Symptoms and Assessment
Joint pain is one of the most common symptoms of Sjögren’s disease. Multiple joints are painful, usually episodically with periods of joint pain, known as “flares”, followed by periods of little or no joint pain.
When joint pain is accompanied by swelling or tenderness, it may indicate inflammatory arthritis. In Sjögren’s disease, this most often affects the fingers, wrists, and ankles, although the shoulders, hips, and knees may also be involved.
Some patients with Sjögren’s disease also have fibromyalgia, which can cause widespread pain that may feel like it is coming from the joints. Fibromyalgia pain is usually present most days and may worsen with stress, poor sleep, or physical exertion.
A physical examination is important to look for joint swelling, warmth, tenderness, and reduced range of motion. In some cases, additional tests may be used to help distinguish Sjögren’s-related arthritis from other causes of joint pain such as Osteoarthritis.
Treatment
Many treatment modalities are available to treat joint pain associated with Sjögren’s disease depending on the severity and the individual patient.
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
If the joint pain is mild and intermittent, acetaminophen or short courses of non-steroidal anti-inflammatory drugs (NSAIDs) available without prescription may suffice. If the joint pain is more persistent, prolonged use of prescription-strength NSAIDs may be required. Chronic therapy with prescription-strength NSAIDs has a risk of inciting potentially dangerous stomach ulcers in up to 4% of patients each year, particularly in elderly individuals as well as those who are taking blood thinners or corticosteroids or have had a prior history of stomach or peptic ulcers. Steps can be taken to reduce this risk. These include using the lowest dose that controls the joint pain, taking the NSAID with food, choosing an NSAID with a lower risk of gastrointestinal side effects, and taking a proton-pump inhibitor, such as omeprazole or pantoprazole, along with the NSAID on a daily basis.
Disease-Modifying Anti-Rheumatic Drugs (DMARDs)
Hydroxychloroquine (Plaquenil) is commonly used for treating joint pain in Sjögren’s disease patients, based in part on its efficacy in treating the joint pain of patients with systemic lupus erythematosus and rheumatoid arthritis. It is generally well-tolerated but its use for a period of 10 years or more is associated with potential damage to the retina of the eye in 1 out of 1000 patients. Patients taking hydroxychloroquine for prolonged periods should therefore have yearly eye examinations.
More severe forms of arthritis associated with Sjögren’s disease may require treatment with other DMARDs including methotrexate, leflunomide, cyclosporine, TNF antagonists (such as etanercept, adalimumab and infliximab), and rituximab.
Prednisone can be a very effective and quick-acting treatment for arthritis, but chronic therapy, even in low doses, leads to an increased risk of osteoporosis. Higher doses should only be used for short periods of time, since these can result in so-called Cushingoid side effects, such as weight gain, diabetes, bruising and increased risk of infection.
Non-pharmacologic
Non-pharmacologic measures are also important aspects of the therapeutic program. The application of moist heat to the hands with a paraffin bath can help relieve stiffness of the fingers and wrists in the morning. Gentle exercise, including Tai Chi, yoga and dancing, can serve to strengthen muscles and preserve joint range of motion. Nutritional supplements, such as glucosamine or fish oils, may also help some patients. Finally, experimenting with one’s diet may reveal certain foods that aggravate the joint pain. This is variable, but elimination of dairy, bread products, or excessive salt can reduce joint pain in some individuals.
