British Society for Rheumatology guideline on management of adult and juvenile onset Sjögren disease

Can we cure Sjogren's disease? Unmet needs and raising questions in the era of Precision medicine

The wide spectrum of Sjögren's disease (SjD) clinical manifestations coupled with its multifaceted pathogenesis has complicated drug target development, optimal clinical trial design, identification of suitable SjD subgroups, selection of appropriate outcome measures, and interpretation of treatment efficacy. Despite recent advancements in biologic treatments for autoimmune diseases, the targeted therapy(ies) for SjD remain an unmet need, with no regulatory approvals, so far. Recent large, randomized studies have suggested some patient benefits; however, reproducibility is needed, and assessment of treatment efficacy requires refinement. In this review, we explore the potential for curing SjD taking into consideration the main pathogenetic mechanisms, clinical phenotypes, and underlying endotypes. We provide an overview of current recommendations and targeted treatments, identify potential reasons for treatment failures, and propose strategies (in and out of the box) for future directions. By addressing these areas, we offer a comprehensive perspective that may inform future research and therapeutic strategies for SjD.

The necessity for prompt identification of Sjögren syndrome in instances of unexplained heart failure: A case report

RATIONALE

Sjögren's syndrome (SS) is a highly phenotypically diverse autoimmune disorder. It has been reported that 30% to 40% of patients with SS experience systemic complications, including peripheral neuropathies, interstitial lung disease, interstitial nephritis, and lymphoma. To date, SS presenting with heart failure (HF) as the primary manifestation remains exceedingly rare.

PATIENT CONCERNS

We report presents a 70-year-old female patient, devoid of any cardiovascular risk factors, who experienced recurrent episodes of HF.

DIAGNOSES

During the course of treatment, SS was suspected based on her medical history. This suspicion was subsequently confirmed through elevated serum autoimmune antibody levels and a labial gland biopsy.

INTERVENTIONS

The implementation of standard HF management in conjunction with an immunosuppressive regimen.

OUTCOMES

At the one-year follow-up, the patient had not been readmitted for HF.

LESSONS

This case underscores the critical importance of early identification of HF attributable to SS and highlights the efficacy of combining immunosuppressive therapy with conventional HF treatment as the optimal approach for managing such cases.

Emerging Trends and Management for Sjögren Syndrome-Related Dry Eye Corneal Alterations

Background: Sjögren’s syndrome (SS) is a systemic autoimmune condition marked by significant dry eye disease (DED), leading to considerable corneal changes. These modifications, encompassing punctate epithelial erosions, chronic epithelial abnormalities, and corneal ulcers, significantly impact eyesight and quality of life. Progress in comprehending the corneal pathophysiology associated with SS has prompted innovative diagnostic and treatment approaches. Aim: This narrative review aims to examine developing trends in the pathogenesis, diagnostic methods, and treatment strategies for Sjögren’s syndrome-associated corneal changes. Methods: The study was based on a narrative review of the current literature available on PubMed and Cochrane from Jan 2000 to December 2024. Results: Corneal changes associated with Sjögren’s syndrome result from a multifactorial interaction of ocular surface inflammation, tear film instability, and epithelium degradation. Recent research underscores the significance of immune-mediated pathways, such as T-cell-induced inflammation and cytokine dysregulation, as crucial factors in corneal disease. Innovations in diagnostic instruments, including in vivo confocal microscopy and tear proteomics, provide earlier and more accurate identification of subclinical alterations in the corneal epithelium and stroma. Therapeutic developments concentrate on meeting the specific requirements of SS-related DED. Biological treatments, especially tailored inhibitors of interleukin-6 and tumor necrosis factor-alpha, show potential in mitigating inflammation and facilitating epithelial repair. Moreover, regenerative approaches, such as autologous serum tears and mesenchymal stem cell therapies, provide innovative methods to repair ocular surface integrity. Advanced drug delivery technologies, including nanoparticle-loaded eye drops, enhance bioavailability and therapeutic efficacy. Conclusion: Recent developments in comprehending SS-related corneal changes have transformed the management approach to precision medicine. The combination of improved diagnostics and innovative therapy approaches offers potential for reducing disease progression, maintaining corneal health, and enhancing patient outcomes. Subsequent investigations ought to concentrate on enhancing these tactics and examining their long-term safety and effectiveness. Clinicians and researchers must adopt these developments to successfully tackle the difficulties of SS-related corneal illness, providing hope for improved care and higher quality of life for those affected.

Effects of exercise in primary Sjögren's syndrome: a systematic review and meta-analysis of randomized clinical trials

PURPOSE

To systematically review the effects of exercise interventions on pain, fatigue, quality of life, disease activity, aerobic capacity, and dryness in primary Sjögren's syndrome (pSS), and to determine the most effective type of exercise.

MATERIALS AND METHODS

A literature search was conducted using Web of Science, PubMed/MEDLINE, ProQuest, SCOPUS, Cochrane Library, and PEDro databases. Randomized clinical trials (RCTs) examining the effects of exercise interventions in patients with pSS were included. Methodological quality was assessed using the Risk of Bias version-2 tool and PEDro scale.

RESULTS

Five RCTs, including 269 female patients with pSS were analyzed. High-quality studies indicated that exercise interventions significantly improved pain (p = 0.008), fatigue (p < 0.00001), quality of life (p = 0.0003), and aerobic capacity (p = 0.009) compared to controls. Sensitivity analysis indicated that resistance exercise was particularly effective, significantly improving pain (p < 0.00001), fatigue (p < 0.00001), quality of life (p < 0.00001), and disease activity (p = 0.02).

CONCLUSION

Exercise interventions may offer significant benefits in reducing pain and fatigue, as well as improving quality of life and aerobic capacity, in patients with pSS compared to no-treatment. Resistance exercise appears to be more effective than other exercise models.

A comparative analysis of large language models on clinical questions for autoimmune diseases

Background

Artificial intelligence (AI) has made great strides. To explore the potential of Large Language Models (LLMs) in providing medical services to patients and assisting physicians in clinical practice, our study evaluated the performance in delivering clinical questions related to autoimmune diseases.

Methods

46 questions related to autoimmune diseases were input into ChatGPT 3.5, ChatGPT 4.0, and Gemini. The responses were then evaluated by rheumatologists based on five quality dimensions: relevance, correctness, completeness, helpfulness, and safety. Simultaneously, the responses were assessed by laboratory specialists across six medical fields: concept, clinical features, report interpretation, diagnosis, prevention and treatment, and prognosis. Finally, statistical analysis and comparisons were performed on the performance of the three chatbots in the five quality dimensions and six medical fields.

Results

ChatGPT 4.0 outperformed both ChatGPT 3.5 and Gemini across all five quality dimensions, with an average score of 199.8 ± 10.4, significantly higher than ChatGPT 3.5 (175.7 ± 16.6) and Gemini (179.1 ± 11.8) (p = 0.009 and p = 0.001, respectively). The average performance differences between ChatGPT 3.5 and Gemini across these five dimensions were not statistically significant. Specifically, ChatGPT 4.0 demonstrated superior performance in relevance (p < 0.0001, p < 0.0001), completeness (p < 0.0001, p = 0.0006), correctness (p = 0.0001, p = 0.0002), helpfulness (p < 0.0001, p < 0.0001), and safety (p < 0.0001, p = 0.0025) compared to both ChatGPT 3.5 and Gemini. Furthermore, ChatGPT 4.0 scored significantly higher than both ChatGPT 3.5 and Gemini in medical fields such as report interpretation (p < 0.0001, p = 0.0025), prevention and treatment (p < 0.0001, p = 0.0103), prognosis (p = 0.0458, p = 0.0458).

Conclusions

This study demonstrates that ChatGPT 4.0 significantly outperforms ChatGPT 3.5 and Gemini in addressing clinical questions related to autoimmune diseases, showing notable advantages across all five quality dimensions and six clinical domains. These findings further highlight the potential of large language models in enhancing healthcare services.

Use of complementary and alternative medicine (CAM) among people living with Sjögren's: a cross-sectional survey using a modified international CAM questionnaire (I-CAM-Q)

Sjögren's is a chronic autoimmune disease with diverse symptomatology, and varying patient satisfaction with management. Patients with chronic conditions are known to be higher users of complementary and alternative (CAM) practices, yet little information regarding extent of such use exists. This paper describes usage of CAM practices among people living with Sjögren's, encompassing visits to healthcare providers, CAM practitioners, self-administered CAM and self-help practices. We explored both purposes and perceived helpfulness of the various modalities utilised. 296 respondents completed an online survey administered through Sjögren's Research Ireland in 2023. An adapted form of the International Complementary and Alternative Medicine Questionnaire (I-CAM-Q) was utilised as the survey instrument. 88.5% of respondents had a formal diagnosis of Sjögren's. The majority (93.6%) were female, across all age groups. Over half (52%) of non-retired respondents were at least partially unable to work due to their diagnosis. Over half of all respondents (58.8%) listed at least one concomitant health problem. Most respondents (248, 83.8%) had used some form of CAM within the preceding 12 months. One-in-four had attended a CAM practitioner, most commonly chiropractors (8.4%) or acupuncturists (7.8%). Conventional healthcare and CAM providers were both consulted more commonly for management of chronic conditions or for well-being than for acute symptom management, although this was particularly stark for CAM consultations. 196 respondents (66.2%) reported use of self-administered CAM, predominantly vitamins/minerals or dietary supplements. 69.9% used various self-care practices, with the most reported being meditation, relaxation techniques and prayer. People living with Sjögren's attend both conventional healthcare providers and CAM practitioners to a high degree and use a diverse range of complementary therapies and practices. Health care professionals need to consider and discuss potential CAM use by this patient cohort and offer evidence-based patient education about therapies and practices encountered.

Autoimmune Thyroid Disease and Sjögren Disease: Organ-Specific Disease Triggered by Systemic Autoimmunity?

Background and Objectives: Autoimmune thyroid diseases are more prevalent in patients diagnosed with Sjögren disease (SD) than in the general population. SD and autoimmune thyroid diseases are two distinct yet interrelated autoimmune disorders. The objective of this study was to determine the frequency of autoimmune thyroiditis (AT), autoantibody relationships, and clinical features in patients with SD. Materials and Methods: The study included 525 patients. A retrospective evaluation was conducted on the demographic data, biochemical and serological tests, and pathological data of the patients. An anti-nuclear antibody (ANA) test was performed using the indirect immunofluorescence (IIF) method using HEp-2 (HEp-2000) cells as substrate. The Schirmer test and minor salivary gland biopsy were conducted on all patients. Results: AT was detected in 167 (31.8%) of 525 patients who participated in the study. The anti-nuclear antibody (ANA) test and anti-SS-A positivity rate were higher in the AT group (p value < 0.001 and 0.002 respectively). We found that the likelihood of developing AT increased as ANA titres increased. ANA positivity titres were found to be significant at 2+, 3+, and 4+ values (odd ratios 2.41, 3.40, and 4.21, respectively). Additionally, histological examination of salivary gland biopsies revealed a significantly higher prevalence of diffuse lymphocytic infiltration in the AT group. Conclusions: AT was present in 31% of patients with SD. The presence of ANA positivity, anti-SS-A positivity, and diffuse lymphocytic infiltration appears to exert an influence on the association between these two diseases.

A Review of the Impact of Sjögren's Syndrome and/or the Presence of Anti-Ro/SS-A Antibodies on Therapeutic Strategies for Rheumatoid Arthritis

Rheumatoid arthritis (RA) is an immune-mediated disease characterized by polyarthritis that affects the small joints of the bilateral upper and lower extremities. RA shares several common clinical symptoms with Sjögren's syndrome (SS), another rheumatic disease caused by the lymphocytic infiltration of exocrine glands, with dry eye and dry mouth being the two most common symptoms. Anti-Ro/SS-A antibodies, a diagnostic biomarker of SS, are positive in patients with RA at a certain rate. The coexistence of SS and/or positivity for anti-Ro/SS-A antibodies in patients with RA influences disease activity and the effectiveness of several classes of disease-modifying antirheumatic drugs (DMARDs). Furthermore, RA, SS, and certain DMARDs, including methotrexate, are associated with the onset of lymphoproliferative disorders (LPD). In contrast, several biological DMARDs, such as tocilizumab and rituximab, are plausible options without the risk of LPD relapse. Considering the results of the studies introduced in this article, RA with SS and/or positivity for anti-Ro/SS-A antibodies could be considered a phenotype different from isolated RA from the perspective of refractoriness to DMARD therapy and LPD risk. Hence, rheumatologists should observe caution when choosing DMARDs. Further studies are needed to establish the appropriate treatment for patients with RA, SS, and/or the presence of anti-Ro/SS-A antibodies.

Outcome Measures for Sjögren Disease-Novel Developments and Further Needs

Sjögren disease (SjD) is a systemic autoimmune disorder affecting both children and adults, with a wide range of clinical phenotypes. It remains a challenging condition to recognise and diagnose early and manage effectively. The heterogeneous nature of the presentation, variable disease course and overlapping symptoms with other autoimmune conditions often result in delayed diagnosis. This, coupled with the lack of licensed effective therapies frequently leads to suboptimal patient outcomes. Improved outcome measures are crucial for advancing our understanding of SjD pathogenesis and developing effective treatments. They can help ensure that clinical trials are accurately capturing the impact of potential therapies on the disease and the quality of life of people with SjD. Further developments are needed in the areas of age and developmentally appropriate disease and patient-reported outcome measures, with adequate sensitivity to evaluate treatment efficacy, as well as predictor biomarkers for both treatment response and poor prognostic outcomes associated with SjD. Advancing these areas will help ensure that clinical trials adequately select the most suitable SjD cohorts to treat with a certain therapy, as well as accurately reflect the impact of a certain intervention on disease activity, progression, and quality of life, ultimately leading to better care for people with SjD.

Novel electroretinography devices to detect hydroxychloroquine retinopathy: study protocol for a diagnostic accuracy and feasibility study

INTRODUCTION

Annual screening for hydroxychloroquine (HCQ) retinopathy is recommended, and electroretinography (ERG) is considered a gold-standard test, but there are screening shortfalls and standard ERG is burdensome and has limited availability. Newer, portable ERG devices using skin-based electrodes may increase screening capacity but need validation. This study aims to determine initial device accuracies and feasibility of further research.

METHODS AND ANALYSIS

Prospective diagnostic device accuracy and feasibility study comparing novel ERG devices to standard screening tests. Three groups of 35 participants on HCQ, categorised by HCQ retinopathy (definite, possible and no retinopathy), and 35 healthy control participants, recruited by consecutive sampling, will have full field and multifocal ERG index tests, delivered using skin-contact electrodes by two devices-RETEval full-field and UTAS multifocal ERG, both manufactured by LKC Technologies (Gaithersburg, Maryland, USA), compared with spectral-domain optical coherence tomography and autofluorescence reference tests graded by two masked, independent retinal specialists. Eligible HCQ participants will either have diagnosed HCQ retinopathy or be eligible for screening per UK guidelines. Healthy control participants will have no prior HCQ exposure and be of similar age and sex to HCQ participants. Primary outcome is device-specific sensitivity and specificity. Secondary outcomes include the effect of dilation on device outputs, analysis of discriminatory waveforms, device acceptability and recruitment rate. Safety outcomes include adverse and serious adverse events and device events.

ETHICS AND DISSEMINATION

Cambridge East ethics committee gave a favourable opinion (24/EE/0011, 23/02/2024). Results will be published in a peer-reviewed ophthalmology journal.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT06035887.

Antimalarial Drugs at the Intersection of SARS-CoV-2 and Rheumatic Diseases: What Are the Potential Opportunities?

Background and Objectives: The coronavirus disease of 2019 (COVID-19) pandemic has posed a serious threat to humanity and is considered a global health emergency. Antimalarial drugs (ADs) have been used in the treatment of immuno-inflammatory arthritis (IIA) and coronavirus infection (COVID-19). The aim of this review is to analyze the current knowledge about the immunomodulatory and antiviral mechanisms of action, characteristics of use, and side effects of antimalarial drugs. Material and Methods: A literature search was carried out using PubMed, MEDLINE, SCOPUS, and Google Scholar databases. The inclusion criteria were the results of randomized and cohort studies, meta-analyses, systematic reviews, and original full-text manuscripts in the English language containing statistically confirmed conclusions. The exclusion criteria were summary reports, newspaper articles, and personal messages. Qualitative methods were used for theoretical knowledge on antimalarial drug usage in AIRDs and SARS-CoV-2 such as a summarization of the literature and a comparison of the treatment methods. Results: The ADs were considered a "candidate" for the therapy of a new coronavirus infection due to mechanisms of antiviral activity, such as interactions with endocytic pathways, the prevention of glycosylation of the ACE2 receptors, blocking sialic acid receptors, and reducing the manifestations of cytokine storms. The majority of clinical trials suggest no role of antimalarial drugs in COVID-19 treatment or prevention. These circumstances do not allow for their use in the treatment and prevention of COVID-19. Conclusions: The mechanisms of hydroxychloroquine are related to potential cardiotoxic manifestations and demonstrate potential adverse effects when used for COVID-19. Furthermore, the need for high doses in the treatment of viral infections increases the likelihood of gastrointestinal side effects, the prolongation of QT, and retinopathy. Large randomized clinical trials (RCTs) have refuted the fact that there is a positive effect on the course and results of COVID-19.