title: Treatment Guidelines for Rheumatologic Manifestations of Sjögren's Syndrome: Use of Biologic Agents, Management of Fatigue, and Inflammatory Musculoskeletal Pain.
abstract: The Sjögren's Syndrome Foundation clinical practice guidelines (CPGs) are designed to improve quality and consistency of care in Sjögren's syndrome by offering recommendations for management.
  
  
  
  Management questions for the systemic manifestations of Sjögren's syndrome were posed by the CPG committee with input from patients and rheumatologists. Clinical questions were assigned to a topic review group that performed systematic reviews and data extraction and drafted guidelines. Quality of evidence and strength of recommendation were rated using the American Society of Clinical Oncology's modification of the Grading of Recommendations Assessment, Development, and Evaluation. Guideline recommendations were reviewed by a consensus expert panel (CEP) composed of 30-40 clinicians from academia and community practices, as well as registered nurses and patients, using a modified Delphi process. A CEP agreement level of 75% was set as a minimum for adoption of a guideline recommendation.
  
  
  
  Consensus was achieved for 19 recommendations; for 11 additional modules, available data were insufficient to allow a recommendation to be formulated. Of the 19 recommendations, 15 required 1 Delphi round, 2 required 2 rounds, and 2 required 3 rounds.
  
  
  
  Key recommendations include a decision tree for the use of oral disease-modifying antirheumatic drugs for inflammatory musculoskeletal pain, use of self-care measures and advice regarding exercise to reduce fatigue, and the use of rituximab in selected clinical settings for oral and ocular dryness and for certain extraglandular manifestations, including vasculitis, severe parotid swelling, inflammatory arthritis, pulmonary disease, and mononeuritis multiplex. The CPG committee strongly discouraged the use of tumor necrosis factor inhibitors for sicca symptoms and for the majority of clinical contexts in primary Sjögren's syndrome.
authors.affiliation: Winthrop-University Hospital Campus, State University of New York, Stony Brook, Mineola.
authors.forename: Steven E
authors.initials: SE
authors.lastname: Carsons
authors.affiliation: University of Pennsylvania, Philadelphia.
authors.forename: Frederick B
authors.initials: FB
authors.lastname: Vivino
authors.affiliation: University of Connecticut Health Center, Farmington.
authors.forename: Ann
authors.initials: A
authors.lastname: Parke
authors.affiliation: University of California at San Francisco.
authors.forename: Nancy
authors.initials: N
authors.lastname: Carteron
authors.affiliation: University of Texas San Antonio Dental School, San Antonio.
authors.forename: Vidya
authors.initials: V
authors.lastname: Sankar
authors.affiliation: Washington University, St. Louis, Missouri.
authors.forename: Richard
authors.initials: R
authors.lastname: Brasington
authors.affiliation: Carolinas Medical Center, Charlotte, North Carolina.
authors.forename: Michael T
authors.initials: MT
authors.lastname: Brennan
authors.affiliation: University of Connecticut Health Center, Farmington.
authors.forename: William
authors.initials: W
authors.lastname: Ehlers
authors.affiliation: Scripps Memorial Hospital Xi-Med, La Jolla, California.
authors.forename: Robert
authors.initials: R
authors.lastname: Fox
authors.affiliation: University of Oklahoma Health Sciences Center, Oklahoma Medical Research Foundation, and Oklahoma City Department of Veterans Affairs Medical Center, Oklahoma City.
authors.forename: Hal
authors.initials: H
authors.lastname: Scofield
authors.affiliation: Sjögren's Syndrome Foundation, Bethesda, Maryland.
authors.forename: Katherine M
authors.initials: KM
authors.lastname: Hammitt
authors.affiliation: Johns Hopkins University, Baltimore, Maryland.
authors.forename: Julius
authors.initials: J
authors.lastname: Birnbaum
authors.affiliation: University of Colorado, Denver.
authors.forename: Stuart
authors.initials: S
authors.lastname: Kassan
authors.affiliation: Lenox Hill Hospital, New York, and Hofstra Northwell School of Medicine, Hempstead, New York.
authors.forename: Steven
authors.initials: S
authors.lastname: Mandel
mesh_terms: D018501:Antirheumatic Agents / Q000009:adverse effects / Q000627:therapeutic use*; D001688:Biological Products / Q000009:adverse effects / Q000627:therapeutic use*; D032921:Consensus; D003663:Decision Trees; D003697:Delphi Technique; D019317:Evidence-Based Medicine; D005221:Fatigue / Q000175:diagnosis / Q000188:drug therapy* / Q000209:etiology; D006801:Humans; D007249:Inflammation / Q000175:diagnosis / Q000188:drug therapy* / Q000209:etiology; D059352:Musculoskeletal Pain / Q000175:diagnosis / Q000188:drug therapy* / Q000209:etiology; D012648:Self Care; D012859:Sjogren's Syndrome / Q000150:complications / Q000175:diagnosis / Q000188:drug therapy*; D016896:Treatment Outcome
chemical_list: D018501:Antirheumatic Agents; D001688:Biological Products