Sjogren’s Flashcards
Key Points:
•Lymphocytic attack on ? glands (? and ?)
•Classified as ? complex: dry ? and dry ?
•Symptoms are ? (primary) and ? (secondary).
•Secondary Sjögren’s is often associated with other ? conditions.
•Triggers include ? and ?.
Key Points:
•Lymphocytic attack on secretory glands (lacrimal and salivary)
•Classified as sicca complex: dry eyes and dry mouth
•Symptoms are glandular (primary) and extraglandular (secondary).
•Secondary Sjögren’s is often associated with other autoimmune conditions.
•Triggers include viral infections and hormone imbalances.
Etiology:
The etiology of Sjögren’s is largely unknown.
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Etiology:
The etiology of Sjögren’s is largely unknown.
- •Genetics
•Strongest association with HLA-DR region (HLA-DRB1)
•Genes associated with innate immunity: IRF5 TNIP1 – affect cytokine production. - •Hormones
- •Infections – viral
•EBV and CMV- often raised antibodies to these
•Coxsackievirus
•Retroviruses – HIV and HTLV-1 can sometimes cause Sjögren-like symptoms of diffuse infiltrative lymphocytosis in salivary glands.
Clinical Features:
Exocrine gland features: 6
Clinical Features:
Exocrine gland features:
- •Keratoconjunctivitis sicca (dry eyes)
- •Xerostomia (dry mouth)
- •Salivary gland enlargement (parotid, submandibular…)
- •Lacrimal gland enlargement
- •Nonspecific cough, recurrent rhinitis/sinusitis
- •Vaginal dryness
Extra-glandular Symptoms (usually from other conditions) •Skin: 3 •Musculoskeletal: 2 •Thyroid: 2 •Pulmonary: 1 •Cardiac: 1 •GI: 5 •Liver: 2 •GU: 4 •Neuro: 3 •Lymphatic: 2 •General: 3
Extra-glandular Symptoms (usually from other conditions)
- Skin: Raynaud’s, vasculitis, photosensitivity
- Musculoskeletal: arthralgias (usually RA picture), myalgias
- Thyroid: Hashimoto’s, hypothyroidism
- Pulmonary: interstitial lung disease
- Cardiac: pericarditis
- GI: dysphagia, dyspepsia, epigastric pain, nausea, gastritis
- Liver: primary biliary cirrhosis, chronic active hepatitis.
- GU: interstitial nephritis, dysuria, nocturia, urgency.
- Neuro: Peripheral neuropathy, ataxia, CN neuropathy
- Lymphatic: non-hodgkins lymphoma, B-cell lymphoma
- General: Fatigue, depression, anxiety
Diagnostic Testing:
Serologic testing:
- Antinuclear antibodies - ?
- Anti-SSA/Ro and anti-SSB/La- ?
- Rheumatoid factor – often ?
Diagnostic Testing: Serologic testing: •Antinuclear antibodies - elevated •Anti-SSA/Ro and anti-SSB/La- elevated •Rheumatoid factor – often elevated
Follow-Up Testing:
All patients with Sjögren’s should be tested for additional autoimmunity
- Other antibodies – 6
- CBC – 3
- Chem panel – 2
- inflamation labs 2
- Urinalysis – 2
Follow-Up Testing:
All patients with Sjögren’s should be tested for additional autoimmunity
•Other antibodies – anti-dsDNA, anti-centromere, anti-topoisomerase, anti-TPO, anti-TG, anti-CCP
•CBC – leukopenia, thrombocytopenia, anemia
•Chem panel – creatinine, liver enzyme tests
•ESR/CRP
•Urinalysis – proteinuria/hematuria
Dietary Modifications: •Modifications for dysbiosis: 2 •Anti-inflammatory diet – 4 •Elimination of ?, specially ? •Short-term ?
Dietary Modifications:
•Modifications for dysbiosis: low carbohydrate, low sugar
•Anti-inflammatory diet – reduction in red meat, dairy, sugar, carbohydrates.
•Elimination of food allergens specially Gluten
•Short-term fasting
Hormones: elevated or decreased
A. Prolactin – ? in Sjögren's B. Estrogen (Estradiol) – ? in Sjögren's C. Cortisol – usually ? D. Testosterone – usually ? E. DHEA – usually ? F. Thyroid hormone – usually ?
Hormones:
A. Prolactin – elevated in Sjögren’s
- •Check for hypothyroidism which may influence hyperprolactinemia
- •Vitex astus-cagnus – 200mg BID12 in dry herb equivalent (DHE)
- •Bromocriptine – 2.5mg qd - standard medication to reduce prolactin
B. Estrogen (Estradiol) – elevated in Sjögren’s
- •Reduce alcohol consumption
- •Reduce obesity
- •Indole-3-carbinol – 325mg per day13
C. Cortisol – usually decreased
- •Cortef – 20mg in am, 5mg late morning, 5mg in mid-afternoon
- •Pregnenolone – 10-15mg in the morning
D. Testosterone – usually decreased
- DHEA – 200mg/day16
- Transdermal testosterone (Androgel) – 5-10mg/day (women); 50 – 100mg/day (men)
E. DHEA – usually decreased
- •Anti-inflammatory, immunomodulatory and commonly deficiency
- •DHEA – 200mg/day
F. Thyroid hormone – usually decreased
Viral Infections: 4
Viral Infections:
•EBV, CMV, HIV, HTLV-1 associated with Sjögren’s
- Andrographis (Chuan Xin Lian) – SE with 30mg of andrographolides TID x 2-3 weeks
- Monolaurin – Antiviral properties against CMV – 600mg TID
- Reishi –(Ganoderma lucidum) – 2-6g of raw reishi or equivalent of concentrated extract.
Dysbiosis:
•Oral Candidiasis present in over ? of pts w/Sjögren’s
•Responses to bacterial DNA can trigger ? to human DNA
•Antimicrobial agents: 4
Dysbiosis:
•Oral Candidiasis present in over 1/3 of patients with Sjögren’s
•Responses to bacterial DNA can trigger cross-reactivity to human DNA
•Antimicrobial agents:
- •Berberine – 500mg BID for 3 – 6 months
- •Oregano Oil – emulsified and time released – 300mg BID
- •Artemisia annua – 100mg BID
- •Probiotics
Vitamin D:
•Vitamin D status is ? associated w/inflammation in pts w/Sjogren’s s/d.
•Vitamin D supports normal ?, is ? and ?.
•There is not a lot of evidence that supplementation with Vitamin D promotes ? in flares or ? remission.
Vitamin D:
•Vitamin D status is inversely associated with inflammation in patients with Sjogren’s syndrome.29
•Vitamin D supports normal immune function, is anti-inflammatory and analgesic
•There is not a lot of evidence that supplementation with Vitamin D promotes reduction in flares or improves remission.
Additional Treatments: 3
Additional Treatments:
- •Essential Fatty Acids – 3 – 6g EPA+DHA per day
•Well proven anti-inflammatory benefits in Sjögren’s - •Green tea extract – 240-320mg of polyphenols30
•Inhibits the expression of autoantigens in vitro - •High Dose short-term oral vitamin A – 100,000IU per day for 2 weeks
•Improved NK cell activity in those with Sjogren’s31
Local Treatments:
- •Sip fluids with ? throughout the day
- •Chew ? –
- •? to help with salivary flow
- •If mouth sores present from dryness: 4?
Local Treatments:
- •Sip fluids with lemon throughout the day
- •Chew sugarless gum – promote saliva flow
- •Acupuncture to help with salivary flow
- •If mouth sores present from dryness: liquid folic acid, topical vitamin E and glutamine or chewable deglycyrrhizinated licorice.
