Fall 2016 (Volume 26, Number 3)

SJSC: Professional Education Day

By Arthur Bookman, MD, FRCPC

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On April 29th a Professional Education Day was held on Sjogren’s syndrome at the Hilton Meadowvale Hotel and Conference Centre in Mississauga.

Dr. Rookaya Mather, an ophthalmologist from Western University, discussed the diagnosis and management of xerophthalmia. Dr. Mather made the point that treatment is aimed at maintaining the integrity of the tear film and ocular surface through tear replacement, enhancing tear retention and maximizing meibomian gland function. She addressed four levels of tear dysfunction, from mild to severe, and gave strategies for each. She noted the advent of Lifitegrast, a potential new agent that would prevent T-cell activation on the ocular surface. She also addressed the improvement in artificial tears with the advent of hyaluronic-acid-based preparations.

Dr. Robert Fox was a guest speaker from the Scripps Memorial Hospital in La Jolla. He took an overview approach to future directions for investigations and management of Sjogren’s. He addressed the fact that the spectrum of the disease may not be fully appreciated, as many older patients with systemic lupus erythematosus may actually have Sjogren’s syndrome. He discussed the fact that many clinical trials are underway, but they do not address the key features of distress in Sjogren’s, namely dryness, pain and fatigue. He felt that interferon activation might underlie the fatigue. He also made the point that whereas SLE is largely an “immune complex” disorder, Sjogren’s is mainly a “lymphocyte aggressive” disorder. He demonstrated how bits of cellular debris could mimic viral RNA and link to Ro antigen to induce anti-Ro antibodies.

Dr. Leslie Laing, on staff at the University of Toronto School of Medicine, discussed the major issues with dental deterioration seen in Sjogren’s syndrome. She addressed the fact that implant survival was as high as 97% in patients with Sjogren’s, but about 14% had unsatisfactory results. Bone and gingival resorption about the transplant posts were the main issues.

In my own presentation, I addressed the controversial outcomes of clinical trials to date, and the development of the EULAR Sjogren’s Syndrome Disease Activity Index (ESSDAI) and the EULAR Sjogren’s Syndrome Patient Reported Index (ESSPRI) to gauge the extra-glandular activity of the disease. New clinical trials underway were described, along with their clinical targets.

Dr. Julius Birnbaum is the only certified internist, neurologist and rheumatologist in the United States. He was a guest speaker from Johns Hopkins Hospital in Baltimore. He covered the neurological manifestations in Sjogren’s syndrome, his special area of interest and research. Most interestingly, he described the pathology and clinical manifestations of small fiber neuropathy. The pathological illustrations were quite convincing, but more importantly, he described two subtypes: 1) Length dependent with peripheral pain and sensory loss; and 2) Non-length-dependent, which is a “ganglionopathy” involving the dorsal root ganglia. The diagnosis is best made with skin biopsy, and the prevalence is around 9.7%. Devic’s disease as a cause of spinal cord demyelination in Sjogren’s was also discussed.

Finally, Dr. Christina McCord, an oral pathologist at Western University, reviewed the mucosal pathology seen with Sjogren’s syndrome, including the many forms of candidiasis. She discussed the reasons for salivary gland swelling and methods for management. She reviewed the difficulty with dentures, and the trauma they produce. Topical modalities for management were reviewed. Dr. McCord also addressed the indications and methodology for minor salivary gland biopsy.

The Professional Education Day had more than 90 registrants, and the feedback indicated that the information provided was outstanding. The organizers (Toronto Western Hospital Division of Rheumatology and the Sjogren’s Society of Canada) were inundated with requests for a repeat performance, and discussions are underway to consider another CME event in western Canada.

Arthur A.M. Bookman, MD, FRCPC
Coordinator, Multidisciplinary Sjogren’s Clinic
University Health Network
Associate Professor of Medicine, University of Toronto,
Toronto, Ontario