Table 17.4.

Extraglandular manifestations of pSS

General manifestations	Main therapeutic modalities
Fatigue Sleep disorder Fibromyalgia	• Pentagabalin (Neurontin) • Pregabalin (Lyrica) • Duloxetine (Cymbalta) • Milnacipram (Savella) • Cognitive therapy and stress reduction • Avoid tricyclic anti-depressants due to dryness, exercise, and myofascial therapy
Cutaneous Dryness Vasculitis Cryoglobulinemia	• Moisturization • Recognition and treatment of yeast infection • Corticosteroids, agents to spare corticosteroids (methotrexate, leflunomide, mycophenolic acid (mofetil), rituximab)
Arthritis, arthralgia, and myalgia	• Acetaminophen • Non-steroidal agents and disalcid • Hydroxychloroquine (6–8 mg/kg/day) • Methotrexate (either oral or self-injected) • Leflunomide (20 mg/day) • Rituximab (dosing similar to RA)
Raynaud’s phenomenon and acrocyanosis	• Avoidance of cold and stress exposure • Avoid sympathomimetic drugs (such as decongestants, amphetamines, diet pills, and herbs containing ephedra) • Calcium channel blockers • Ketanserin, a selective antagonist of the S2-serotonergic receptor • Sildenafil • Ilosprost
Circulating anti-coagulants	• Aspirin • Warfarin (if prior thrombotic episode) or lovenox