Sjögren’s Syndrome 

What Is Sjögren’s Syndrome?

[dropcap]S[/dropcap]jögren’s syndrome is a systemic inflammatory autoimmune disease with a chronic, progressive course that primarily attacks the lacrimal glands of the eye and the salivary glands of the mouth, which are exocrine glands. Exocrine glands secrete the substances they produce through a duct.

Sjögren’s syndrome is ordinarily characterized by dysfunction of the lacrimal glands to produce tears causing dry eye and the salivary glands to produce saliva causing dry mouth, but is not limited by or to these features.

Besides involvement of these exocrine glands, there may be involvement of other parts of the body, termed extraglandular, which may be more severe than eye or mouth features.

There is not yet agreement on classifying Sjögren’s syndrome. Primary and secondary are the two forms generally accepted.¹ Both forms can cause mild to severe disease, called the spectrum:

• Primary Sjögren syndrome. Disease occurs without involvement of other linked autoimmune disorders. In addition to the eyes and mouth, the nose, throat and skin may also be affected and joints, lungs, kidneys, blood vessels, digestive organs and nerves as well.² Systemic manifestations (other than eyes and mouth) concern a third of patients, including lymphoma in 5% of the patients.³
• Secondary Sjögren’s syndrome. Disease complicates other autoimmune disease such as systemic lupus erythematosus, rheumatoid arthritis, primary biliary cirrhosis, and celiac disease.

Diagnosis  of Sjögren’s syndrome is made by most doctors based on Schimer’s test for tears and unstimulated whole salivary flow to assess objective eye and oral involvement, since these are the tests most physicians use in clinical practice.⁴ Specific antibody tests would be  positive for anti-Ro (SSA)/anti-La (SSB) autoantibodies. Sjögren’s syndrome should also be considered when extraglandular manifestations such as vasculitis, polyneuropathy or arthritis occur, even when the patients do not complain of dry eyes and mouth.⁵

There is no cure for Sjögren’s syndrome. Treatment is aimed to diminish symptoms. For example, steroids and Ibupropen are used to decrease inflammation and pain in joints. Artificial tears and ointments are used for dry eye.

Most people who develop Sjogren’s syndrome are older than 40 years. Nine of ten people with Sjögren’s syndrome are women.²

What Is Sjögren’s Syndrome In Celiac Disease and/or Gluten Sensitivity?

• Relationship between Sjögren’s syndrome and celiac disease. Sjögren’s syndrome is an associated immune disorder of celiac disease.

• Relationship between Sjögren’s syndrome and gluten. The association between celiac disease and other immune disorders may be due to the sharing of a common genetic background, such as HLA antigens. However, in a very large study, involving 909 patients with celiac disease, Ventura and his associates found that the development of immune disorders in celiac disease was clearly related to the duration of exposure to gluten.⁶

• Relationship between Sjögren’s syndrome and inflammation. A prospective study investigating the occurrence of celiac disease and small-bowel mucosal inflammation in patients with primary Sjögren’s syndrome found a close association between Sjögren’s syndrome and celiac disease.⁷

• Relationship between Sjögren’s syndrome and vitamin D deficiency. A nationwide public health study investigating a possible association between vitamin D deficiency and the risk of developing immune-mediated diseases found that patients with vitamin D deficiency may have an increased risk of developing Sjogren’s syndrome, although reverse causality or confounding cannot be ruled out.⁸

• Relationship between Sjögren’s syndrome and selenium deficiency. Selenium is a powerful anti-inflammatory nutrient. In the reverse, inadequate levels of selenium promote inflammatory conditions such as Sjögren’s syndrome and lower resistance to infection by opportunistic organisms. Such germs include candida albicans yeast that more easily invade inflamed tissues of the mouth, throat, esophagus, stomach, and small intestine and by H. pylori bacteria that invades the stomach.

• Relationship between Sjögren’s syndrome and zinc deficiency. Zinc is a vital part of the immune system. Patients with an accompanying zinc deficiency have increased risk for impaired immune response to infection by organisms like candida albicans yeast that can invade the mouth, throat, esophagus, stomach, and small intestine and by H. pylori bacteria that invades the stomach.

How Prevalent Is Sjögren’s Syndrome In Celiac Disease and/or Gluten Sensitivity?

• Prevalence of Sjögren’s syndrome is reported in 1.0% of patients with dermatitis herpetiformis and 2.9% with celiac disease.⁹
• Celiac disease occurs in 12% of patients with Sjögren’s syndrome.¹⁰
• 14.7% of 34 Sjögren’s syndrome patients were found to have celiac disease in a prospective study investigating the occurrence of celiac disease and small-bowel mucosal inflammation in patients with primary Sjögren’s syndrome.⁷

What Are The Symptoms Of Sjögren’s Syndrome?

Sjögren’s syndrome may be asymptomatic or cause these symptoms.

Mild disease:

• Antibody levels are low.
• Chronic dry cough.
• Decreased tear production (dry eye) with blurry vision.
• Decreased saliva production leading to dry mouth.
• Dental decay.
• Difficulty chewing and swallowing.
• Distorted sense of taste.
• Gingivitis (inflammation of gums).
• Heartburn.
• Lowered resistance to infection that may invade the stomach such as H.pylori or candida albicans.
• There may be fatigue, arthralgias, and cognitive impairment, commonly called “brain fog.”
• Vaginal dryness.

Severe disease:

• Keratomalacia sicca syndrome with damage to the eye surface that impairs sight.
• Greatly swollen salivary glands and swollen lymph nodes in the neck.
• Disposes to kidney disease (such as IgA nephropathy).
• Disposes to lung disease (such as bronchoalveolitis and pneumonia).
• Arthritis.
• Thyroid disorders.
• Digestive disorders such as GERD, Slow Motility.
• Higher risk of non-Hodgkin’s lymphoma.

How Does Sjögren’s Syndrome Develop In Celiac Disease and/or Gluten Sensitivity?

• Sjögren’s syndrome in celiac disease results from a linked immune mechanism.
• A nationwide study in England investigating the reported association between vitamin D deficiency and the risk of developing immune-mediated diseases showed that patients with vitamin D deficiency have an increased rate of developing Sjögren’s syndrome.¹¹

Does Sjögren’s Syndrome Respond To Gluten-Free Diet?

Studies are inadequate to determine effect of gluten free diet on the course of Sjögren’s syndrome but can improve the nutritional status and damaging effects of gluten in celiac disease.

6 Steps To Improve Sjögren’s Syndrome In Celiac Disease and/or Gluten Sensitivity:

• [dropcap]1[/dropcap]Remove the Trigger. Maintain a Strict, Nutritious Gluten Free Diet:

[box type=”shadow” ]Treatment. This condition responds to the complete elimination of gluten, which is the required treatment that improves both Sjögren’s syndrome and gut health.

• Gut health is the foundation to restore ALL health. Restored health will enable you to maintain a strict gluten free diet, just as other life tasks will be easier.
• A strict gluten free diet means removing 100% of wheat, barley, rye and oats from the diet.
• Cutting out bread and other obvious sources of gluten is not good enough for recovery. Even 1/8th teaspoon of flour or bread crumb is enough to sustain the inflammation that is damaging your small intestine, causing increased permeability (leaky gut) and allowing undigested gluten to enter your body where it can damage structures and function, and instigate immune inflammatory responses.

Correct Your Individual Nutritional Needs.

• Eat foods that can replenish missing nutrients. Find them under NUTRIENT DEFICIENCIES.
• Take nutritional supplements as needed. Find them under NUTRIENT DEFICIENCIES.

Recovery. You should begin to feel better within a week and notice more energy as inflammation subsides and the  absorbing cells that make up the surface lining of your small intestine are better able to function.

• Intestinal lining cells are replaced every 5 days. The healing process is like sunburn where the damaged surface layer of skin sloughs off and is replaced with new normal cells.
• Leaky gut normally resolves in two month after starting a gluten free diet and brings about a big improvement in health. Improvement in intestinal permeability precedes morphometric recovery (cell appearance and structure) of the small intestine in celiac disease.¹²
• The intestinal lining may take up to a year to heal.[/box]

• [dropcap]2[/dropcap] Reduce Inflammation. Foods to Eat and Foods Not to Eat:

Because gluten is inflammatory, eliminate OTHER inflammatory foods from your diet to reduce an additive effect to gluten. At the same time, try to eat foods that reduce inflammation (anti-inflammatory).

[box type=”shadow” ]Here Are Major Inflammatory Food Types That Reduce Healing:

• Damaging Foods. In susceptible persons, includes corn, dairy (cow), and soy. Lactose, the sugar in any animal milk disrupts intestinal permeability causing leaky gut.¹³
• Allergenic Foods. Includes foods that trigger the immune sytem to produce IgE antibodies. Allergy testing is the usual way to discover these offending foods.
• Shelf Stable Processed Foods. Includes any that contain additives and preservatives. Look for them on the nutrition label of the box or package. Additives and preservatives also disrupt intestinal permeability causing leaky gut.¹³
• Fats. Limit deep fried foods, trans-fats, saturated fats (animal fat/butter), and EXCESSIVE omega-6 fatty acid oils like corn oil. Rancid fats, sodium caprate (a medium chain fat), and sucrose monester fatty acid (a food grade surfactant) induce significant disruption of the intestinal barrier that causes leaky gut.¹³.
• Excessive Refined White Flours (bran layer removed). Includes products made from them such as cookies, bread, cakes, pies. Bran contains the vitamins and minerals that metabolize grains and slows the otherwise rapid entry of sugar from their digestion into the bloodstream. Also disrupt intestinal permeability causing leaky gut.¹³
• Refined Sugars.  Includes white sugar, corn fructose and high fructose corn syrup.
• Certain Spices. Includes paprika and cayenne pepper which disrupt intestinal permeability causing leaky gut.¹³
• Alcohol and Caffeine. Disrupt intestinal permeability causing leaky gut.¹³[/box]

[box type=”shadow” ]Here Are Important Anti-Inflammatory Food Types to Promote Health:

• Fruits. Contain ample amounts of vitamins, minerals and phytochemicals which are naturally occuring components in plants that detoxify toxins, carcinogens (reducing the risk by 50%) and mutagens.
• Non-Starchy Vegetables. Support intestinal integrity and provide ample amounts of vitamins, minerals and phytochemicals. Includes green leafy vegetables such as lettuce and kale, also onion, broccoli, garlic, and others.
• High Quality Complex Carbohydrates. Provide vitamins, minerals, and fiber while boosting serotonin levels to help you relax and feel calm. Includes whole grains, legumes, and root vegetables such as carrots, parsnips, sweet potatoes, turnips, red beets, and others.
• Antioxidants. Protect the body from inflammatory oxidant molecules that continually occur and help us handle stress and reduce irritability. Includes vitamin C-containing foods such as lemon, grapefruit, apricot, Brussels sprouts and strawberries, and others. Also, includes vitamin E-containing foods such as nuts, seeds, avocado, olive oil, and others. Cocoa is good, too.
• Omega-3 Fatty Acids. Balance opposing omega-6 fatty acids and bad fats. Fish sources includes tuna, salmon, cod, and others. Plants sources include flax, chia seeds, canola oil, and others.
• Probiotics. Supply normal microbes needed for colon health and health of the body such as these fermented foods: yogurt, kefir, and unpasteurized apple cider vinegar.
• Prebiotics/ High Fiber Foods.  Food with fiber keeps our population of colonic microbes healthy.
• Protective Herbs and Spices.  See below #6 below for examples.[/box]

• [dropcap]3[/dropcap] Information Sheet You Can Take to Your Doctor or Other Health Professional:

Click here.

• [dropcap]4[/dropcap] Manage Your Medications Safely:

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• Some medicines used for other conditions can cause eye and mouth dryness which worsen Sjögren’s syndrome. If you are taking one of the drugs listed below, ask your doctor about them.  Do not stop prescribed medications without supervision.

Drugs that can cause dryness include:

• Those used for allergies and colds (antihistamines and decongestants).
• Those used to lower fluids (diuretics).
• Some used to treat diarrhea.
• Some used to treat blood pressure.
• Some antipsychotic medicines.
• Tranquilizers.
• Antidepressants.¹⁴

• Some medicines used for Sjögren’s syndrome deplete nutrients that promote deficiencies. Ask your doctor or pharmacist about this possible adverse effect if you are taking any of the drugs listed below. Do not stop prescribed medications without supervision.

 This is not a complete listing.

ANTI-INFLAMMATORIES disrupt intestinal permeability which complicates celiac disease.

• Corticosteroids (Prednisone, Medrol®, Aristocort®, Decadron) deplete Calcium, Vitamin D, Magnesium, Zinc, Vitamin C, Vitamin B6, Vitamin B12, Folic Acid, Selenium, Chromium, Phosphorus.
• NSAIDS (Motrin®, Aleve®, Advil®, Anaprox®, Dolobid®, Feldene®, Naprosyn® and others) deplete Folic acid.

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• [dropcap]5[/dropcap]Nutritional Supplements To Help Correct Deficiencies:

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The type and quantity of nutritional supplements that may be needed depend on which nutrients are deficient.

• Multivitamin/mineral combination that provides 100% once a day is useful to improve overall nutrient levels. This is a safe dose, but always check with your doctor to avoid interactions with medications.
• B-Vitamin Complex as prescribed to restore folic acid, vitamin B6, and vitamin B12 following blood test for status.
• Calcium citrate is the best absorbed of calcium supplements. Calcium carbonate is a poor choice.
• Vitamin D3 as prescribed following blood test for status.
• Chelated magnesium as prescribed, but do not take at same time as calcium because they compete for absorption if needed.
• Zinc as prescribed following blood test for status if needed.
• Chromium and/or selenium following blood test for status if needed.

Storage Note: Store container tightly sealed, away from heat, moisture and direct light to avoid loss of potency. That is, in a safe kitchen cabinet – not in the bathroom or on the kitchen table.[/box]

• [dropcap]6[/dropcap]Manage Natural Remedies: 

[box type=”shadow” ]Hydration:

• Eight glasses of water are recommended per day unless there is a contraindication such as kidney or heart disease. The Institute of Medicine recommends approximately 2.7 liters (91 ounces) of total water, from all beverages and foods, each day for women and 3.7 liters (125 ounces) daily of total water for men.
• If you are thirsty, drink water. Add fresh, squeezed lemon to water. Lemon is anti-inflammatory, alkalizing and provides vitamin C.
• Hydration Test: Urine should be pale yellow. Fingertips should be plump, without pruning but this may not be reliable when fingers are swollen with edema. Lips should be plump, without puckering. The feeling of thirst can be unreliable.
• What is wrong with soda, coffee, tea, and alcohol? These drinks are dehydrating, increase acid, and deplete nutrients.[/box]

[box type=”shadow” ]Carminatives. The following  anti-inflammatory plant sources called carminitives help heal the digestive tract. They also tone the digestive muscles which improves peristalsis, thus aiding in the expulsion of gas from the stomach and intestine to relieve digestive colic and gastric discomfort.

Carminative Food Remedies:

• Raspberry.
• Carrot is also a cleansing digestive tonic.
• Grape is also bile stimulating and a cleansing remedy for sluggish digestion and laxative.
• Redbeets also stimulate and improve digestion and are easily digested.
• Cabbage also stimulates and improves digestion and is also a liver decongestant.
• Lettuce also stimulates and improves digestion and is also an alterative, meaning it improves the function of organs involved with the digestion and excretion of waste products to bring about a gradual change.
• Potatoes are antispasmodic (due to atropine like properties) and a liver remedy.

Carminative Herb Remedies:

• Sage is also a digestive, astringent, bile stimulant and energy tonic that heals the mucosa.  Drink as tea or use in cooking.
• Chamomile, lemon balm, and fennel, (as a tea) also help relieve nervous tension.
• Parsley also relieves indigestion.
• Rosemary as a tea and in cooking also is a nervous system tonic for stress and fatigue, bile stimulant, and can relieve headaches and indigestion.
• Thyme is also soothing remedy useful for stimulating digestion of rich, fatty foods.

Carminative Spice Remedies:

• Cloves are also antispasmodic.
• Nutmeg is also useful for indigestion.
• Ginger.[/box]

[box type=”shadow” ]Exercise Helps:

Exercise improves circulation and rids the body of toxins.

• Walking is aerobic exercise that reconditions the whole body to improve stamina. Read more about Exercise and Fitness.
• Weight training builds muscle. Read more about Exercise and Fitness.
• Stretching improves flexibilty. Read more about Exercise and Fitness.

Note: Exercise is important, but the amount and type of exercise undertaken depends on your health. Your first priority is to heal. [/box]

What Do Medical Research Studies Tell About Sjögren’s Syndrome In Celiac Disease and/or Gluten Sensitivity?

RESEARCH STUDY SUMMARIES

“Hospital admissions for vitamin D related conditions and subsequent immune-mediated disease: record-linkage studies.” This public health study investigating a possible association between vitamin D deficiency and the risk of developing immune-mediated diseases found that patients with vitamin D deficiency may have an increased risk of developing some immune-mediated diseases, including Sjogren’s syndrome, although reverse causality or confounding cannot be ruled out.

A database of linked statistical records of hospital admissions and death registrations for the whole of England (from 1999 to 2011) were analyzed. Rate ratios for immune-mediated disease were determined, comparing vitamin D deficient cohorts (individuals admitted for vitamin D deficiency or markers of vitamin D deficiency) with comparison cohorts. After hospital admission for either vitamin D deficiency, osteomalacia or rickets, there were significantly elevated rates of Addison’s disease, ankylosing spondylitis, autoimmune hemolytic anemia, chronic active hepatitis, celiac disease, Crohn’s disease, diabetes mellitus, pemphigoid, pernicious anemia, primary biliary cirrhosis, rheumatoid arthritis, Sjogren’s syndrome, systemic lupus erythematosus, thyrotoxicosis.⁸

“Autoantibodies to tissue transglutaminase in Sjogren’s syndrome and related rheumatic diseases.” This study evaluating the prevalence of IgA-anti-tissue tranglutanimase antibody (Anti-tTG ELISA) in patients with Sjogren’s syndrome demonstrated that anti-tTG ELISA is a reliable method to indicate a coexisting diagnosis of celiac disease in patients with Sjogren’s syndrome. Anti-tTG is more prevalent in Sjogren’s syndrome than in other systemic rheumatic diseases. It may be used as a screening test to identify patients with Sjogren’s syndrome who are at risk and require further evaluation for the presence of celiac disease.¹⁰

“Celiac disease and markers of celiac disease latency in patients with primary Sjögren’s syndrome.” This prospective study investigating the occurrence of celiac disease and small-bowel mucosal inflammation in patients with primary Sjögren’s syndrome found a close association between Sjögren’s syndrome and celiac disease. Even among nonceliac patients with primary Sjögren’s syndrome, an ongoing inflammation is often present in the small bowel mucosa.

A total of 34 patients with primary Sjögren’s syndrome and 28 controls underwent small bowel biopsy. Villous morphology, jejunal intraepithelial lymphocytes, and mucosal HLA-DR were evaluated and DQA and DQB alleles, serum anti-endomysial, and antigliadin antibodies were examined.

Five (14.7%) of 34 Sjögren’s syndrome patients were found to have celiac disease. The density of jejunal intraepithelial gammadelta+ T cells was increased in all celiac and in four nonceliac patients. All celiac patients, 69% of non-celiac Sjögren’s syndrome patients, and 11% of control subjects showed enhanced HLA-DR expression (p < 0.001). HLA DQ2 was present in 19 (56%) patients with Sjögren’s syndrome, including all five with celiac disease.⁷

“Diseases associated with dermatitis herpetiformis.” This study investigating the occurrence of associated diseases in a cohort of 305 patients with dermatitis herpetiformis  followed for a mean of 10 years compared with results from a cohort of patients with celiac disease demonstrated Sjogren’s syndrome in 1.0% of patients with dermatitis herpetiformis and 2.9% of celiac disease patients.⁹

Sources:

1. Huang YF, Cheng Q, Jiang CM, An S, Xiao L, Gou YC, Yu WJ, Lei L, Chen QM, Wang Y, Wang J. The immune factors involved in the pathogenesis, diagnosis, and treatment of Sjogren’s syndrome. Clin Dev Immunol. 2013;2013:160491. doi: 10.1155/2013/160491. Epub 2013 Jul 9. [↩]
2. nlm.nih.gov [↩] [↩]
3. Fazaa A, Bourcier T, Chatelus E, Sordet C, Theulin A, Sibilia J, Gottenberg JE. Classification criteria and treatment modalities in primary Sjögren’s syndrome. Expert Rev Clin Immunol. 2014 Apr;10(4):543-51. doi: 10.1586/1744666X.2014.897230. [↩]
4. Cornec D, Saraux A, Cochener B, Pers JO, Jousse-Joulin S, Renaudineau Y, Marhadour T, Devauchelle-Pensec V. Level of agreement between 2002 American-European Consensus Group and 2012 American College of Rheumatology classification criteria for Sjogren’s syndrome and reasons for discrepancies. Arthritis Res Ther. 2014 Mar 19;16(2):R74. [↩]
5. Witte T. Pathogenesis and diagnosis of Sjögren’s syndrome. Z  Rheumatol. 2010 Feb;69(1):50-6. doi: 10.1007/s00393-009-0519-2. [↩]
6. La Villa G, Pantaleo P, Tarquini R, Cirami L, Perfetto F, Mancuso F, Laffi G. Multiple immune disorders in unrecognized celiac disease: a case report. World J Gastroenterol. 2003;9(6):1377-1380, Available at: http://www.wjgnet.com/1007-9327/9/1377.asp. Accessed Jan 3, 2005. [↩]
7. Iltanen S, Collin P, Korpela M, Holm K, Partanen J, Polvi A, Mäki M. Celiac disease and markers of celiac disease latency in patients with primary Sjögren’s syndrome. Am J Gastroenterol. 1999 Apr;94(4):1042-6. [↩] [↩] [↩]
8. Ramagopalan SV1, Goldacre R, Disanto G, Giovannoni G, Goldacre MJ. Hospital admissions for vitamin D related conditions and subsequent immune-mediated disease: record-linkage studies. BMC Med. 2013 Jul 25;11:171. doi: 10.1186/1741-7015-11-171. [↩] [↩]
9. Reunala T, Collin P. Diseases associated with dermatitis herpetiformis. British Journal of Dermatology. Mar 1997;136(3):315-8. [↩] [↩]
10. Luft LM, Barar SG, Martin LO, Chan EK, Fritzler MJ. Autoantibodies to tissue transglutaminase in Sjogren’s syndrome and related rheumatic diseases. Journal of Rheumatology. Dec 2003;30(12):2613-9. [↩] [↩]
11. Ramagopalan SV, Goldacre R, Disanto G, Giovannoni G, Goldacre MJ. Hospital admissions for vitamin D related conditions and subsequent immune-mediated disease: record-linkage studies. BMC Med. 2013 Jul 25;11:171. doi: 10.1186/1741-7015-11-171. [↩]
12. Cummins AG, Thompson FM, Butler RN, et al. Improvement in intestinal permeability precedes morphometric recovery of the small intestine in coeliac disease. Clinical Science. Apr 2001;100(4):379-86. [↩]
13. Farhadi A, Banan A, Fields J, Keshavarzian A. Intestinal barrier: an interface between health and disease. Journal of Gastroenterology and Hepatology. 2003;18:479-91. [↩] [↩] [↩] [↩] [↩] [↩]
14. National Institute of Arthritis and Musculoskeletal and Skin Disease [↩]