EULAR recommendations for the management of Sjögren's syndrome with topical and systemic therapies

Correlation among ocular surface changes and systemic hematologic indexes and disease activity in primary Sjögren's syndrome: a cross-sectional study

BACKGROUND

To explore the relationship among ocular surface changes, systemic hematologic indexes, and disease activity in primary Sjögren's syndrome patients.

METHODS

Thirty-three primary Sjögren's syndrome patients and 36 healthy controls were recruited in this cross-sectional study. All participants underwent complete ocular surface testing, including dry eye symptoms and signs, tear multi-cytokine analysis, and conjunctival impression cytology (CIC). Multiple systemic hematologic indexes and disease activity were also evaluated, including autoantibodies, immune cells, the EULAR Sjögren's Syndrome Patient Reported Index (ESSPRI), and the EULAR Sjögren's Syndrome Disease Activity Index (ESSDAI).

RESULTS

Primary Sjögren's syndrome patients exhibited significant dry eye, severe conjunctivochalasis, decreased goblet cell density, and severe squamous epithelial on the ocular surface. Interferon-inducible T cell alpha chemoattractant (I-TAC), granulocyte-macrophage colony-stimulating factor (GM-CSF), interleukin (IL)-1β, IL-5, IL-8, IL-10, IL-13, IL-21, C-C motif chemokine ligand (CCL)4, interferon-gamma (IFN-γ), CCL20, and tumor necrosis factor-gamma (TNF-α) in the tear fluid of pSS patients changed significantly. Correlation analysis showed that anti-SSA was relevant to ocular surface disease index (OSDI) score, tear break-up time (TBUT), and meibomian gland secretion (MGS). CD8+ T cell percentages were relevant to TBUT and corneal fluorescein staining score (CFS). IL-8, IL-13, CCL4, and TNF-α were correlated with RF-IgA. IL-1β, CCL4, and TNF-α were correlated with CD8+ T cell counts. IL-5 and CCL20 were correlated with the ratio of helper T cells and suppressor T cells. Tear I-TAC, IL-8, CCL20, and TNF-α were significantly correlated with the ESSDAI of different domains.

CONCLUSIONS

Our results revealed that the ocular surface changes in pSS patients were significantly correlated with systemic hematologic indexes and disease activity.

Autologous corneal patch for simultaneous bilateral perforation in Sjögren's syndrome. A case report

PurposeTo present a case of simultaneous bilateral corneal perforation in a patient affected by Sjögren syndrome (SjS) successfully managed with corneal transplantation on the left eye and placing an autologous corneal patch on the right eye.ObservationsA 71-year-old woman with SjS presented at our attention complaining of pain, redness, and blurred vision in both eyes persisting for 4 days. Clinical and instrumental investigations led to the diagnosis of bilateral corneal perforation in the context of Sjögren syndrome. Therapeutic contact lenses were initially placed, followed by surgical intervention using an autologous corneal patch for the right eye and a corneal transplant for the left eye. Postoperative recovery was successful, with stable corneal condition and normal intraocular pressure observed at 3 and 6-months follow-ups.Conclusions and importanceThis case underscores the complexity of managing SjS-related ocular complications and propose the use of autologous corneal patches to minimize immune rejection risks in cases where corneal transplantation cannot be performed.

Diagnosing a child presenting with symptoms suggesting Sjögren's disease: a tool for clinical practice

OBJECTIVE

Childhood SjD (cSjD) is a rare disease. There are no widely accepted diagnostic or classification criteria for cSjD. To fill this gap, members from the CARRA Sjögren Disease Workgroup and the International Childhood Sjögren Disease Workgroup created a clinical diagnostic algorithm. This study evaluated the accuracy of this algorithm using an international cohort of participants with clinician-diagnosed cSjD.

METHODS

First, experts developed a cSjD diagnostic algorithm through a series of virtual workgroup meetings. Using the adult classification criteria as a framework, experts modified the algorithm through opinion and literature review. The group discussed and finalized each algorithm step by achieving majority rule. Then, R statistical software was used to evaluate each participant's disease status in the diagnostic algorithm via an international cohort of 300 cSjD cases.

RESULTS

The diagnostic algorithm has three distinct clinical pathways representing the key clinical presentation in cSjD: parotitis, extraglandular manifestations, and sicca symptoms. The algorithm showed an overall sensitivity of 75% in the population that had enough data to complete at least one pathway of the algorithm (n = 100 filtered out of 300). The parotitis (70%) and sicca pathways (82%) had the highest sensitivity, and the extraglandular pathway (52%) had the lowest.

CONCLUSION

As cSjD lacks a diagnostic strategy, this algorithm provides a clinical tool for evaluating children with cSjD-like symptoms. It performed well in an international cohort of cSjD, supporting the integration of this algorithm into clinical practice; however, its utility may be limited by low utilization of diagnostic testing in this population.

Rheumatologic Issues in Women and Rehabilitation

This article discusses rheumatologic conditions in women including rheumatoid arthritis, lupus, Sjogren's syndrome, inflammatory myopathies, systemic sclerosis, and polymyalgia rheumatica. These conditions, often affecting muscles, joints, and other organ systems, require early diagnosis and multidisciplinary management. Treatment includes medications, braces, therapy services, education, and lifestyle modifications including energy conservation techniques. These conditions can also impact pregnancy and require close monitoring and careful disease control. It also highlights the benefits of pulmonary rehabilitation that can be helpful for patients with chronic respiratory disease secondary to their rheumatologic conditions.

Clinical targeted treatment in Sjogren's disease: A systematic literature review for an evidence-based medicine approach

Sjögren's disease is a systemic autoimmune disease that primarily affects the exocrine glands, causing the main symptoms of xerostomia and xerophthalmia. In about half of the patients, it also causes systemic symptoms, which can potentially involve any organ or system. To date, the management of these patients is particularly complex due to the lack of recognized and approved therapies for the disease, except for medications used as symptomatic treatment for dryness. Due to the limited evidence available, therapeutic decisions in daily practice are frequently based on a combination of expert opinions and personal experience, which can vary significantly between clinicians. On these bases, we performed as systematic literature review critically analyzing the results of the previous trials, unpacking the single domains of ESSDAI, to evaluate if there are treatments significantly effective in some manifestations of the disease.

A first-in-human, prospective pilot trial of umbilical cord-derived mesenchymal stem cell eye drops therapy for patients with refractory non-Sjögren's and Sjögren's syndrome dry eye disease

BACKGROUND

Patients with refractory dry eye disease (DED) often face the threat of diminished visual quality and have limited responses to existing treatments. Ocular injection of Mesenchymal stem cells (MSCs) has recently emerged as a promising new therapeutic strategy for DED. Topical eye drops are the clinical favorable choice for drug administration in DED. To date, the clinical use of MSC eye drops has not been reported in settings. This clinical trial represents a groundbreaking exploration into the preliminary therapeutic potential and safety of umbilical cord MSC eye drops for patients with refractory DED, including both non-Sjögren's dry eye (NSDE) and Sjögren's syndrome dry eye (SSDE). The study also aimed to investigate the possible underlying mechanisms.

METHODS

In this open-label, prospective, single-arm, self-controlled trial, 11 NSDE and 5 SSDE patients received twice-daily MSC eye drops for two weeks, subsequent follow-up visits were scheduled at 4 weeks and 12 months after treatment. The primary efficacy was evaluated using the ocular surface disease index (OSDI) score, tear meniscus height (TMH), non-invasive break-up time (NIBUT), Schirmer I test (SIT), and corneal fluorescein staining (CFS) score. Secondary assessments focused on the evaluation of lipid layer, meibomian gland function, and bulbar conjunctival redness. Safety was monitored by recording adverse events (AEs) throughout the study. Changes in tear levels of interleukin-6 (IL-6), IL-17A, Mucin 5AC (MUC5AC), C-C chemokine ligand 20 (CCL20) and IL-23, along with proteomic alterations, were compared between baseline and T-week2.

RESULTS

Significant clinical improvements were observed in most symptoms and signs following MSC eye drops treatment in both NSDE and SSDE patients, particularly in tear production as measured by SIT and TMH, and the alleviation of meibomian gland blockage. The therapeutic effect on OSDI, NIBUT, and the lipid layer was more pronounced in NSDE patients compared to SSDE. No serious AEs were reported during the treatment and follow-up period. Post-treatment reductions in tear levels of IL-6 and IL-17A, along with an increase in MUC5AC, further confirmed the efficacy. Tear proteomic analysis indicated that the efficacy of MSC eye drops is associated with the inhibition of inflammation caused by T helper 17 (Th17) cells in both NSDE and SSDE groups.

CONCLUSIONS

In this prospective exploratory clinical study, we have demonstrated that MSC eye drops might offer clinical efficacy and manageable safety in treating refractory DED for the first time, potentially bringing a new perspective on the treatment of such patients. Our research represents a preliminary exploratory endeavor, paving the way for future large-scale randomized positive-controlled trials.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05784519. Registered 28 February 2023, https://clinicaltrials.gov/study/NCT05784519 .

Unlocking the Power of the Mediterranean Diet: Two in One-Dual Benefits for Rheumatic and Thyroid Autoimmune Diseases

In recent years, autoimmune diseases are becoming more and more prevalent worldwide, with this rapid rise being influenced by environmental factors linked to lifestyle changes in modern societies. In this context, the role of diet has been the topic of extensive research as evidence has mounted that particular dietary patterns may contribute to or modulate autoimmunity. The present review specifically focuses on the Mediterranean diet (MD) as a whole dietary pattern, and on its peculiar components, such as n-3 polyunsaturated fatty acids (PUFAs), polyphenols and fiber. We explored their potential benefits in a spectrum of both systemic and organ-specific autoimmune disorders, including rheumatic diseases (like rheumatic arthritis and systemic lupus erythematosus), and thyroid diseases (like Hashimoto's thyroiditis), since they often occur in the same individuals. Here, we offer a comprehensive review about the influence of dietary factors on these autoimmune diseases and potential translation into therapeutic interventions, as an adjuvant therapeutic approach to improve autoimmunity-related outcomes.

Hydroxychloroquine dose-dependently reduces the risk of incident diabetes in primary Sjögren syndrome patients on glucocorticoids: a nationwide population-based cohort study

BACKGROUND

Hydroxychloroquine (HCQ) is commonly used to treat Sjögren syndrome (SS). Glucocorticoids, which are commonly applied for managing primary SS (pSS), can disrupt glucose metabolism and increase diabetes mellitus (DM) risk. HCQ reduces DM risk in systemic lupus erythematosus and rheumatoid arthritis.

OBJECTIVE

This study aimed to investigate the relationship between HCQ and glucocorticoids in the incidence of new-onset diabetes in pSS.

METHODS

This nationwide population-based cohort study identified patients diagnosed with pSS from the Taiwan's National Health Insurance Research Database from 2006 to 2015. Multivariate and stratified analyses, Kaplan-Meier method, and Cox proportional hazard regression were used to evaluate DM risk associated with the use of HCQ and glucocorticoid, both individually and in combination.

RESULTS

Among pSS patients (4,874 HCQ users and 2,437 HCQ nonusers), 497 patients developed DM over an average follow-up of 4.89 years. Multivariate analysis revealed significantly lower adjusted hazard ratios (aHRs) for DM in HCQ users in the 151-350 cumulative defined daily dose (cDDD) and ≥ 351 cDDD subgroups (0.600, 95% CI: 0.454-0.794 and 0.326, 95% CI: 0.246-0.433, respectively) compared with HCQ nonusers. High-dose glucocorticoids (≥ 151 cDDD) were linked to increased DM risk (aHR: 1.833, 95% CI: 1.410-2.383). However, high-dose HCQ (> 350 cDDD) mitigated this risk, even the risk caused by the use of high-dose glucocorticoids (≥ 151 cDDD) (aHR: 0.632, 95% CI: 0.421-0.948, P < 0.01).

CONCLUSIONS

Our study demonstrated that HCQ exposure significantly reduces the risk of developing diabetes in patients with pSS. While higher doses of glucocorticoids are associated with an increased diabetes risk, concurrent HCQ use mitigates this risk in a dose-dependent manner.

Plasma extracellular vesicles promote follicular T helper cell expansion in primary Sjögren's syndrome

Primary Sjögren's syndrome (pSS) is a prevalent autoimmune disease characterized by exocrine gland dysfunction, with hallmarks of B cell and T cell overactivation, whose underlying mechanism remains largely unknown. Herein, we show that pSS plasma contained more extracellular vesicles (EVs) than HC plasma, which promoted CD4+ T cell activation, Th1, and follicular T helper cell (Tfh) differentiation, aggravating pSS immunopathology. Notably, pSS plasma EVs were enriched with miR-501-3p, mediating CD4+ T cell activation and Tfh cell differentiation. Furthermore, miR-501-3p downregulated special AT-rich sequence-binding protein-1 (SATB1) to promote Tfh differentiation. These findings suggested pSS plasma EVs as an important contributor to pSS pathogenesis, which was of potential clinical interest in managing pSS.

Association between interleukin-12 p40 subunit and risk of primary Sjögren's disease: a Mendelian randomization study

OBJECTIVES

IL-12 signalling was proposed in the immunopathogenesis of primary Sjögren's disease. The efficacy of therapies targeting this pathway is currently unclear. Herein, we investigated the associations between circulating proteins involved in the IL-12 and IL-23 signalling pathways on primary Sjögren's disease using Mendelian randomization.

METHODS

We selected single nucleotide polymorphisms from protein quantitative trait loci of IL12A, IL12B, IL12Rβ1, IL12Rβ2 and IL23R to examine the association between alterations in their levels and risk of primary Sjögren's disease. Genetic association data for proteins were taken from studies ranging from 3301 to 54 306 in sample size, and from 3232 cases of primary Sjögren's disease and 17 481 controls. The Wald ratio or inverse variance weighted methods estimated causal effects. We applied colocalization and pleiotropy-robust methods as sensitivity analyses for confounding.

RESULTS

There was a negative association between genetically predicted IL-12p40 (encoded by IL12B) and primary Sjögren's disease. In the two independent exposure datasets odds ratio (OR), 0.79 (95% CI 0.68-0.93; P-value = 0.004) and OR 0.86 (95% CI 0.78-0.95; P-value = 0.003) per S.D. decrease in genetically predicted IL-12p40. Neither IL-12Rβ2 nor IL-23R met the threshold P-value after Mendelian randomization analyses (P-value < 0.01) for colocalization assessment. No variants for the IL12A gene met prerequisite thresholds for weak instrument bias.

CONCLUSION

This study provides genetic evidence that IL-12p40 has a causal role in primary Sjögren's disease pathogenesis. Our data suggest that decreasing levels of IL-12p40 may be deleterious. We would not suggest selecting this drug target as a therapeutic option.

Hydroxychloroquine: A double‑edged sword (Review)

Hydroxychloroquine (HCQ) is an antimalarial drug that has historically been used to treat and prevent malaria. However, its mechanism of action has not yet been fully elucidated. HCQ affects various cellular and molecular pathways through different mechanisms. HCQ has also been shown to be a disease‑improving agent for the treatment of rheumatic diseases, including systemic lupus erythematosus, antiphospholipid syndrome, rheumatoid arthritis and primary Sjögren's syndrome. Although generally considered safe, adverse reactions have been reported with the use of HCQ and clinicians should carefully monitor patients with rheumatism when prescribing these drugs. The purpose of the present review is to strengthen the clinical use of HCQ for autoimmune diseases while highlighting the adverse effects that may occur during treatment.

Patients with AMA/anti-sp100/anti-gp210 Positivity and Cholestasis Can Manifest Conditions Beyond Primary Biliary Cholangitis

Background and Aims

The diagnostic value of primary biliary cholangitis (PBC)-specific antibodies in patients with elevated alkaline phosphatase (ALP) and gamma-glutamyl transferase (GGT) levels, and other identifiable causes, was unclear. Our study aimed to determine whether etiological treatments in PBC-specific antibody-positive patients could improve liver biochemical tests, thereby distinguishing them from individuals with PBC.

Methods

We enrolled patients who were positive for PBC-specific antibodies and elevated ALP and/or GGT levels but with other identifiable etiologies. Changes in liver biochemistry following non-ursodeoxycholic acid etiological treatments were monitored.

Results

A total of 155 patients with positive PBC-specific antibodies and elevated ALP and/or GGT levels due to non-PBC diseases were enrolled. Among them, 100 patients were diagnosed with non-PBC liver diseases, mainly metabolic-associated fatty liver disease, drug-induced liver injury, and autoimmune hepatitis. Additionally, 55 patients had non-liver diseases, predominantly connective tissue diseases. The median follow-up duration was 15.9 (4.7-25.6) months. Among 141 patients who completed follow-up after receiving etiological treatments, 85.1% (120/141) showed improvement in ALP and/or GGT levels, with 51.8% (73/141) achieving normalization of both ALP and GGT. However, 68 patients continued to exhibit elevated ALP and/or GGT, with 55 patients displaying isolated GGT elevation and 11 patients showing liver histological changes not consistent with PBC.

Conclusions

PBC-specific antibodies, along with elevated ALP and GGT levels, may occur in various non-PBC diseases. Etiological treatments may improve or even resolve cholestatic biochemistry. For these patients, initiating etiological treatment rather than immediately starting ursodeoxycholic acid therapy would be justified.

miRNA let-7f-5p-encapsulated labial gland MSC-derived EVs ameliorate experimental Sjögren's syndrome by suppressing Th17 cells via targeting RORC/IL-17A signaling axis

Sjögren's syndrome (SS) is an autoimmune disease primarily affecting salivary glands, with xerostomia as a distinct clinical manifestation. This disease also poses a significantly increased risk of lymphoma, severely impacting patients' quality of life. The imbalance between Th17 and Treg cells plays a critical role in SS progression, driving severe immune dysregulation, chronic inflammation, and escalating tissue dysfunction. However, current clinical treatments for SS still remain limited, and it continues to be recognized as a refractory disease. Therefore, the development of novel and effective therapeutic strategies is a pressing demand in clinical research. In recent years, extracellular vesicle (EV) therapy has emerged as a promising approach for autoimmune disease treatment, showing encouraging outcomes in modulating immune balance and alleviating symptoms. EVs carry diverse cargo, among which microRNAs (miRNAs) are highly abundant and play critical roles. These small RNAs are essential for EV-mediated functions, particularly in regulating gene expression and modulating the immune microenvironment. Our research team first isolated labial gland mesenchymal stem cells (LGMSCs) and their derived EVs (LGMSC-EVs), which offer potential therapeutic advantages in SS due to their salivary gland origin. Then we screened and identified the highly enriched miRNA let-7f-5p as a key regulator through miRNA profiling analysis. To achieve better therapeutic outcomes, we transfected exogenous miRNA let-7f-5p into LGMSC-EVs to upregulate its expression, thereby constructing let-7f-5p-encapsulated LGMSC-EVs. These modified EVs were subsequently tested in an experimental SS mouse model to evaluate their therapeutic potential. The upregulation of miRNA let-7f-5p in LGMSC-EVs significantly enhanced their therapeutic effects, resulting in clinical improvements such as increased salivary flow and reduced lymphocytic infiltration. Mechanistically, let-7f-5p-encapsulated LGMSC-EVs suppressed Th17 cells by directly targeting the 3'-untranslated region (3'UTR) of RORC, inhibiting the RORC/IL-17A signaling axis, and reducing IL-17A production, thereby restoring Th17/Treg balance and promoting an anti-inflammatory profile. Collectively, this let-7f-5p-encapsulated LGMSC-EV therapy offers a promising target-driven approach for the treatment of SS, achieving improved clinical outcomes and immune rebalance after modification with miRNA let-7f-5p, which presents new potential for the clinical treatment of SS.

Trends in Initial Hospitalizations of Patients with Newly Diagnosed Sjogren's Disease in Poland Between 2012 and 2023: A Retrospective Data Analysis

Background/Objectives: Sjögren's disease (SjD) is a chronic autoimmune disease primarily affecting exocrine glands, often leading to systemic complications and comorbidities. While SjD is known to impact quality of life, research on hospitalization trends, demographic characteristics, and factors influencing hospital stay duration remains limited. This study aims to analyze hospitalizations due to SjD in Poland between 2012 and 2023, identifying key trends, risk factors, and healthcare implications. Methods: A retrospective analysis was conducted using data from the National General Hospital Morbidity Study, covering 13,999 first-time hospitalizations with an SjD diagnosis (ICD-10: M35.0). Descriptive statistics were applied to evaluate patient demographics, hospitalization trends, and comorbidities. The Mann-Whitney U test and chi-square test were used to compare groups, while a linear regression model identified predictors of hospital stay duration. Results: Women accounted for 90.3% of hospitalizations, with a median age of 57 years, compared to 53 years for men. The hospitalization rate fluctuated over time, with a decline in 2020, possibly due to the COVID-19 pandemic, followed by an increase in 2021-2023. The most common comorbidities included musculoskeletal disorders (17.8%), cardiovascular diseases (16.6%), and endocrine disorders (13.6%). Women had longer hospital stays than men (median 5 vs. 4 days, p < 0.001). Older patients and those admitted in emergency settings had significantly longer hospital stays. The overall mortality rate was low (0.2%), with a slightly higher but statistically insignificant mortality rate among men. Conclusions: The study highlighted the increasing burden of SjD-related hospitalizations and the need for improved outpatient management to reduce inpatient admissions. Factors such as older age, female sex, and emergency admissions were associated with prolonged hospitalization. Strengthening early diagnostic strategies, optimizing access to specialist care, and monitoring comorbidities could enhance patient outcomes and reduce hospital resource utilization.

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.

The Expanding Therapeutic Potential of Deucravacitinib Beyond Psoriasis: A Narrative Review

Deucravacitinib is an allosteric, selective tyrosine kinase 2 (TYK2) inhibitor that has demonstrated significant efficacy in the treatment of psoriasis. TYK2, a member of the Janus kinase (JAK) family, plays a critical role in intracellular signaling pathways for pro-inflammatory cytokines. Unlike traditional JAK inhibitors, which target active domains, deucravacitinib selectively binds to the pseudokinase domain of TYK2. This binding induces a conformational change that locks the enzyme in an inactive state, ensuring superior selectivity for TYK2 over JAK 1/2/3. This unique mechanism specifically inhibits key pro-inflammatory cytokines, including IL-12, IL-23, and type I interferons, critical in the pathogenesis of psoriasis and other immune-mediated diseases. As a result, deucravacitinib represents a promising option for targeted therapy in immune-mediated diseases and may reduce adverse events commonly associated with broader immunosuppressive treatments. Furthermore, its oral administration offers a convenient alternative to injectable biologics, potentially improving patient adherence and treatment satisfaction. This review highlights recent studies suggesting that deucravacitinib may also have therapeutic benefits in psoriatic arthritis, palmoplantar pustulosis, systemic lupus erythematosus, Sjogren's disease, and inflammatory bowel disease. Given its expanding therapeutic potential, deucravacitinib may provide a safer and more effective alternative to current therapies, offering a tailored approach to treatment.

Increased risk of dementia in patients with primary Sjogren's syndrome: a nationwide population-based cohort study

BACKGROUND/AIMS

This nationwide cohort study aimed to evaluate (1) whether primary Sjogren's syndrome (pSS) can contribute to the development of dementia and (2) whether the use of hydroxychloroquine (HCQ) can decrease the incidence of dementia in patients with pSS using the Health Insurance Review and Assessment database.

METHODS

We established a cohort between 2008 and 2020 of 20,160 patients with pSS without a history of dementia. The control group comprised sex- and age-matched individuals with no history of autoimmune disease or dementia. Cox proportional hazard analyses were performed to identify the association between pSS and dementia development. We also assessed the hazard ratio (HR) of dementia in early users of HCQ (within 180 days of the diagnosis of pSS) compared to non-users, adjusted for age, sex, and comorbidities.

RESULTS

The incidence of dementia was 0.68 (95% CI 0.64-0.72) cases per 100 person-years in pSS, and it was 0.58 (0.56-0.60) in the controls. The adjusted HR (aHR) of developing dementia was 1.16 (1.09-1.25) times greater in the pSS group than in the controls. The risk of dementia did not increase in HCQ users (aHR 1.07 [0.94-1.21]), but HCQ non-users had a 1.22 (1.12-1.33) higher risk of developing dementia than the matched controls. The use of HCQ lowered the risk of dementia in comparison with non-users in patients with pSS (aHR 0.82 [0.71-0.94]).

CONCLUSION

Our results suggest that pSS is associated with an increased risk of dementia. HCQ may prevent dementia in patients with pSS.

Risk Allele rs117026326-Mediated Alternative Splicing of GTF2I Promotes B Cell Proliferation in Primary Sjögren's Syndrome

Objectives: Primary Sjögren's syndrome (pSS) is associated with a risk allele T of rs117026326 located at a potential splicing enhancer within the intronic region of general transcription factor II-I (GTF2I). This study aimed to explore the rs117026326-regulated alternative splicing of GTF2I and its role in B cell overactivation in pSS. Methods: GTF2I isoform expressions and rs117026326 genotypes of pSS peripheral blood mononuclear cells (PBMCs) were examined using quantitative PCR and Sanger sequencing, respectively. GTF2IΔ was overexpressed in B cells, T cells, and macrophages using plasmid transfection. Proliferation of B cells and T cells was determined using Cell Counting Kit-8 (CCK8) assay. CD4+ T cell differentiation was inspected using flow cytometry. Proinflammatory cytokine production of macrophages was investigated using quantitative PCR. c-FOS expression in GTF2IΔ-transfected B cells was tested by quantitative PCR, and proliferation of GTF2IΔ-transfected B cells treated with c-FOS siRNA or c-FOS inhibitor was interrogated using CCK8 assay. Results: pSS patients with risk allele of rs117026326 expressed higher levels of GTF2IΔ and GTF2Iζ isoforms. GTF2IΔ expression was correlated with serum immunoglobulin G (IgG). GTF2IΔ promoted B cell proliferation and upregulated c-FOS expression. Knocking down or inhibition of c-FOS reversed B cell proliferation driven by GTF2IΔ. Conclusion: pSS risk allele of rs117026326 modulates alternative splicing of GTF2I and upregulates GTF2IΔ isoform, which promotes B cell proliferation through enhancing binding and transcription of c-FOS.

Immunomodulatory effects of Yu-Ping-Feng formula on primary Sjögren syndrome: interrogating the T-cell response

Ethnopharmacological treatments have shown beneficial effects in the clinical practice of autoimmune disorders. However, the underlying mechanism of immunomodulatory effects remains challenging, given the complicate composition of herbal medicines. Here, we developed an immunological approach to interrogate the T helper cell response. Through data mining, we hypothesized that Chinese medicine formula Yu-Ping-Feng might be a promising candidate for treating primary Sjögren syndrome, a common autoimmune disease manifested by exocrine gland dysfunction. We took advantage of a mouse model of experimental Sjögren syndrome that we previously established for Yu-Ping-Feng formula treatment. Yu-Ping-Feng therapy ameliorated the experimental Sjögren syndrome pathology in mice with active disease, showing improved salivary function and decreased serum levels of autoantibodies. Phenotypic analysis suggested that both effector T and B cells were significantly suppressed. Using coculture assay and adoptive transfer models, we demonstrated that Yu-Ping-Feng formula directly restrained effector/memory T-cell expansion and differentiation into Th17 and T follicular helper cells, the key subsets in experimental Sjögren syndrome pathogenesis. Importantly, we recruited 20 patients with primary Sjögren syndrome and conducted a pilot study of 8-wk therapy of Yu-Ping-Feng formula. Yu-Ping-Feng treatment effectively improved fatigue symptoms and exocrine gland functions, as well as reduced serum IgG/IgA levels, while effector T- and B-cell subsets were significantly decreased. There was a trend of reduction on disease activity, but not statistically significant. Together, our findings suggest a novel approach to assess the immunomodulatory effects of Yu-Ping-Feng formula, which may be favorable for patients with autoimmune disorders.

How to focus on autoantigen-specific lymphocytes: a review on diagnosis and treatment of Sjogren's syndrome

Sjogren's syndrome (SS) is an autoimmune epithelitis characterized by focal lymphocytic infiltration against self-antigens leading to progressive glandular dysfunction, which can develop to multisystem manifestation. The classification criteria for SS emphasizes glandular lymphocyte infiltrates and anti-SSA/SSB seropositivity, which is usually manifested in advanced patients. Therapeutically, apart from symptomatic treatment, treatment of SS is based on glucocorticoids and conventional synthetic disease-modifying antirheumatic drugs with global immunosuppression, but the efficacy of biologic or targeted synthetic therapies is still sparse. Currently, emerging studies focus on autoantigen-specific immunotherapies to treat autoimmune disorders by directly eliminating autoreactive cell subsets and inducing tolerance by increasing the autoreactive regulatory lymphocytes. Herein, we summarize the current state of research on the autoantigen-specific approaches for detecting autoreactive lymphocytes and outline the current autoantigen-specific immunotherapies in other autoimmune disorders and their attempts in treatment of SS. Last, we discuss the potential value of focusing on autoantigen-specific lymphocytes in the early diagnosis, monitoring, and targeted treatment of SS. Potential strategies for targeting autoreactive lymphocytes need to be confirmed in SS.

Recommendations on neurologic, cognitive, and psychiatric manifestations in patients with Sjögren's disease by the Brazilian Society of Rheumatology

BACKGROUND

Neurological and psychiatric manifestations occur in patients with primary Sjogren's disease (SjD) with a wide-ranging clinical presentation, affecting quality of life, social participation, and prognosis. Despite this, neither central nor peripheral neurological symptoms are systematically evaluated in the context of autoimmunity or identified as manifestations of SjD. The EULAR Sjogren's Syndrome Disease Activity Index (ESSDAI) covers only part of them in the neurological domain.

METHODS

We performed a systematic review of the diagnosis and prevalence of central, peripheral, and autonomic nervous system manifestations in primary SjD, following the recommendations proposed by the Cochrane Collaboration Handbook. Observational studies were included when their main issue was the diagnosis and the prevalence of the manifestations individually. We employed a generalized linear mixed model (GLMM) method with a random-effects model, and the results were computed using logit transformation, implemented through the 'meta' and 'metafor' packages in the R software (version 3.6.1). To present these recommendations, agreement among experts was investigated using the Delphi method in in-person meetings.

RESULTS

We propose ten recommendations regarding the investigation and management of neurological involvement in SjD that had 100% agreement among participants.

CONCLUSION

These recommendations add to the literature on the clinical care of patients with SjD.

Application of lacrimal gland ultrasonography in the evaluation of chronic ocular graft-versus-host-disease

Objective

To investigate the effectiveness of lacrimal gland ultrasonography in the assessment of chronic ocular graft-versus-host-disease (oGVHD) after allogeneic hematopoietic stem cell transplantation (allo-HSCT) and to establish the correlation between the ocular surface and ultrasonographic results.

Method

The cross-sectional study included 57 participants aged 18 and older, who were at least 100 days after allo-HSCT. The study was conducted at the oGVHD clinic of Peking University People's Hospital between March to June 2023. Patients were categorized into groups according to the International Chronic oGVHD (ICCGVHD) consensus group diagnostic criteria or the 2005 National Institutes of Health (NIH) classification criteria for Chronic GVHD. Demographics and transplantation-related information were collected for all participants, including age, gender, donor-recipient HLA matching, donor-recipient ABO matching, donor-recipient gender combination and duration after allo-HSCT. The disease activity of oGVHD and the severity of ocular surface involvement were assessed using various parameters such as Ocular Surface Disease Index (OSDI), Schirmer test, tear film break-up time (BUT), tear meniscus height, corneal/conjunctival staining and meibomian gland dropout. Lacrimal gland structures were assessed by B-mode and Doppler ultrasonography to measure parameters such as the long diameter, thick diameter, homogeneity and parenchymal vascularization. Statistical analyses were performed to determine differences in ocular surface conditions and lacrimal gland ultrasonographic parameters between groups as well as to determine the correlation between ocular surface condition and lacrimal gland ultrasonographic findings.

Result

(1) Patients with definite and probable oGVHD exhibited a significantly longer duration after allo-HSCT compared to non-oGVHD patients (H=11.264, p<0.01), The median durations were 247(164,894) days and 525(310,928) days, respectively, compared to 204(169,323.25) days for non-oGVHD patients. (2) Compared to non-oGVHD patients, both definite oGVHD patients and probable oGVHD patients showed lower average of Schirmer test (H=31.188, p<0.01), TBUT (H=11.853, p<0.01), tear meniscus height (H=13.630, p<0.01) and higher average of OSDI (F=27.992, p<0.01), corneal staining scores (χ²=23.66, p<0.05) and temporal conjunctival staining scores (χ²=14.84, p<0.05). (3) The B-mode and Doppler ultrasonography parameters in lacrimal glands including long diameter, thick diameter, homogeneity and parenchymal vascularization did not exhibit significant differences between the three groups. (4) The long diameter in lacrimal ultrasonography had significantly positive correlations with tear meniscus height (r=0.297, p<0.05) and significantly negative correlations with temporal conjunctival staining scores (r=-0.313, p<0.05) and staining total scores (r=-0.285, p<0.05). The thick diameter in lacrimal ultrasonography demonstrated significantly positive correlations with tear meniscus height (r=0.404, p<0.01), and significantly negative correlations with OSDI (r=-0.273, p<0.05), corneal staining scores (r=-0.264, p<0.05), nasal conjunctival staining scores (r=-0.271, p<0.05) and staining total scores (r=-0.312, p<0.05). Homogeneity and parenchymal vascularization were not found to be significantly correlated with ocular surface status.

Conclusion

The ocular surface condition in oGVHD patients is worse than that observed in non-GVHD patients. The main manifestations include keratoconjunctival injury and a reduction in tear secretion and tear film stability. These effects appear to be a common result of chemoradiotherapy-induced inflammation and rejection-associated responses. There were no significant differences in the morphology of lacrimal glands as revealed by ultrasonography. This suggests that ocular rejection may not be the primary cause of lacrimal gland changes in oGVHD patients. While ultrasonography can provide insight into tear secretion, its efficacy in diagnosing oGVHD appears limited.

The prevalence, clinical features, and long-term outcome of patients with primary Sjögren's syndrome with renal involvement

This multicenter, retrospective longitudinal study identified primary Sjögren's syndrome (pSS) patients with clinically significant renal involvement, and analyzed factors associated with predisposition. To investigate clinical features and long-term prognosis of renal involvement, we compared the clinical outcomes for the entire cohort based on the presence or absence of renal involvement. Among 1306 pSS patients (mean age, 51 ± 12 years; 98% female), 36 (2.8%) had renal involvement; 17 patients had tubular involvement, 15 had glomerular involvement, one had both, and 3 were unclassified. The presence of anti-La antibodies was associated with renal involvement. Over the median 5-year follow-up period, the renal function did not change significantly; however, 44% of patients with renal involvement showed impaired renal function at the last visit. Impaired renal function at the last visit was inversely associated with baseline renal function and hemoglobin levels. Among the entire cohort, the prevalence of lymphoproliferative disease (LPD) was significantly higher in pSS patients with renal involvement than those without. Renal involvement is a rare manifestation of pSS; however, it is associated with impaired renal function and LPD. Therefore, screening for renal involvement is important for preserving renal function and early detection of LPD.

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

Sjögren disease (SD) is a chronic, autoimmune disease of unknown aetiology with significant impact on quality of life. Although dryness (sicca) of the eyes and mouth are the classically described features, dryness of other mucosal surfaces and systemic manifestations are common. The key management aim should be to empower the individual to manage their condition-conserving, replacing and stimulating secretions; and preventing damage and suppressing systemic disease activity. This guideline builds on and widens the recommendations developed for the first guideline published in 2017. We have included advice on the management of children and adolescents where appropriate to provide a comprehensive guideline for UK-based rheumatology teams.

Efficacy of RCI001 as a Therapeutic Candidate in a Primary Sjögren Syndrome Mouse Model

PURPOSE

The aim of this study was to investigate the efficacy of RCI001 (RCI) in a mouse model of primary Sjögren syndrome.

METHODS

Eight 12-week-old NOD.B10-H2b mice were used in this study. All experimental animals were randomly divided into phosphate-buffered saline (PBS) and RCI groups in NOD.B10-H2b mice. The eyes of mice were topically treated with PBS or RCI twice a day for a week. Ocular surface staining (OSS) and tear secretion were compared between before and after treatment. The transcript levels of inflammatory cytokines and nicotinamide adenine dinucleotide phosphate oxidase (NOX) in the conjunctiva and cornea (CC) and lacrimal gland were assayed. In addition, immunofluorescence staining of the conjunctiva was assessed.

RESULTS

The RCI group showed significant clinical improvement in OSS and tear secretion after 1 week of treatment compared with the baseline (both P < 0.001) and showed better improvement in OSS and tear secretion than the PBS group after 1 week of treatment (both P < 0.05). The levels of IL-1β and IL-17 in CC and IL-6 in the lacrimal gland were also significantly reduced in the RCI group compared with the PBS group (each P < 0.05). Transcript levels of NOX2 and NOX4 were also significantly reduced in CC of the RCI group compared with those of the PBS group ( P < 0.05). The RCI group also resulted in lower conjunctival expression of oxidative stress markers (4-hydroxy-2-nonenal, hexanoyl-lysine, and NOX4) than the PBS group.

CONCLUSIONS

Topical RCI001 demonstrated excellent therapeutic efficacy in a mouse model of primary Sjögren syndrome by inhibiting inflammation and oxidative stress.

Management of Dry Mouth

Background: Dry mouth, or xerostomia, is a common complaint among older people. Dry mouth can result in a variety of dental complications, oral discomfort, difficulty swallowing and eating, and decreased taste sensation, all of which can adversely affect quality of life. Objective: To provide an overview of the definition, diagnosis, causes, potential complications, and treatment strategies for dry mouth. Data Sources: PubMed, Proquest, Cochrane Library, drug prescribing information, drug information databases, and manufacturers' websites were used. Search terms were "xerostomia," "dry mouth," "hyposalivation," "causes," "treatment," and "pharmacology." The resources identified included clinical practice guidelines, review articles, and original research articles. Data Synthesis: The literature described the causes and treatment strategies for managing xerostomia, including concerns for older adults, and pharmacists' involvement for providing care. Discussion: The most common cause of dry mouth in the general population and in older adults is medication use. Individual medications may cause dry mouth, primarily through anticholinergic side effects. Polypharmacy is also a cause. Other causes are dehydration, alcohol and caffeine intake, and systemic diseases such as Sjögren's disease. If not addressed, individuals experiencing chronic dry mouth are at increased risk for various oral conditions such as dental caries, periodontal disease, and infections. Interventions such as good oral hygiene methods, using saliva substitutes containing xylitol and prescription cholinergic agonists, if appropriate, can reduce symptoms and complications. Conclusion: Pharmacists can play an important role in managing dry mouth by conducting medication reviews, providing patient education for oral health practices, and recommending treatment strategies.

Interstitial lung disease in rheumatic diseases: an update of the 2018 review

INTRODUCTION

Interstitial lung disease (ILD) is a potential severe complication of various rheumatic diseases, typically connective tissue diseases (CTD), associated with significant morbidity and mortality. ILD may occur during the course of the disease but may also be its first manifestation. Several cell types are involved in ILD's pathogenesis, and if not controlled, pulmonary inflammation may lead to pulmonary fibrosis.

AREAS COVERED

We searched PubMed, Medline, and the Cochrane Library for papers published between 1995 and February 2017 in the first version, and between 2017 and April 2023 using combinations of words. The most frequent systemic rheumatic diseases associated with ILD are systemic sclerosis (SSc), rheumatoid arthritis (RA), and idiopathic inflammatory myositis. Treatment and monitoring guidelines are still lacking, and current treatment strategies have been extrapolated from the literature on SSc and established treatments for non-pulmonary systemic rheumatic manifestations.

EXPERT OPINION

Given the complexity of diagnosis and the paucity of treatment trials, managing CTD patients with ILD is challenging. It requires the skills of multidisciplinary CTD-ILD clinics including at least rheumatologists and lung specialists.

Systemic disease activity measured with ESSDAI varies largely over 5 years in a prospective, longitudinal cohort of patients with Sjögren's disease

OBJECTIVES

The objectives are to evaluate variation in systemic disease activity (European Alliance of Associations For Rheumatology (EULAR) Sjögren's Syndrome Disease Activity Index (ESSDAI)) over time at group and individual patient level and to assess associations of ESSDAI low disease activity (LDA) with other outcome measures in a standard-of-care cohort of patients with Sjögren's disease (SjD).

METHODS

Patients with SjD participating in a prospective longitudinal study (REgistry of Sjögren Syndrome LongiTudinal cohort) fulfilling the 2016 American College of Rheumatology/EULAR classification criteria with ≥2 years of follow-up were included. ESSDAI was assessed at least yearly, up to 5 years. Patient-reported, objective glandular and laboratory outcomes were compared between patients with ESSDAI LDA (score<5) for <75% vs ≥75% of time.

RESULTS

Of 265 included patients with SjD, 236 (89%) were women, median disease duration was 6 years (IQR 2-10) and 114 (43%) received immunosuppressive treatment at some point during follow-up. At group level, median ESSDAI decreased slightly, from 4 (IQR 2-7) at baseline to 3 (IQR 2-5) at year 5, with a concomitant decrease in variation, indicating regression to the mean. At the individual patient level, ESSDAI varied in the majority of patients: 50/102 (49%) untreated patients with ESSDAI<5 at baseline changed to ESSDAI≥5 at least once during follow-up. Of the untreated patients with ESSDAI≥5 at baseline, 41/45 (91%) changed to ESSDAI<5. Patients with ESSDAI LDA for ≥75% of time showed better outcomes on saliva production.

CONCLUSIONS

In this cohort of patients with SjD, overall ESSDAI slightly decreased during 5 years of follow-up, whereas at individual patient level, large variation was seen over time for the majority of patients. Longer time in ESSDAI LDA was associated with better salivary gland outcomes.

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.

Genetic insight into dissecting the immunophenotypes and inflammatory profiles in the pathogenesis of Sjogren syndrome

BACKGROUND

Sjogren syndrome (SS) is a chronic systemic autoimmune disease and its pathogenesis often involves the participation of numerous immune cells and inflammatory factors. Despite increased researches and studies recently focusing on this area, it remains to be fully elucidated. We decide to incorporate genetic insight into investigation of the causal link between various immune cells, inflammatory factors and pathogenesis of Sjogren syndrome (SS).

METHODS

Our study leveraged the genetic variants of multi-omics statistics extracted from genome-wide association study (GWAS), the University of Bristol and the FinnGen study. We performed a bidirectional Mendelian randomization and mediation study based on randomly allocated instrumental variables to infer causality, followed by external validation with UK Biobank data and Bayesian colocalization.

RESULTS

We demonstrated that an elevated level of CD27 on IgD + CD24 + B cell, a subset of B cells expressing both IgD and CD24, was associated with a higher risk of SS (OR = 1.119, 95% CI: 1.061-1.179, P < 0.001), while CD3 on CD45RA + CD4 + Treg was a protective factor (OR = 0.917, 95%CI: 0.877-0.959, P < 0.001). Results of meta-analysis and colocalization further supported the significant results identified in the primary analysis. A total of 4 inflammatory cytokines and 7 circulating proteins exhibited potential causal relationships with SS despite no significant result achieved after FDR correction. Finally, results of mediation analysis indicated that CD40L receptor levels had significant mediating effects (β = 0.0314, 95% CI: 0.0004-0.0624, P = 0.0471) at a mediation proportion of 28% (95% CI: 0.364%-55.6%) in causal relationship between CD27 on IgD + CD24 + B cell and SS.

CONCLUSIONS

By providing a novel genetic insight into unveiling the roles of autoimmunity and inflammation in Sjogren syndrome, our findings may potentially lead to identifying new clinical biomarkers for disease monitoring and therapeutic targets that offer more effective alternatives for treating this condition. Therefore, our study may provide valuable evidence for future clinical intervention and targeted immunotherapy.

S100A8/A9 Promotes Dendritic Cell-Mediated Th17 Cell Response in Sjögren's Dry Eye Disease by Regulating the Acod1/STAT3 Pathway

Purpose

To investigate the role of S100A8/A9 in the pathogenesis of Sjögren's dry eye disease (SjDED) and explore its potential mechanism of action.

Methods

S100A8/A9 expression was determined by western blot and quantitative real-time polymerase chain reaction (qRT-PCR). Tear secretion, corneal fluorescein staining, and hematoxylin and eosin staining were used to evaluate the effect of paquinimod, a S100A8/A9 inhibitor, on dry eye disease in nonobese diabetic (NOD) mice. Immune cell infiltration and percentage were assessed by immunofluorescence and flow cytometry. Proinflammatory cytokine levels were examined by qRT-PCR or ELISA. The mechanism of action was analyzed using western blot, immunofluorescence, and chromatin immunoprecipitation.

Results

S100A8/A9 was upregulated in peripheral blood mononuclear cells of patients with SjDED and lacrimal glands (LGs) of SjDED mice. The upregulation of S100A8/A9 was correlated with the dry eye severity and inflammatory infiltration levels in LGs. Administration of paquinimod ameliorated clinical and histopathological phenotypes of SjDED mice and reduced the proportion of Th17 cells in LGs, lymph nodes, and spleens. Further experiments revealed that S100A8/A9 did not directly affect Th17 generation and function but upregulated the expression of major histocompatibility complex Ⅱ (MHC Ⅱ) and Th17-polarizing cytokines in dendritic cells (DCs) to augment Th17 cell response. Mechanistically, S100A8/A9 induced the expression of Acod1 and thereby promoted the activation and nuclear translocation of signal transducer and activator of transcription 3 (STAT3), resulting in increased Il23a transcription. STAT3 activator reversed the therapeutic effect of paquinimod on SjDED mice.

Conclusions

S100A8/A9 activated the Acod1/STAT3 pathway to promote DC-driven Th17 cell responses in SjDED. The S100A8/A9/Acod1/STAT3 pathway may represent a promising therapeutic target for SjDED.

Primary Sjogren's Disease Coexisting With Myasthenia Gravis: Two Distinct Autoimmune Diseases Successfully Treated With a Rituximab-Based Induction Regimen

Primary Sjögren's syndrome (pSS) and myasthenia gravis (MG) are autoimmune diseases and are rarely reported in coexistence. MG is a chronic autoimmune neuromuscular disease where antibodies bind to acetylcholine receptors or to functionally related molecules in the postsynaptic membrane, weakening the skeletal muscles and causing diplopia, ptosis, and difficulty in breathing and swallowing. In this report, we discuss the case of a 43-year-old female patient who presented with dry eyes, weight loss, fatigue, ptosis, dysarthria, and quadriparesis, which ultimately led to the diagnosis of pSS and MG. Severe dry eyes, myasthenic symptoms, hypokalemic paralysis, and pancytopenia were among the disease and treatment-related consequences that had to be managed during the course of treatment. The symptoms of MG and pSS were initially managed with high-dose corticosteroids, azathioprine, and pyridostigmine/neostigmine. Escalation to an induction regimen based on rituximab was required due to persistent disease activity of both MG and pSS. Significant hematological and clinical improvements were noted after treatment, highlighting rituximab's effectiveness in inducing remission in these overlapping autoimmune diseases. To the best of our knowledge, this is the first case in the literature where these coexisting diseases were simultaneously, successfully treated with a rituximab-based induction regimen.

Hydroxychloroquine and Sjögren's disease: current evidences for its use

About 25-50% of patients with primary Sjögren's disease (SjD) take hydroxychloroquine (HCQ). Although it is widely prescribed, and recommended in international guidelines, its use is mostly based on expert opinion and personal experience. Our aim was to provide a comprehensive overview of the pathogenic mechanisms of HCQ, the current clinical evidence for its use, and its safety in primary SjD. HCQ plays an immunomodulatory and anti-inflammatory role, mainly by regulating some interferon proteins, chemokines, BAFF levels, and by modifying gut microbiota. It decreases immunoglobulins and ESR levels. In a Latin-American cohort, the main indications were arthritis, parotid gland enlargement and sicca-only symptoms. In the clinical setting, most studies showing a positive effect of HQC are open trials or retrospective cohorts. Some of these studies may be biased due to the use of non-validated outcomes, and a placebo response effect. To date, only 3 RCTs have investigated the benefits of HCQ, the JOQUER being the pivotal one. This study failed to improve oral/ocular symptoms or ESSDAI score. However, a re-analysis by symptomatology subgroups detected some differences in the ESSPRI. Recently, promising data from a small phase II RCT of the combination of HCQ/leflunomide was reported, but results should be replicated. Currently, the NECESSITY study is investigating treatment combinations that will provide new insights. In the meantime, HCQ plays a central role in the treatment of SjD due to its excellent benefit-risk profile. Data on damage accrual, quality of life, mortality and prevention of cardiovascular risks are also still lacking.

Dry eye and systemic diseases

Tear film instability and reduced tear production initiate a vicious circle where hyperosmolarity, ocular inflammation, and apoptosis may induce a damage of the ocular surface including keratitis which is all included in a common condition called dry eye disease (DED). DED can be apparently an isolated ocular surface condition; however, multiple ocular and systemic risk factors have been identified. The association with systemic diseases such as autoimmune diseases, hormonal imbalance, dietary imbalance, metabolic diseases, infections, psychological conditions, and aging together with external causative factors may act independently or interacting each other to initiate and/or perpetuate signs and symptoms typical of this very common ocular surface disease. Rheumatological disorders are most typically associated with dry eye; therefore, strict interaction with rheumatologists is important for the diagnosis and management of DED patients. In the present narrative review, we highlight associations between DED and some of the systemic disorders that may be implicated in the development of the disease.

Development of Behçet's disease on maintenance therapy for autoimmune hepatitis

Behçet's disease is a clinical diagnosis with variable presentations. Liver involvement is rare in the absence of vascular complications. We describe a patient diagnosed with Hashimoto's thyroiditis and autoimmune hepatitis on azathioprine who developed extensive aphthous ulcers approximately 10 years later. She was initially diagnosed with an overlap autoimmune connective tissue disorder in the setting of a positive anti-Ro antibody. Symptoms did not resolve with prednisone, hydroxychloroquine or mycophenolate mofetil. She subsequently developed pseudofolliculitis, erythema nodosum-like lesions, large cutaneous ulcers and pathergy phenomenon at sites of venipuncture consistent with Behçet's disease. She was successfully treated with infliximab, azathioprine, colchicine and apremilast. This case represents an unusual sequence of autoimmune conditions and a diagnostic challenge.

Severe Hypokalemia and Respiratory Muscle Paralysis: An Atypical Manifestation of Primary Sjögren's Syndrome

Primary Sjögren's syndrome (SS) is a systemic autoimmune disorder primarily affecting exocrine glands, that may occasionally present with severe extra-glandular manifestations. Although rarely, severe hypokalemia and respiratory muscle paralysis may be initial presentations. We report the case of a 33-year-old woman with a recent history of severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infection who presented with headache and generalized muscle weakness. An evaluation revealed severe hypokalemia, acute kidney injury, and metabolic acidosis. Despite intravenous potassium supplementation, her condition rapidly deteriorated, leading to respiratory failure requiring invasive ventilation. Further investigations showed a urinary pH >5.5, indicating distal renal tubular acidosis (dRTA). Positive antinuclear antibody (ANA) titers, SS-related antigen A antibody (anti-Ro/SSA), and lymphocytic infiltration on parotid gland biopsy confirmed a diagnosis of primary SS. Treatment with bicarbonate, potassium supplementation, and oral corticosteroids was initiated, leading to clinical improvement. This case underscores the importance of considering SS in patients with unexplained dRTA and severe hypokalemia, emphasizing the importance of timely diagnosis and tailored therapy in managing systemic manifestations.

G protein-coupled receptor kinase 2 as a novel therapeutic target for gland fibrosis of Sjögren's syndrome

Sjogren's syndrome (SS) is a chronic, progressive autoimmune disorder characterized by gland fibrosis. We previously found a close correlation between gland fibrosis and the expression of G protein-coupled receptor kinase 2 (GRK2). In this study we explored the pathological and therapeutic significance of GRK2 in SS. Submandibular gland (SMG) antigen-induced SS mouse model was established in WT and GRK2+/- mice. We showed that the expression levels of GRK2 were significantly up-regulated in glandular tissue and positively correlated with fibrotic morphology in SS patients and mice. Hemizygous knockout of GRK2 significantly inhibited the gland fibrosis. In mouse salivary gland epithelial cells (SGECs), we demonstrated that GRK2 interacted with Smad2/3 to positively regulate the activation of TGF-β-Smad signaling with a TGF-β-GRK2 positive feedback loop contributing to gland fibrosis. Hemizygous knockout of GRK2 attenuated TGF-β-induced collagen I production in SGECs in vitro and hindered gland fibrosis in murine SS though preventing Smad2/3 nuclear translocation. Around 28 days post immunization with SMG antigen, WT SS mice were treated with a specific GRK2 inhibitor paroxetine (Par, 5 mg·kg-1·d-1, i.g. for 19 days). We found that Par administration significantly attenuated gland fibrosis and alleviated the progression of SS in mice. We conclude that genetic knockdown or pharmacological inhibition of GRK2 significantly attenuates gland fibrosis and alleviates the progression of SS. GRK2 binds to Smad2/3 and positively regulates the activation of TGF-β-Smad signaling. A TGF-β-GRK2 positive feedback loop contributes to gland fibrosis. Our research points out that GRK2 could be a promising therapeutic target for treating SS.

Autoimmune dysphagia

PURPOSE OF REVIEW

Dysphagia is a complication of several autoimmune rheumatic diseases and otorhinolaryngologists are likely to be involved in the assessment and management of patients with such conditions. This review provides an update on rheumatic diseases that may cause swallowing impairment, with particular focus on the epidemiology, pathophysiology and management of dysphagia in these conditions.

RECENT FINDINGS

Dysphagia is a common complication of the following rheumatic diseases: idiopathic inflammatory myopathies, systemic sclerosis, Sjogren's syndrome, systemic lupus erythematosus and rheumatoid arthritis. It may also be a complication of rarer autoimmune conditions such as Bechet's syndrome, sarcoidosis and granulomatosis with polyangiitis. All three stages of swallowing (oral, pharyngeal and oesophageal) may be impaired in these conditions. Both medical therapy and surgical intervention play an important role in the management of autoimmune dysphagia.

SUMMARY

The investigation and management of autoimmune dysphagia requires close collaboration between rheumatologists and otorhinolaryngologists. There is a need for further research to establish standardised guidelines on the assessment and management of autoimmune dysphagia.

Traditional Chinese medicine-based drug delivery systems for anti-tumor therapies

The treatment of tumors continues to be significantly challenging. The presence of multiple modalities, including surgery, radiation, chemotherapy and immunotherapy, the therapeutic outcomes remain limited and are often associated with adverse effects and inconsistent efficacy across cancer types. Recent studies have highlighted the potential of active components from traditional Chinese medicine (TCM) for their anti-cancer properties, which are attributable to multi-targeted mechanisms and broad pharmacological actions. Despite this potential, TCM-derived compounds are commonly limited by poor water solubility, low bioavailability, and suboptimal targeting. Currently, it is believed that advances in nanotechnology could address these limitations. Nanoparticles (NPs), which possess properties such as enhanced bioavailability, controlled release and precise targeting, have been used to improve the therapeutic efficacy of TCM components in cancer therapy. This review discusses the use of NPs for the delivery of active TCM compounds via organic-inorganic nanocarriers, highlighting innovative strategies that enhance the effectiveness of TCM-based anti-tumor components to provide insights into improving clinical outcomes while advancing the modernization and global application of TCM in oncology.

Therapeutic potential of interleukin-17 neutralization in a novel humanized mouse model of Sjögren's disease

Sjögren's disease (SjD) is a chronic autoimmune disease, in which the immune system targets exocrine glands and leads to dryness symptoms. There is an increasing need to develop novel therapeutic approach as the treatment plan has not been changed in the past decade. However, findings in mouse model may not be directly applied in patients, given the substantial differences of immune system between human and mice. In the present study, using antigens derived from human salivary A-253 cells, we established experimental Sjögren's syndrome (ESS) in mice with human immune system (HIS). HIS-ESS mice exhibited key features of human disease, including salivary hypofunction, increased serum levels of autoantibodies and tissue destruction in the salivary glands. Phenotypic analysis revealed enhanced effector B and T cell subsets, including Th1, Th17 and T follicular helper (Tfh) cells in HIS-ESS mice, while multiplex imaging analysis suggested enlarged B cell follicles and expanded memory B cells. IL-17 neutralization therapy significantly ameliorated disease pathology at both acute and chronic stages, in which B cells were mainly affected, to the less extent Th1 and Tfh cells in HIS-ESS mice. Together, HIS-ESS mouse model highly recapitulated SjD features and immunopathogenesis, which may serve as a useful tool in drug screening and pre-clinical studies.

Sjogren's syndrome: Everything you always wanted to know about genetic and epigenetic factors

Primary Sjögren's syndrome (pSS) is a chronic, systemic autoimmune disease characterized by a wide spectrum of glandular and extra-glandular features. Genetic and epigenetic factors play an important role in the disease susceptibility and phenotype. There are a multitude of genes that have been identified as implicated in the pathogenesis of pSS, both in HLA and extra-HLA regions with a strong contribution given by genes in interferon signalling pathways. Among the HLA alleles, the most consistent associations have been found with DR2 and DR3 alleles at the DRB1 locus. Moreover, several gene variants outside the MHC locus are in genes involved in NF-κB signalling, B- and T-cell function and methylation processes possibly responsible for lymphomagenesis. There is still a lack of knowledge on precise genetic patterns and prediction models of diseases, and data on pharmacogenetics is scarce. A comprehensive summary of the common genetic factors and an extensive analysis of novel epigenetic aspects is provided, together with a view on the relationships between novel therapeutic agents for pSS and genetic targets in signalling pathways, aiming at improving tailored treatment strategies in the view of a more personalized medicine.

Can unstimulated whole salivary flow objectively classify salivary gland secretory function in Sjögren's syndrome?

INTRODUCTION

The aim of this study is to investigate whether the testing time for unstimulated whole salivary flow (UWSF) can be shortened to 5 min in patients with suspected Sjögren's syndrome (SjS); and which SjS patients can use UWSF to evaluate salivary gland (SG) secretory function.

METHOD

A diagnostic cohort comprising suspected SjS patients was conducted to investigate the correlation between UWSF measurements taken at 10 min (UWSF_10 min) and those taken at 5 min (UWSF_5 min). A group of SjS patients was enrolled for a comparison between UWSF and stimulated whole salivary flow (SWSF).

RESULTS

In 734 suspected SjS patients, there was a remarkably high concordance between UWSF_10 min and UWSF_5 min (ICC 0.970, P < 0.001; r 0.973, P < 0.001). Reducing the testing time for UWSF to 5 min resulted in a high PPV of 83.8% and an exceptionally high NPV of 98.7%. In 408 SjS patients, the cut-off values of UWSF_10 min were investigated to classify SG secretory function. Using a threshold of > 0.2 mL/min (36.8%, 150/408) instead of SWSF > 0.7 mL/min (indicating mild secretory hypofunction), the specificity and PPV were found to be 94.2% and 94.0%, respectively; and using a threshold of < 0.05 mL/min (16.9%, 69/408) instead of SWSF ≤ 0.7 mL/min (indicating moderate to severe secretory hypofunction), the specificity was remarkably high at 97.6%, accompanied by a high PPV of 91.3%.

CONCLUSIONS

This study supports the possibility of reducing UWSF testing time to 5 min; and the SWSF test may be skipped for SjS patients with USWF > 0.2 mL/min, indicating mild secretory hypofunction, or < 0.05 mL/min, indicating moderate to severe secretory hypofunction. Key Points •A diagnostic cohort of 734 patients with clinical suspicion of SjS provides compelling evidence for the potential to reduce the testing time for UWSF from 10 to 5 min. •Our finding challenges the 2019 treatment recommendation for SjS, which does not require SWSF measurement in SjS patients with UWSF ≥ 0.1 mL/min. •We propose that it may be feasible to consider utilizing UWSF instead of SWSF test for objective classification of SG secretory function in over half of SjS patients.

Overlap syndrome of anti-aquaporin 4 positive neuromyelitis optica spectrum disorder and primary Sjögren's syndrome: a systematic review of individual patient data

Central nervous system (CNS) involvement can occur in primary Sjögren's syndrome (pSS) due to co-existing neuromyelitis optica spectrum disorder (NMOSD) which has a highly relapsing course requiring indefinite immunosuppression, and if not diagnosed early, damage accrual occurs over time leading to permanent disability and morbidity. In this review, we describe and outline the clinical course and outcomes of anti-aquaporin 4 (AQP4) antibody seropositive NMOSD with pSS overlap cases. To investigate the co-existence of AQP4 + NMOSD with pSS, we conducted a review of individual patient data from case reports and case series found in major databases. The study extracted clinico-demographic features, imaging and laboratory profiles, treatment approaches, and outcomes of these patients. Inclusion criteria for the review required patients to have positivity for anti-AQP4 or NMO-IgG autoantibodies in the blood and/or cerebrospinal fluid (CSF) and exhibit at least one manifestation of both pSS and NMOSD. In this overlap between AQP4 + NMOSD and pSS, 44 patients were included of whom 41 (93.2%) were females. The mean age of pSS onset was 44.8 ± 18.4 years and NMOSD onset was 43.2 ± 19.8 years. In 20 (45.5%) patients, NMOSD preceded pSS onset, 13 (29.5%) NMOSD occurred after pSS onset, and 11 (25%) patients had a simultaneous presentation. 31 (70.5%) patients experienced acute transverse myelitis, 21 (47.7%) optic neuritis, 14 (31.8%) cerebral syndrome, 10 (22.7%) acute brainstem syndrome, 5 (11.4%) area postrema syndrome, and 2 (4.5%) diencephalic clinical syndromes. For the treatment of acute phase, 40 (90.9%) patients received intravenous methylprednisolone, 15 (34.1%) received plasma exchange, and 10 (22.7%) received intravenous immunoglobulin; and for the induction/maintenance therapy, 16 (36.4%) patients received cyclophosphamide, 6 (13.6%) received rituximab, 16 (36.4%) received azathioprine, and 10 (22.7%) received mycophenolate mofetil. Disease course was monophasic in 2 (4.5%) and relapsing in 27 (61.4%) patients. At median (IQR) follow-up duration of 2.4 (6) years, 39 (88.6%) patients showed improvement, 3 (6.8%) showed stabilization and 2 (4.5%) showed worsening of their NMOSD manifestations. In this overlap syndrome of AQP4 + NMOSD and pSS, patients have a neurologically disabling disorder that can mimic neurological manifestations of pSS, frequently occurs prior to the onset of pSS, has a relapsing course, responds well to immunosuppressants, and necessitates indefinite treatment. Collaborative multicentre studies are needed to clarify the natural history and outcomes of this rare overlap syndrome.

Psychological resilience in patients with primary Sjögren's syndrome: effect of involvement of major salivary and lacrimal glands

The aim of this study was to assess whether the involvement of major salivary and lacrimal glands in primary Sjögren's syndrome (pSS) affected the psychological resilience of patients. This cross-sectional study included 116 patients with pSS. Data were collected through clinical examinations, measurement of salivary flow rates (SFRs), and from Schirmer's test, as well as from patient-reported outcome measures (PROMs), such as the European League Against Rheumatism (EULAR) Sjögren's Syndrome Patient Reported Index (ESSPRI), Brief Resilience Scale (BRS), Work Productivity and Activity Impairment (WPAI), Oral Health Impact Profile-14 (OHIP-14), and the Hospital Anxiety and Depression Scale (HADS). Hyposalivation was defined as an unstimulated SFR of ≤0.1 mL/min. The BRS score (mean ± SD = 2.60 ± 0.69) was lower in patients with recurrent parotitis (2.11 ± 0.37) than in those without recurrent parotitis (2.67 ± 0.86), in the whole group. In patients with an unacceptable symptom state (ESSPRI score ≥ 5 points), a lower BRS score was observed in patients with both hyposalivation and ocular dryness (2.59 ± 0.69) than in patients with isolated hyposalivation (2.84 ± 0.84). The BRS score was also negatively associated with the WPAI-Daily Impairment and OHIP-14 scores in patients with hyposalivation as well as with HADS-A (the seven items of HADS relating to the anxiety dimension) and HADS-D (the seven items of HADS relating to the depression dimension) in the whole group. The results suggest that psychological resilience in pSS may be affected by recurrent parotitis, the levels of anxiety and depression, as well as hyposalivation with ocular dryness.

Efficacy of disease-modifying antirheumatic drugs in primary Sjögren's syndrome-related interstitial lung disease

OBJECTIVES

To evaluate the treatment modalities and their effects in primary Sjögren's syndrome (pSS) patients with interstitial lung disease (ILD).

METHODS

In this chart review study, patients diagnosed with pSS-related ILD (pSS-ILD) between January 2004 and August 2022 were screened. Glucocorticoid use and administered disease-modifying antirheumatic drugs (DMARDs) were determined. The difference between forced vital capacity (FVC) and diffusion capacity of the lungs for carbon monoxide (DLCO) before and after treatment was evaluated.

RESULTS

ILD was present in 44 of 609 patients (7.2%) diagnosed with pSS. In 27 patients included in the study, steroid usage was 81.5%. There was a statistically insignificant increase in FVC% (from 80.20±22.1 to 81.6±23.0) and a decrease in DLCO% (53.7±15.3-52.2±19.3) with DMARD treatment (p=0.434 and p=0.652, respectively). There was no significant difference between the treatment groups (azathioprine [AZA], mycophenolate mofetil [MMF], and rituximab [RTX]) in terms of the change in FVC% and DLCO% compared with baseline levels. The effect of treatment on FVC and DLCO was similar in UIP and NSIP patterns.

CONCLUSIONS

AZA, MMF, and RTX have similar effects on pulmonary functions in pSS-ILD and provide disease stabilization.