitality in aging. Manageable medical comorbidities, such as diabetes, hypertension, and hyperlipidemia, also contribute to cognitive decline in older persons. Other comorbidities such as smoking and excess alcohol intake may contribute to cognitive decline, and avoiding these activities may promote cognitive vitality in aging. Various therapeutics, including cognitive enhancers and protective agents such as antioxidants and anti-inflammatories, may eventually prove useful as adjuncts for the prevention and treatment of cognitive decline with aging. The data presented in this review should interest physicians who provide preventive care management to middle-aged and older individuals who seek to maintain cognitive vitality with aging.

Xerostomia and the geriatric patient

Saliva is essential for the preservation of oral-pharyngeal health, and disorders of salivary physiology are associated with numerous oral and pharyngeal problems, particularly in older people. Although salivary function is remarkably intact in healthy aging, medical problems, medications, and head and neck radiotherapy can cause salivary dysfunction and complaints of xerostomia among older people. Sjögren's syndrome, an autoimmune exocrinopathy, is the most common medical disease associated with salivary dysfunction. Medications with anticholinergic side effects will impair salivary output, and head and neck radiotherapy for cancer will cause permanent destruction of salivary glands. Treatments for salivary problems are based upon establishing a diagnosis, protecting oral and pharyngeal health, stimulating remaining glands, and replacing lost salivary fluids.

Use of muscarinic agonists in the treatment of Sjögren's syndrome

Two muscarinic agonists (pilocarpine and cevimeline) have recently been approved for the treatment of symptoms of xerostomia in Sjögren's syndrome (SS). These agents stimulate the M1 and M3 receptors present on salivary glands, leading to increased secretory function. The use of these agents emphasizes the importance of neuroendocrine mechanisms in SS, which is considered an autoimmune disorder. We review recent studies on the release of cytokines and metalloproteinases in SS-affected glands and their influence on the release of and response to neurotransmitters. Also, we review the structure and function of muscarinic receptors as they may relate to SS and the potential use of novel muscarinic agonists in SS.