Joint pain, fatigue, dry eyes, dry mouth
by Nathan Wei, MD, FACP, FACR
Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.
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While there are multiple causes of this combination of symptoms, I will discuss only a few of the more common ones.
Sjogren's disease is a common autoimmune disease that affects approximately 200,000 Americans. Ninety per cent of those affected are women. This condition is often misdiagnosed or undiagnosed.
Many women have the disease but do not recognize the symptoms which are similar to those of other conditions including menopause. Sjogren's syndrome is an autoimmune disease. Abnormal production of autoantibodies in the blood attack different organs in the body causing the various diseases. For example, in Sjogren's, autoimmunity leads to inflammation in the glands that produce secretions.
Dry mouth, dry eyes, vaginal dryness, skin dryness, and fatigue characterize the disease.
When only gland inflammation and resulting dry eyes and mouth are involved the disease is known as primary Sjogren's syndrome. When the gland inflammation exists in combination with a connective tissue disease such as lupus, scleroderma, or rheumatoid arthritis the disease is known as secondary Sjogren's syndrome. There can also be extraglandular problems associated with Sjogren's which may include joint pain, Raynaud's phenomenon, lung inflammation, enlarged lymph nodes, vasculitis, kidney, nerve, or muscle disease.
The diagnosis of Sjogren's syndrome is based largely on the detection of dry eyes and mouth. Schirmer's test for dry eyes, salivary flow testing, biopsy of salivary glands, and blood tests serve as helpful tools in making the diagnosis.
There is no cure for Sjögren's syndrome. However, treatment can help control symptoms. Treatment options include medications to supplement tears and saliva, as well as measures one can take at home to prevent eye damage and dental problems. If eye symptoms are severe, surgery may relieve excessive dryness.
A physician may suggest treatments to:
• Provide moisture to the eyes and mouth, by using artificial teardrops and saliva.
• Prevent eye damage, by protecting the eyes from wind, smoke, and other irritants.
• Prevent dental problems, by brushing and flossing teeth.
• Prevent fatigue, by balancing rest and exercise.
• Relieve respiratory and skin problems, by humidifying the home and office and using moisturizing creams.
• Relieve stomach problems, by taking antacids to reduce heartburn.
• Replenish vaginal moisture.
• Control inflammation and pain with gentle exercise and nonsteroidal anti-inflammatory drugs (NSAIDs).
• Recommend that the use of artificial saliva products, which coat the mouth, and/or place lemon drops under the tongue to stimulate saliva production.
• Prescribe antifungal medications if a yeast infection such as thrush develops in the mouth.
• Recommend a fluoride rinse or brush-on topical fluoride varnish, such as Colgate Duraphat or Prevident Prophylaxis Paste, to help prevent cavities caused by rapid tooth decay.
• Prescribe a saliva stimulant, such as pilocarpine tablets or cevimeline capsules.
• Recommend that avoidance of antihistamine medications, which can worsen dry mouth.
For vaginal dryness, a physician may prescribe the hormone estrogen in either topical creams or oral doses if nonprescription vaginal moisturizers and lubricants have not relieved dryness and painful intercourse.
Progression of Sjögren's syndrome varies by individual. Most people with this disease have chronic dryness of the eyes and mouth that lasts throughout their lives.
If extremely dry eyes are not helped by tear substitutes, topical cyclosporine ophthalmic eyedrops (Restasis) may provide relief.
If neither tear substitutes nor cyclosporine eyedrops ease dry eyes, an eye surgeon may perform a surgical procedure called punctal occlusion, in which he or she places temporary or permanent plugs in the tear ducts (lacrimal ducts) to help keep moisture in your eyes. These plugs keep tears from draining away from the eyes and leaving them dry.
For joint pain, chronic inflammation in saliva and tear glands, or other serious symptoms, treatment may include:
• Corticosteroids (such as prednisone), which are used to relieve muscle and joint inflammation but can have serious side effects, including osteoporosis, glaucoma, and diabetes.
1. Disease-modifying antirheumatic drugs (DMARDs), also known as slow-acting antirheumatic drugs (SAARDs). These medications may be prescribed by themselves or in combination to manage the symptoms of joint and muscle pain and dry skin from Sjögren's syndrome. DMARDs that may be prescribed include hydroxychloroquine sulfate (Plaquenil) or methotrexate.
2. Non-steroidal anti-inflammatory drugs (NSAIDs). NSAIDs may provide relief from inflammation, but people with Sjögren's syndrome may be more susceptible to developing gastroesophageal reflux disease (GERD) after taking NSAIDs.
3. Biologic therapies such as Enbrel, Humira, Remicade, Cimzia, or Simponi. This is particularly true of joint symptoms are severe.
Research to develop new medications to treat the symptoms of Sjögren's syndrome is ongoing.
• Interferon alpha may help increase the production of saliva.
• Bromhexine cough syrup may stimulate the production of tears.
Other conditions need to be ruled out before settling on the diagnosis of Sjogren's.
Hypothyroidism (an underactive thyroid gland) can not only cause aches and pains but also lead to chronic fatigue, dryness of the eyes and mouth, sluggishness, memory problems, and other disturbing symptoms. If undiagnosed it may be life-threatening.
Another condition that causes joint aches and pains along with dry eyes and dry mouth if fibromyalgia. This is felt to be due to disorder of central neurotransmitter function. In addition to aches and pains that affect the soft tissues as well as the joints, a patient may complain of fatigue, dryness of the eyes and mouth, irritable bowel or bladder, shortness of breath, headaches, and chest pains.
Fibromyalgia is a diagnosis of exclusion and other conditions need to be considered. The treatment for fibromyalgia is highly individualized and is discussed elsewhere on this website.
Generally when patients with systemic lupus, scleroderma, or rheumatoid arthritis have this constellation of symptoms they also have Sjogrens.
Sarcoidosis is another autoimmune condition that can be associated with joint pains, fatigue, dry eyes and dry mouth. Sarcoidosis typically affects the lungs and may also affect the heart and brain as well.
The treatment is highly variable, depending on the individual’s clinical course.
Unfortunately, malignancies can occasionally present in this fashion. Lymphomas may affect the glands that produce secretions, cause fatigue, and be accompanied by aches and pains.
The point is that this group of symptoms are relatively common and have multiple possible diagnoses. A thorough evaluation by an experienced clinician is advisable.
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