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Ask the Expert: Sjögren’s and Fibromyalgia

Posted on Wed, May 31, 2017

Sjogren's Body 2017.png

"I have been diagnosed with Sjögren’s and fibromyalgia. How do I know what symptoms are because of my Sjögren’s and which are from the fibromyalgia? 

Should I change how I treat a symptom based on which disease caused it?"

There are many symptoms of Sjögren’s and fibromyalgia that overlap, and many people suffer from both conditions simultaneously, so this is a very good question. For example, both disorders can cause symptoms of dry eyes. If the dry eyes is due to Sjögren’s the person’s eyes will actually be dry, and artificial tears or medications to increase tearing can help. That same symptom seen in fibromyalgia is not due to the eye really being dry, but instead the nerves throughout the body being more sensitive, and feeling dryness when there is none.

Pain is another symptom that both disorders can cause. If it is from Sjögren’s the pain will typically be in the joints, whereas if it is due to fibromyalgia it can be anywhere, and will especially involve the trunk, muscles, etc.

Fatigue is a characteristic of both disorders as well, but it is difficult to differentiate the fatigue of Sjögren’s from that of fibromyalgia, except by “the company it keeps.” By this I mean that if you have overall symptoms of fibromyalgia (pain in many areas, sleep problems, sensitivity to brightness of lights, noises, odors, etc), then the fatigue you are experiencing is likely more due to the fibromyalgia, whereas if there are no other symptoms of fibromyalgia and you primarily are experiencing symptoms of Sjögren’s, then the fatigue is more likely due to the Sjögren’s. 

by Daniel Clauw, MD, Michigan

 

This information was first printed in The Moisture Seeker, SSF's patient  
newsletter for members.

Take Control of Your Health!  Receive our Newsletter by Becoming an SSF Member



 

Topics: Dry Eyes, Symptoms, Sjogren's, Joint Pain, Fatigue, Chronic Pain, Ask the Expert, Fibromyalgia

Ask the Expert: How will the recently published SSF Ocular Clinical Practice Guidelines for Sjögren’s affect you

Posted on Fri, Nov 11, 2016

Question_and_Answer-1.jpg"How will the recently published Clinical Practice Guidelines (CPG) for Ocular Management affect my next visit to my eye care professional?"

The recently published SSF Clinical Practice Guidelines for Ocular Management of Sjögren’s were developed to provide evidence-based recommendations for physicians and eye-care providers to advise a logical sequence of treatment options for dry eye. One aspect of the recommendations was to describe methods of grading the severity of dry eye disease and basing therapy on severity and the patient’s response to previous therapy. The guidelines also put into perspective some of the recently developed techniques for diagnosing dry eye and monitoring therapy.

Many of the measures described in the report have been used by practitioners in previous therapy of dry eye, but some of the newer options may not yet have been incorporated into all eye care practices and the described system of grading severity may be new to some practices. Therefore, the effect of the published guidelines may have different implications to different patients.

Your physician or eye care provider may discuss some of the newer options for diagnosis and grading of severity in particular cases. This will probably be true for the testing of tear osmolarity and testing for presence of the inflammation marker MMP-9, as those new tests are of assistance in grading severity of dry eye and recommending treatment options, as well as monitoring the effect of some treatments. Some of the recommendations for such testing may depend upon availability of the in-office tests and whether the symptoms or signs of dry eye have changed in particular patients. The provider may advise additional testing or a change in therapy, but not all patients will require such testing or altered treatment.

The treatment options recommended by a patient’s care provider will depend upon the severity of dry eye disease and the response to previous therapy as well as any existing contraindications to particular treatment options. It also is important to remember that these are recommended guidelines and not mandatory standards of care for all patients with dry eye. The clinical evaluation and overall assessment of each individual patient determines appropriate management as well as the cost/benefit balance for any given patient.

Click here to view the U.S. Clinical Practice Guidelines  for Ocular Management in Sjögren’s  

by Gary N. Foulks, MD
Co-Chair of the Ocular Working Group for the Sjögren’s Syndrome Foundation Clinical Practice Guidelines Committee
 

This information was first printed in The Moisture Seeker, SSF's member newsletter.

Click here to learn more about the SSF Sjögren’s Clinical Practice Guidelines initiative   

Topics: Dry Eyes, Sjogren's, Treatment, coping with sjogren's, Ask the Expert, Clinical Practice Guidelines for Ocular Management, Clinical Practice Guidelines

Managing Sjögren’s Vasculitis

Posted on Sun, Oct 30, 2016

Ask the Expert:
“How can I manage my vasculitis so that it doesn’t become too severe?”

Vasculitis usually manifests with purplish skin lesions on the legs and sometimes the trunk. It is usually associated with high levels of gammaglobulin in the serum. The skin may become easily irritated and even break down in areas where numerous lesions develop. The skin around the ankles is most susceptible. Skin break-down and ulcerations may form.

Although severe vasculitis from Sjögren’s may require hydroxychloroquine (Plaquenil), oral corticosteroids and immunosuppressive medications, milder forms can be managed with simple conservative measures.

TMS October 2016.pngSkin breakdown occurs with greater frequency when there is fluid accumulation around the ankles so measures that minimize edema (excess fluid accumulation) in the legs can be helpful. Such measures include elevation of the legs and the use of support hose. When sitting, your legs should be propped up on a chair and not left dangling for too long. Support hose to control edema should be of the above-knee variety. Hose that bunch up below the knee may actually act like a tourniquet and impede blood flow in the legs making edema worse.

Mild trauma to the skin of the legs can also favor skin ulceration so wearing pants may provide an extra layer of protection. Edema can also be controlled with diuretics. Some patients with vasculitis may benefit from low dose aspirin to keep the blood vessels open.

Of course these conservative measures should also be applied in instances when immunosuppressive therapy is needed. Consult with your doctor if diuretic therapy or low dose aspirin is right for you.

by Herbert S. B. Baraf, MD, FACP, MACR

This information was first printed in The Moisture Seeker, SSF's member newsletter.

Take Control of Your Health!  Receive our Newsletter by Becoming an SSF Member

Topics: Plaquenil, Sjogren's, Treatment, Dry Skin, Immunosuppressant, Ask the Expert, Hydroxychloroquine, Vasculitis

Dry Eye Awareness Month: Serum Tears & Sjögren’s

Posted on Fri, Jul 01, 2016

July is Dry Eye Awareness Month! The Sjögren’s Syndrome Foundation partners with various organizations during July to help educate the public about dry eye symptoms, treatment options, and the possible cause being Sjögren’s. We hope you enjoy our July blogs aimed to promote dry eye awareness and education.   

Q) I have heard a lot about some Sjögren’s patients finding relief from Serum Tears. What are they, how are they made and will it help me with my dry eye?

SSF_Dry_Eye.jpgA) Topical autologous serum used to treat ocular surface damage from dry eye disease is usually reserved for the most severe cases that have not responded to other treatments, particularly intensive lubricant and anti-inflammatory therapy. Autologous describes the fact that it is taken from the patient themselves; serum describes the component of the blood that is used to prepare the drop. It was first reported to improve dry eye symptoms and signs in 1984, but there are now a number of reports supporting its beneficial effect in Sjögren’s disease. Most often prepared as a 20% topical solution, autologous serum must be prepared by removing blood from the patient’s vein and spinning down the clotted cells to isolate the liquid serum which is then diluted in artificial tears solution into small vials. It is not specifically approved by the FDA. Autologous serum contains fibronectin, vitamin A, cytokines, and growth factors, as well as anti-inflammatory substances, such as interleukin receptor antagonists and inhibitors of matrix metalloproteinases. It is not clear which of these components is most helpful, but significant improvement in symptoms, tear break up time, and surface staining have been reported.

The disadvantages of the use of autologous serum include the issue that it must be prepared by the eye care practitioner under well controlled conditions or by a compounding pharmacy, as well as the need to refrigerate the drops. There is a potential risk of infection if contamination of the solution occurs. The stability of frozen autologous serum has been verified for up to 3 months.

Typically, the serum is applied topically four times daily, and this can be done in conjunction with other therapy including topical lubricants, topical cyclosporine, or oral tear stimulants. The serum does not work well with contact lens wear.

This option may not work for every Sjögren’s patient and thus one will need to find an ophthalmologist or optometrist that is familiar with Serum Tears to accurately gauge the benefits.

-Gary Foulks, MD, FACS

This information was first printed in The Moisture Seeker, SSF's patient 
newsletter for members.

Click Here to Receive our Newsletter  by Becoming an SSF Member

Topics: Dry Eyes, Sjogren's, Treatment, coping with sjogren's, Ask the Expert, Serum Tears

Ask the Expert: Plaquenil and Sjögren’s

Posted on Mon, May 23, 2016

Question_and_Answer-1.jpgWhat is Plaquenil and what are its benefits for Sjögren’s patients?

Plaquenil (hydroxychloroquine) is a medication that has been used for many years to help musculoskeletal symptoms and fatigue in patients with autoimmune conditions such as rheumatoid arthritis, lupus and Sjögren’s. While there is good clinical evidence demonstrating the drug’s efficacy in rheumatoid arthritis and lupus, there are very few studies looking at hydroxychloroquine as a treatment for Sjögren’s. The studies that do exist show mixed results (some show benefit and some show no benefit) in whether or not the drug is effective in helping with pain, fatigue, dry eyes or dry mouth.

Nonetheless, despite the lack of clinical studies, rheumatologists feel that hydroxychloroquine may have a potential beneficial effect in helping patients with symptoms of fatigue and achiness, which are common complaints in patients with Sjögren’s.

TMS.pngHow the drug works is unclear, but recent research has pointed to an inhibitory effect on toll-like receptors that are proteins involved with inflammation. The good news is that hydroxychloroquine targets the immune system without causing an increase in the risk of infection or cancer that can be seen with other immunosuppressant medications. The typical dose for hydroxychloroquine is 200-400mg per day and is based on a person’s body weight (or if you are overweight, your ideal body weight). While hydroxychloroquine is considered a relatively safe medication, like all medications there are potential risks. These include body rashes that often will itch. The rash typically occurs in the first 6 weeks and is usually mild. In general, the rash will resolve within 2 weeks after stopping the drug. A more severe rash affecting larger areas of the body may occur but is not common. If this type of rash occurs, other medications such as anti-histamines and steroids may be required to help with symptoms.

Over time, hydroxychloroquine may uncommonly have an adverse effect on the retina that can lead to permanent visual damage if not picked up early. In order to protect the eyes, a baseline exam is recommended be- fore starting the drug if you are color blind, have prior retinal problems or have never had a dilated exam (checking color vision is one way the doctor monitors for early damage) or within the first 6-12 months if you have a history of healthy eyes and a recent retinal examination. After the baseline exam, it is recommended that patients get a dilated exam at the minimum of once per year. Retinal problems are more likely to occur after 5 years of use. Newer technologies are available (OCT-optical coherence tomography) that can pick up early changes. If early changes are found on exam, it would be uncommon to have progression of eye toxicity or visual changes.

Other potential side effects include but are not limited to nausea, changes in mood, muscle weakness, skin pigmentation and anemia. While the drug may be used during pregnancy, the potential benefits and risks should be discussed with your doctor.

In summary, if you have Sjögren’s, hydroxychloroquine may be an option to help your symptoms. Because there are other more effective therapies available to treat dry eyes and dry mouth, it is typically prescribed to help musculoskeletal pain and fatigue. Be patient, as the drug may take up to 6 months to see a beneficial effect.

by Scott Zashin, MD Internist & Rheumatologist in Dallas, TX

This information was first printed in The Moisture Seeker, SSF's patient 
newsletter for members.

Click Here to Receive our Newsletter  by Becoming an SSF Member

Topics: Plaquenil, Dry Eyes, Sjogren's, Fatigue, Treatment, coping with sjogren's, Immunosuppressant, Ask the Expert

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