When do you consider immunosuppression in patients with Sjogren's neuropathy?

Only when disease activity is moderate-severe, impairing QoL, or rapidly progressive, ie mononeuritis multiplex/vasculitis, with significant risk of end-organ/tissue damage. Occasionally, autonomic neuropathy in SjD can be so debilitating to patient, and all other supportive treatments have failed, IVIG trial can be considered. Sjogren's Foundation is working on Clinical Practice Guidelines for peripheral neuropathy in SjD (includes autonomic neuropathy). The topic review groups include both neurologists and rheumatologists experienced in treating SjD, and the expert consensus panel will include sjogren's patients. Prior to COVID-era, mycophenolate, rituximab were options considered/used. Personally, at present, would only consider IVIG tri...

@Dr. First Last: I totally agree with your answer.

I'll add (and I'm sure you'll agree), I find this question one of the most difficult dilemmas in my SLE and Sjogren's patients. Even with moderate to severe neuropathy that is progressing... without a sural nerve biopsy showing active inflammation, we are truly guessing as to what is going on. Even in the context of elevated inflammatory markers and serologies. The severity and worsening could be due as much to decreased blood flow to the nerves due to vasculopathy (irreversible with immunosuppression, and the tx for which is exercise, weight loss, etc) vs active inflammation for which immunosuppression would be absolutely needed.

I wish we had a noninvasive diagnostic test that could help...

If the neuropathy is vasculitic, in association with cutaneous LCV, with palpable purpura and a foot drop, for example, I would definitely use DMARDS. These vasculitic neuropathies (mononeuritis multiplex) tend to be motor as well as sensory. I would screen for concomitant hep C infection in every such patient.