According to the guidelines, HCQ remains the first-line option for inflammatory musculoskeletal pain; however, other disease-modifying anti-rheumatic drugs (DMARDs), such as methotrexate, may be considered in certain situations, including more severe cases when the perceived benefits outweigh the risk of increased toxicity. These situations include:
- Patients who are HCQ responsive but must discontinue therapy due to toxicity or adverse effects;
- Patients who have inadequate response to HCQ;
- Patients with severe steroid-responsive musculoskeletal pain and persistent symptoms who need another DMARD for steroid-sparing effect; and for
- Patients with objective evidence of synovitis.
The decision tree also states that when HCQ or methotrexate alone or the two in combination are ineffective, ≤15 mg/day of corticosteroids for one month or shorter time frame may be considered. Corticosteroids may be used for more than one month to manage inflammatory musculoskeletal pain, “but efforts should be made to find a steroid-sparing agent as soon as possible.”
Dr. Carsons
According to Dr. Carsons, clinicians who treat Sjögren’s syndrome should also become familiar with the published oral and ocular guidelines because, although some patients display prominent rheumatologic manifestations, nearly all Sjögren’s patients have dry eyes and dry mouth, complicated by ongoing ocular and dental problems.3,4 The guideline committee feels that rheumatologists should be familiar with the basic principles of managing ocular and oral manifestations in order to guide overall patient management, Dr. Carsons says.
“Managing patients with Sjögren’s syndrome involves multiple specialties, not only for treatment but also for diagnosis. You have to have close cooperation among rheumatologists, ophthalmologists and dentists,” Dr. Carsons says.
