What medications should be avoided with Sjogrens?

Ask the Expert: What medications are used to treat Sjögren’s?

There are many over-the-counter and prescription drugs that can help Sjögren’s patients feel better. I will not discuss the numerous over the counter medications used for pain and moisture nor the prescription pain medications, but will concentrate on the prescription drugs used to increase moisture and to calm down the immune system. The following descriptions are brief. For complete information, ask your doctor or pharmacist.

Salagen (pilocarpine) and Evoxac (cevimeline): These two drugs are approved by the U.S. Food and Drug Administration (FDA) to increase saliva in the treatment of dry mouth. They are prescribed when other dry mouth treatments (such as xylitol gum, xylitol lozenges, and artificial saliva) do not provide enough mouth moisture. Although FDA-approved to treat dry mouth, some people find that they also help other dry areas such as the eyes, nasal passages, and skin. They can help reduce cough when it is due to a dry windpipe from Sjögren’s, and they can improve heartburn (gastroesophageal reflux) by improving the flow of saliva down the esophagus. The most common side effect is excessive sweating. A downside of these drugs is that they need to be taken three to four times a day for full effectiveness.

Plaquenil (hydroxychloroquine, HCQ): Since Sjögren’s is an autoimmune disease where the immune system is overactive, medications that calm down the immune system are sometimes needed. Plaquenil is one of the safest drugs used to treat Sjögren’s. It can especially be helpful for Sjögren’s arthritis, fatigue, and rashes. It is important to get two eye tests done every year to make sure that it doesn’t cause any eye problems. It is best to get both a visual field 10-2 and an SD-OCT test done yearly. If you are of Asian ancestry, you need three tests yearly (the preceding two tests plus a VF 24-2 or a VF 30-2). If your doctor cannot do an SD-OCT or VF 10-2 it is OK to substitute one of these with an FAF or a mfERG test. 1 Make sure to show your eye doctor this paragraph to ensure you are getting the correct tests performed (you should be your own best health advocate to ensure you are getting the proper exams).

Immunosuppressant drugs: These are stronger than Plaquenil and actually decrease (or suppress) immune system activity rather than just calm it down. These medicines are called immunosuppressants. They include methotrexate, mycophenolate mofetil, azathioprine, and cyclophosphamide. These are the most common immunosuppressants used for Sjögren’s. Since they suppress the immune system, they can increase the risk of developing infections, so they should not be used during any periods of active infection. They also require blood counts and liver enzymes to be measured regularly to ensure that they are not causing any problems in the bone marrow (that is where blood cells are made) and liver.

Corticosteroids (steroids): Steroids such as prednisone and Medrol (methylprednisolone) also suppress the immune system. Steroids work much faster than the preceding drugs. Unfortunately, most people get side effects from them. We like to use the lowest doses possible and to get our patients off steroids as soon as possible. Common side effects include weight gain, broken bones from osteoporosis, making diabetes worse, moodiness, cataracts and insomnia.

B-cell depletors: A type of white blood cell called B-cells is overactive in Sjögren’s. Some patients may benefit by using medications that calm down these B-cells. You may see this referred to as “B-cell depletion” when reading the Sjögren’s medical literature. The two drugs used are RITUXAN® (rituximab) and Benlysta (belimumab). They are both liquids requiring infusion into a vein (IV), or by self-injection under the skin (SQ).

References: 1 Marmor MF, et al. Recommendations on screening for chloroquine and hydroxychloroquine retinopathy (2016 revision).
Ophth 2016;123(6):1386.

This article was first printed in the Foundation’s patient newsletter for members.

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What Foods Are Good and Bad for Sjogren’s Syndrome?

Sjogren’s syndrome is a chronic autoimmune disorder in which the body’s own immune system attacks the glands that produce tears and saliva. Foods that help are omega-3 fatty acids, organic meat, whole fruits and vegetables. Bad foods include trans fat, high glycemic, red meat, dairy, and artificial sweeteners.

Sjogren’s syndrome is a chronic autoimmune disorder in which the body’s own immune system attacks the glands that produce tears and saliva. There are two types of Sjogren’s syndrome:

• Primary Sjogren’s Syndrome: The condition occurs alone, with no other accompanying disorder.
• Secondary Sjogren’s Syndrome: The condition occurs alongside another autoimmune disorder (like rheumatoid arthritis)

Some of the earliest symptoms of Sjogren’s syndrome are severe dryness in the eyes and mouth. This is because the condition directly affects the glands which produce moisture.

The symptoms of Sjogren’s include:

• Dry mouth
• Dry eyes
• Swollen glands
• Fatigue
• Joint pain
• Skin rashes
• Shortness of breath
• Changes of taste or smell
• Peeled lips
• Headaches

Rheumatic diseases — conditions affecting the tendons, ligaments, joint bones, and muscles — often accompany cases of secondary Sjogren’s disorder. These can include lupus, polymyositis, scleroderma, and others.

Foods that are good for Sjogren’s syndrome

As much as 90% of people with Sjogren’s have gastrointestinal challenges. Since there’s no cure for Sjogren’s syndrome, much of the treatment revolves around managing the condition. Dietary choices play an important role in this and certain foods are encouraged, such as:

Omega-3 fatty acids

This would include foods like fish, nuts, olive oil, and avocados, all of which are good for inflammation.

Organic meat

The healthier fats in grass-fed meat, especially grass-fed beef or bison, have anti-inflammatory benefits.

Whole fruits and vegetables

The many colorful varieties of fruits and vegetables are loaded with anti-inflammatory nutrients. Choose red, orange, green, and yellow fruits and vegetables for their wealth of helpful vitamins, minerals, and antioxidants.

High fiber

Lentils, kidney beans, quinoa, oats, and more are all high-fiber foods that ease symptoms of inflammation.

Spices and herbs

Various seasonings such as garlic or turmeric have long been recognized for their anti-inflammatory benefits.

QUESTION

Foods that are bad for Sjogren’s syndrome

Another way to manage your Sjogren’s symptoms is to avoid foods that are thought to worsen the condition. These include:

Trans fats

Trans fats are found in foods made with partially hydrogenated vegetable oils, like many types of fried and fast foods. In addition to raising the risk of heart disease, they have a pronounced inflammatory effect on the body that can worsen the symptoms of Sjogren’s syndrome.

High glycemic foods

Foods with a high glycemic index are those that quickly spike your blood sugar levels after consuming. The resulting insulin level can aggravate inflammation caused by Sjogren’s syndrome.

Red meat

Red meat contains arachidonic acid, a type of fat thought to contribute to inflammation in the body. A person with Sjogren’s syndrome should either reduce their consumption of red meat or choose an alternative with a healthier fat profile, such as grass-fed meat.

Dairy

Lactose is a common allergen. Allergens release histamines into the body, which can in turn cause inflammation in people with autoimmune disorders like Sjogren’s syndrome. The saturated fats in dairy may also cause inflammation.

Artificial sweeteners

Artificial sweeteners like aspartame and others may not be recognized by the immune system, potentially triggering an inflammatory autoimmune response. People with Sjogren’s syndrome may better tolerate natural sweeteners like honey.

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Diagnosis and outlook

How can you know if you have Sjogren’s syndrome?

The diagnosis of Sjogren’s syndrome can be quite complicated. Because Sjogren’s can look like other conditions, it can take some time to discover the root of your symptoms. People with this disorder will often see a range of specialists before the final diagnosis is made.

How long will Sjogren’s syndrome last?

While Sjogren’s isn’t a life-threatening condition, it can cause a number of serious complications if left untreated, such as:

• Lymphoma
• Pulmonary Disease
• Dental Cavities
• Eye Damage

Treatment for Sjogren’s is focused on managing symptoms. Doctors may prescribe various remedies for dry eye and mouth and recommend diet and lifestyle choices, such as avoiding alcohol and drinking water regularly.

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References

Johns Hopkins Medicine: «Sjogren’s Syndrome Diagnosis.»

Michigan State University: «Understanding Arthritis: The Benefits of a Healthy Diet.»

Mount Sinai: «Sjogren Syndrome.»

Nutrition Journal: «A Review of the Fatty Acid Profiles and Antioxidant Content in Grass-fed and Grain-fed Beef.»

PloS One: «Trans Fatty Acids Induce Vascular Inflammation and Reduce Vascular Nitric Oxide Production in Endothelial Cells.»

Sjögren’s Foundation: «Symptoms.»

University of Rochester Medical Center: «Sjögren Syndrome.»

UW Medicine Orthopaedics and Sports Medicine: «Sjogren’s Syndrome.»

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What Triggers Sjogren’s Syndrome?

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Sjogren’s Syndrome

Sjögren’s syndrome (SS) is a chronic systemic autoimmune disease characterized by lymphocytic infiltration of exocrine glands. It is a relatively common condition that mainly affects the eyes and salivary glands, but can affect different parts of the body. [1] [2] .

There is no cure, but the condition can be managed with medications and products such as artificial tears and saliva as well as mouth washes and lozenges. [3]

Epidemiology [ edit | edit source ]

SS is the second most prevalent autoimmune rheumatic disease. In 2008, it was estimated that 1.3 million Americans were affected [2] [4] It can present as an entity by itself, primary Sjögren’s syndrome (pSS), or in addition to another autoimmune disease, secondary Sjögren’s syndrome (sSS). pSS has a strong female propensity and is more prevalent in Caucasian women, with the mean age of onset usually in the 4th to 5th decade. [1]

Etiology [ edit | edit source ]

It is not known what causes SS. Genes may play a role, combined with an outside trigger eg bacteria or virus.It’s also more likely to affect people who have conditions such as rheumatoid arthritis, scleroderma and lupus [3] .

Clinical Presentation [ edit | edit source ]

This 90 second video takes a look at this syndrome.

The more common symptoms of Sjogren’s syndrome include:

• dry eyes (irritation, feeling gritty or itchy, burning)
• dry mouth (or difficulty chewing or swallowing).

Symptoms: Sjogren’s

Sjogren’s syndrome is a systemic condition, which means it can affect the entire body, other symptoms can include:

• swelling and tenderness of the glands around your face, neck, armpits and groin
• tiredness (fatigue)
• dry skin or rashes
• joint pain and general achiness
• dryness of the nose, ear and throat
• vaginal dryness
• bowel irritation.

Complications can include:

• increased risk of dental decay
• increased risk of developing thrush infections in the mouth
• vision problems
• inflammation of internal organs (such as the kidneys, lungs or liver)
• problems with the circulatory and nervous system. [3]

Associated Co-morbidities [ edit | edit source ]

Cytokine profile found in SS

Secondary Sjogren’s is a form of the syndrome which develops after the presentation of a primary disease, usually another autoimmune connective tissue disease [2] . Common primary diseases associated with Sjogren’s Syndrome include: Polymyositis; Rheumatoid Arthritis; Scleroderma; Systemic Lupus Erythematosus; Lymphoma. [5]

Image R: The cytokine profile found in Sjogren’s syndrome (SS) is imbalanced with the overexpression of numerous pro-inflammatory cytokines (on the left) vs low or undetectable levels of anti-inflammatory cytokines (on the right in image).

Treatment [ edit | edit source ]

There is no cure for Sjogren’s syndrome, therefore its symptoms are managed through medications, both prescription and over the counter. A variety of medications may be used to treat each of the associated symptoms. Treatment may include:

• artificial tears and lubricating ointments for the eyes
• artificial saliva
• mouth rinses and lozenges
• nasal sprays
• vaginal lubricants
• moisturising lotion for the skin
• non-steroidal anti-inflammatory drugs (NSAIDs) – these medications (for example naproxen and ibuprofen) help control inflammation and provide temporary pain relief
• corticosteroid medications – may be used as a temporary treatment for joint pain
• immunosuppressive medications (for example hydroxychloroquine and methotrexate) – may be used to help control your overactive immune system [3] .

Diagnostic Tests [ edit | edit source ]

Diagnosis of this disease is based on medical history, a physical exam, and results from some clinical and laboratory tests [5] [2] [4] . Due to the nature of the disease in that the symptoms are similar to other diseases and they appear gradually over time, it may take years for Sjogren’s to be properly diagnosed [2] . Nonetheless, diagnostic testing may include the following:

• Schirmer’s test – special blotting paper held to the eye is used to assess the degree of tear production
• eye examination – including the use of special dyes
• biopsy – a small piece of salivary gland tissue is removed (usually from the lip) and examined under a microscope
• blood tests – may be used to check the levels of particular immune system cells in the blood, and to check for any problems with your kidneys or liver [3] .

Physical Therapy Management [ edit | edit source ]

Individuals with Sjogren’s syndrome have reduced physical capacity and tend to fatigue very easily. While research on the effects of exercise on individuals diagnosed with Sjogren’s is limited, the available studies suggest these patients benefit from moderate to high-intensity levels of exercise [4] . This type of activity has a positive influence on aerobic capacity, fatigue, physical function, and mood.

Further research is required to understand the effects exercise may have on individuals with varying severities of this disease, and to determine the long-term effects exercise may have on their symptoms [4] . However, some of the musculoskeletal presentations of SS are muscle and joint pain, along with arthritis. Thererfore, a patient may be treated by a physical therapist to relieve these symptoms [6] .

Lifestyle Changes [ edit | edit source ]

There are also several things a patient can do at home in order to manage his or her symptoms. These may include [2] :

• Over the counter eye drops
• Chewing gum or sucking on hard candy to increase oral secretions
• Drinking water to relieve a dry mouth
• Using lip balm to moisten the lips
• Practice thorough oral hygiene to avoid oral infection
• Heavy moisturizing creams or ointment for dry skin
• Humidifier to hydrate the skin and moisten the air for breathing [3]

References [ edit | edit source ]

1. ↑ 1.01.1 Patel R, Shahane A. The epidemiology of Sjögren’s syndrome. Clin Epidemiol. 2014 Jul 30;6:247-55. doi: 10.2147/CLEP.S47399. PMID: 25114590; PMCID: PMC4122257.Available: https://pubmed.ncbi.nlm.nih.gov/25114590/(accessed 6/3/2022)
2. ↑ 2.02.12.22.32.42.5 National Institute of Arthritis and Musculoskeletal and Skin Diseases. Sjogren’s Syndrome. http://ww.niams.niih.gov/Health_Info/Sjogrens_Syndrome/default.asp (accessed 17 March 2011).
3. ↑ 3.03.13.23.33.43.5 Better Health Sjogren’s Syndrome Available: https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/sjogrens-syndrome#self-management-of-sjogren%E2%80%99s-syndrome(accessed 6.3.2022)
4. ↑ 4.04.14.24.3 Goodman C, Fuller K. Pathology: Implications for the Physical Therapist. 3rd ed. Denver, CO: Saunders, 2009.
5. ↑ 5.05.1 American College of Rheumatology. Sjogren’s Syndrome. http://www.rheumatology.org/practice/clinical/patients/diseases_and_conditions/sjogrens.asp (accessed 17 March 2011).
6. ↑ Medline Plus. Sjogren Syndrome. http://www.nlm.nih.gov/medlineplus/ency/article/000456.htm (accessed 6 April 2011)