Fatigue in Sjögren syndrome
1. Fatigue can be an isolated presenting symptom in SS.
2. It is one of the most common and disabling symptoms of SS, with a severe impact on quality of life.
3. There are multiple causes.
4. It is challenging to treat, but not impossible.
| TREATMENT |
| 1. Start hydroxychloroquine(Drug information on hydroxychloroquine) |
| 2. For treatment failures consider other symptoms such as polyarthralgias. Add second line agent after several months if appropriate (e.g. methotrexate(Drug information on methotrexate)). |
| 3. When in doubt, prescribe prednisone(Drug information on prednisone) 15 mg daily for 2 weeks followed by rapid taper. If condition truly is inflammatory fatigue will resolve within 1-2 days, invariably followed by a flare at taper. |
| 4. If you see a response to steroids, start a second line agent (methotrexate or azathioprine(Drug information on azathioprine)) or in the worst case consider IV rituximab(Drug information on rituximab).1 |
| 5. Treat nocturnal dryness with ocular gels; coat tongue with vitamin E(Drug information on vitamin e) oil or moisturizing gels. Recommend a humidifier at night and secretagogues at bedtime. |
| 6. Prescribe sleep medications, but beware of the risk of increasing dryness. |
| 7. When in doubt, order a sleep study. |
| DIFFERENTIAL DIAGNOSIS |
| Systemic inflammation |
| Disturbed sleep |
| Anxiety and depression |
| Fibromyalgia |
| Hypothyroidism |
| Medication side effects |
| Vitamin D deficiency |
| Vitamin B12 deficiency |
| Muscle inflammation |
| Associated celiac disease |
| Infection |
