Sjogren's Syndrome Questions
Arthritis Today Medical Experts Answer Your Questions About Sjögren's Syndrome
One of the most popular features in Arthritis Today, "On Call" finds answers to your most puzzling arthritis questions by asking a variety of healthcare experts. Just click on the question or title you'd like to see.
What ANA Test Means
Shingles-Sjögren's Connection
Relief for Bad Breath
Arthritis-related Eye Problem
Biologics and Cancer Risk
Q: After two years of suffering from burning, "gritty feeling" eyes, I was referred by my eye doctor to a rheumatologist who told me I have Sjögren's syndrome. His diagnosis was based on a positive ANA test. Can you tell me what an ANA is and what a positive test means?
A: A positive ANA result indicates the presence of special proteins called antinuclear antibodies in the blood which are associated with autoimmune diseases, such as rheumatoid arthritis or lupus. Sjögren's syndrome is diagnosed by the presence of particular antinuclear antibodies in the blood and the characteristic symptoms of dry eyes, dry mouth and enlarged parotid glands under the jaw. The syndrome can occur by itself or in combination with another rheumatic disease such as lupus or rheumatoid arthritis.
Bernard Rubin, DO, Rheumatologist
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Shingles-Sjögren's Connection
Q: When I was in my 20s I experienced symptoms of shingles. Several years later I was diagnosed as having Sjögren's syndrome. Is it common for people with autoimmune diseases to experience shingles at an early age? Is there a connection between the two problems?
A: There is a well-documented association between autoimmune diseases and shingles or, in more technical language, herpes zoster. The relationship has been studied best in patients with systemic lupus erythematosus, who appear to get herpes zoster both at an earlier age and more frequently than does the general population. Studies suggest that lupus itself, as well as the immunosuppressive medications sometimes used to treat it, contribute to this higher incidence of herpes zoster. The natural course of herpes zoster does not appear to be more severe, however, in patients with autoimmune diseases than in the general population.
Jeffrey Katz, MD, Rheumatologist
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Relief for Bad Breath
Q. I was diagnosed with Sjögren's syndrome about six years ago and one of my greatest concerns is bad breath. What solutions are helpful to freshen my breath without irritating my mouth?
A: Bad breath (halitosis) can be a disturbing problem for many people with Sjögren's syndrome.
In Sjögren's, as you may know, the salivary glands in the cheeks and lower jaw are damaged. This eventually leads to reduced amounts of saliva and thus dry mouth.
One of the most important functions of saliva is to protect the surfaces of the mouth, gums and teeth from developing infection -- which can lead to bad breath as well other problems, including tooth loss.
Fortunately, there are many simple things that you can do to prevent bad breath. These include scheduling regular dental checkups and thoroughly brushing your teeth after every meal -- things everyone should do.
In addition, you should take extra care to keep your mouth moist, by taking frequent sips of water and by avoiding things that further dry the mouth. (Cigarette smoking, drugs such as antihistamines and antidepressants, and alcoholic mouthwashes are common culprits.)
Studies have shown that the drug pilocarpine may increase saliva production. Chewing sugar-free gum or sucking sugar-free lemon drops (stay away from sugared varieties, which can promote tooth decay) can help stimulate the flow of saliva.
The fact that you have bad breath may be a sign that an infection has already occurred. I would recommend you see a dentist who can check for signs of tooth decay or gum infection.
If either or both is the case, prompt dental treatment should take care of the problem, and following the preventive measures I detailed earlier can help keep it from coming back.
John Klippel, MD, Rheumatologist
Arthritis-related Eye Problem
Q. I have dry, painful eyes, which until recently my doctor attributed to Sjögren’s syndrome. Now, he says my problem is uveitis. What is the difference between the two?
A: Sjögren’s syndrome is an inflammatory condition that occurs when immune cells attack the moisture-producing glands of the eyes and mouth. It can occur by itself (primary Sjögren’s syndrome) or as part of another inflammatory disease such as rheumatoid arthritis (secondary Sjögren’s syndrome). Sjögren’s syndrome is characterized by dryness of the eyes, and most people with the problem complain of a sensation of pain or grittiness.
Uveitis, by contrast, is an inflammation of the part of the eye called the uveal tract, which is in the front of the eye. Uveitis causes pain, blurriness of vision, sensitivity to light and eye redness.
Because uveitis is also associated with certain forms of arthritis, it is possible that you have both uveitis and Sjögren’s syndrome.
These conditions should be evaluated by an ophthalmologist, who can determine the presence of inflammation in various parts of the eye.
Determining which problem you have is important because treatment for the two is different. Sjögren’s syndrome is usually treated by artificial tears to increase moisture, although therapy may also be given to control the underlying arthritis or connective tissue disease symptoms. Uveitis can be treated with the administration of glucocorticoids to the eye.
David Pisetsky, MD, PHD, Rheumatologist
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Q: I have RA and Sjögren’s syndrome. My doctor recommends a biologic, but I’ve heard having RA and taking biologics increases the risk of lymphoma. Should I avoid biologics?
A:The question of lymphoma risk for patients with rheumatic diseases, particularly rheumatoid arthritis (RA), remains an area of active study. Biologic agents, such as the tumor necrosis factor (TNF) inhibitors – adalimumab (Humira), etanercept (Enbrel) and infliximab (Remicade) – as well as other medications, such as methotrexate, are often highly effective in treating RA but may increase patients’ risk of lymphoma.
Studies of more than 3,000 people with RA, combined, published recently in both the Journal of the American Medical Association and Arthritis & Rheumatism support the concept that the TNF inhibitors adalimumab and infliximab increase the risk of malignancies and serious infections. The studies did not include etanercept. The magnitude of this risk may be increased by the use of other medications – particularly cyclophosphamide – along with TNF inhibitors. The added risk of complications was very small, in the study that included people with RA, and appeared as dosages of the medications increased.
The overall percentage of RA patients who develop lymphoma remains rather low (well under 5 percent) but distinguishing whether the risk of lymphoma is inherent to having RA or is elevated by medications used to treat it has been extremely difficult. It is likely that both the disease and its therapies increase one’s risk of lymphoma.
Primary Sjögren’s syndrome – that is, Sjögren’s syndrome occurring without any other rheumatic disease – also is associated with an increased risk of developing lymphoma. The percentage of patients with primary Sjögren’s who will develop lymphoma is estimated to be around 5 percent. This risk does not necessarily apply to patients who, like you, have secondary Sjögren’s syndrome, which is Sjögren’s associated with another condition, like RA. In such patients, the likelihood of developing lymphoma is substantially lower, although no one knows precisely how low.
In the end, the decision about whether to use biologic agents is an individual one, made with the best possible information. The potential for a slightly increased risk of lymphoma must be weighed against the frequently striking positive effects of the TNF inhibitors for patients with severe RA. If you choose to use them, talk to your doctor about what cancer screenings you should have and when; stay up to date on vaccinations, including flu shots; and be aware of signs of infections, such as fever higher than 100.5 degrees, chills or night sweats.
John H. Stone, MD, MPH, Rheumatologist
