Abstract
Background/purpose
Sjögren's syndrome (SS) is characterized by diminished exocrine secretions with the resultant symptoms of dry mouth and dry eye. As genetic predisposition and ethnicity may alter the effectiveness of drug treatment, evaluation of the efficacy and safety of the secretagogue pilocarpine hy-drochloride in the treatment of xerostomia in patients with SS in different populations is needed.
Methods
Forty-four patients with SS were enrolled in this double-blind, placebo-controlled trial. Patients were randomized to receive 5 mg pilocarpine (Salagen) or placebo tablet four times daily for 12 weeks. Global evaluation and subjective responses of patients were assessed by questionnaires with visual analog scales and categorical checkboxes. Saliva production was also measured by modified Saxon's test.
Results
Pilocarpine treatment significantly improved global assessment of dry mouth, symptoms associated with dry mouth (mouth comfort, ability to sleep and ability to speak), and saliva production compared to placebo. The drug was well tolerated and the most common adverse effect was sweating (5/23, 21.7%) resulting from the muscarinic agonist action of the drug. No serious drug-related adverse effect was found in this study.
Conclusion
The results of this study suggest that therapy with 5 mg pilocarpine four times daily is effective, safe and well tolerated for the relief of oral symptoms in patients with SS in Taiwan.
Key Words: pilocarpine, Sjögren's syndrome, xerostomia
References
- 1.Vitali C, Bombardieri S, Moutsopoulos HM. Preliminary criteria for the classification of Sjögren's syndrome. Results of a prospective concerted action supported by the European Community. Arthritis Rheum. 1993;36:340–347. doi: 10.1002/art.1780360309. [DOI] [PubMed] [Google Scholar]
- 2.Venables PJ. Sjögren's syndrome. Best Pract Res Clin Rheumatol. 2004;18:313–329. doi: 10.1016/j.berh.2004.02.010. [DOI] [PubMed] [Google Scholar]
- 3.Derk CT, Vivino FB. A primary care approach to Sjögren's syndrome. Helping patients cope with sicca symptoms, extraglandular manifestations. Postgrad Med. 2004;116:49–54. doi: 10.3810/pgm.2004.09.1587. 59, 65. [DOI] [PubMed] [Google Scholar]
- 4.Pillemer SR, Matteson EL, Jacobsson LT. Incidence of physician-diagnosed primary Sjögren's syndrome in residents of Olmsted County, Minnesota. Mayo Clin Proc. 2001;76:593–599. doi: 10.4065/76.6.593. [DOI] [PubMed] [Google Scholar]
- 5.Manoussakis MN, Moutsopoulos HM. Sjögren's syndrome: current concepts. Adv Intern Med. 2001;47:191–217. [PubMed] [Google Scholar]
- 6.Andonopoulos AP, Drosos AA, Skopouli FN. Secondary Sjögren's syndrome in rheumatoid arthritis. J Rheumatol. 1987;14:1098–1103. [PubMed] [Google Scholar]
- 7.Andonopoulos AP, Skopouli FN, Dimou GS. Sjögren's syndrome in systemic lupus erythematosus. J Rheumatol. 1990;17:201–204. [PubMed] [Google Scholar]
- 8.Fox RI. Sjögren's syndrome. Lancet. 2005;366:321–331. doi: 10.1016/S0140-6736(05)66990-5. [DOI] [PubMed] [Google Scholar]
- 9.Price EJ, Rigby SP, Clancy U. A double blind placebo-controlled trial of azathioprine in the treatment of primary Sjögren's syndrome. J Rheumatol. 1998;25:896–899. [PubMed] [Google Scholar]
- 10.Vivino FB. The treatment of Sjögren's syndrome patients with pilocarpine-tablets. Scand J Rheumatol. 2001;(Suppl 115):1–13. doi: 10.1080/030097401300232583. [DOI] [PubMed] [Google Scholar]
- 11.Daniels TE. Evaluation, differential diagnosis, and treatment of xerostomia. J Rheumatol. 2000;27(Suppl 61):6–10. [PubMed] [Google Scholar]
- 12.Vivino FB, Al-Hashimi I, Khan Z. Pilocarpine tablets for the treatment of dry mouth and dry eye symptoms in patients with Sjögren's syndrome: a randomized, placebo-controlled, fixed-dose, multicenter trial. P92–01 Study Group. Arch Intern Med. 1999;159:174–181. doi: 10.1001/archinte.159.2.174. [DOI] [PubMed] [Google Scholar]
- 13.Fox RI, Konttinen Y, Fisher A. Use of muscarinic agonists in the treatment of Sjögren's syndrome. Clin Immunol. 2001;101:249–263. doi: 10.1006/clim.2001.5128. [DOI] [PubMed] [Google Scholar]
- 14.LeVeque FG, Montgomery M, Potter D. A multicenter, randomized, double-blind, placebo-controlled, dose-titration study of oral pilocarpine for treatment of radiation-induced xerostomia in head and neck cancer patients. J Clin Oncol. 1993;11:1124–1131. doi: 10.1200/JCO.1993.11.6.1124. [DOI] [PubMed] [Google Scholar]
- 15.Rieke JW, Hafermann MD, Johnson JT. Oral pilo-carpine for radiation-induced xerostomia: integrated efficacy and safety results from two prospective randomized clinical trials. Int J Radiat Oncol Biol Phys. 1995;31:661–669. doi: 10.1016/0360-3016(94)00361-N. [DOI] [PubMed] [Google Scholar]
- 16.Bell M, Askari A, Bookman A. Sjögren's syndrome: a critical review of clinical management. J Rheumatol. 1999;26:2051–2061. [PubMed] [Google Scholar]
- 17.Bolstad AI, Jonsson R. Genetic aspects of Sjögren's syndrome. Arthritis Res. 2002;4:353–359. doi: 10.1186/ar599. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Kang HI, Fei HM, Saito I. Comparison of HLA class II genes in Caucasoid, Chinese, and Japanese patients with primary Sjögren's syndrome. J Immunol. 1993;150:3615–3623. [PubMed] [Google Scholar]
- 19.Nishikawa T, Provost TT. Differences in clinical, serologic, and immunogenetic features of white versus oriental anti-SS-A/ Ro-positive patients. J Am Acad Dermatol. 1991;25:563–564. doi: 10.1016/s0190-9622(08)80413-6. [DOI] [PubMed] [Google Scholar]
- 20.Kohler PF, Winter ME. A quantitative test for xerostomia. The Saxon test, an oral equivalent of the Schirmer test. Arthritis Rheum. 1985;28:1128–1132. doi: 10.1002/art.1780281008. [DOI] [PubMed] [Google Scholar]
- 21.Ho C, Murray N, Laskin J. Asian ethnicity and adeno-carcinoma histology continues to predict response to gefitinib in patients treated for advanced non-small cell carcinoma of the lung in North America. Lung Cancer. 2005;49:225–231. doi: 10.1016/j.lungcan.2005.02.011. [DOI] [PubMed] [Google Scholar]
- 22.PaPas A, Charney M, Goden H. The effectiveness of oral pilocarpine-HCL tablets for the treatment of dry mouth symptoms associated with Sjögren's syndrome-a dose-titration study. Arthritis Rheum. 1997;40(Suppl 9):S202. [Google Scholar]
- 23.Tsifetaki N, Kitsos G, Paschides CA. Oral pilocarpine for the treatment of ocular symptoms in patients with Sjögren's syndrome: a randomised 12 week controlled study. Ann Rheum Dis. 2003;62:1204–1207. doi: 10.1136/ard.2002.003889. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Solans R, Bosch JA, Selva A. Usefulness of oral pilocarpine therapy in the treatment of xerostomia and xerophthalmia in patients with primary Sjögren's syndrome. Med Clin (Barc) 2004;122:253–255. doi: 10.1016/s0025-7753(04)75314-2. [DOI] [PubMed] [Google Scholar]
- 25.Fox RI, Tornwall J, Michelson P. Current issues in the diagnosis and treatment of Sjögren's syndrome. Curr Opin Rheumatol. 1999;11:364–371. doi: 10.1097/00002281-199909000-00007. [DOI] [PubMed] [Google Scholar]
- 26.Konttinen YT, Hukkanen M, Kemppinen P. Peptide-containing nerves in labial salivary glands in Sjögren's syndrome. Arthritis Rheum. 1992;35:815–820. doi: 10.1002/art.1780350717. [DOI] [PubMed] [Google Scholar]
- 27.Beroukas D, Goodfellow R, Hiscock J. Up-regulation of M3-muscarinic receptors in labial salivary gland acini in primary Sjögren's syndrome. Lab Invest. 2002;82:203–210. doi: 10.1038/labinvest.3780412. [DOI] [PubMed] [Google Scholar]
- 28.Soto-Rojas AE, Kraus A. The oral side of Sjögren's syndrome. Diagnosis and treatment. A review. Arch Med Res. 2002;33:95–106. doi: 10.1016/s0188-4409(01)00371-x. [DOI] [PubMed] [Google Scholar]
- 29.Salagen tablets . Physician's Desk Reference. 51st edition. Medical Economics Books; Montvale, NJ: 1997. pp. 1546–1547. [Google Scholar]