What is your approach to managing sicca symptoms in patients not responding or not tolerating conservative measures, pilocarpine, and cevimeline?  

Try lower doses of pilocarpine with just 1/4 tablet at a time. Very slowly go up on the dose as tolerated. The patient's job is to find the maximum tolerated dose. I recommend this pill splitter: Mix capsule of cevimeline in water, just drink a tiny bit at a time tid and go up on dose as tolera...