In Reply: In response to Dr Vissink and colleagues, our review focused on pharmacologic therapy rather than substitutive therapy (artificial tears, salivary substitutes), not because the latter are unimportant components of Sjögren syndrome therapy but rather because of space constraints. Our review of the literature identified 4 articles regarding such therapy,1- 4 all of which had crossover designs and included from 22 to 43 patients. The results of these studies were contradictory and do not permit firm conclusions. Moreover, we are aware of no controlled studies showing that saliva substitutes are more effective than muscarinic agonists in patients with moderate to severe sicca symptoms. Although the existing literature is inconclusive on the issue of saliva substitutes, our opinion is that in clinical practice patients with mild symptoms should be first treated with therapies without adverse effects before drugs with a higher rate of adverse effects are introduced.
Ramos-Casals M, Tzioufas AG, Stone JH. Treatment Approaches in Primary Sjögren Syndrome—Reply. JAMA. 2010;304(18):2015-2016. doi:10.1001/jama.2010.1583