Secondary Sjogren's Syndrome in 83 Patients With Rheumatoid Arthritis


Sjogren syndrome (SS) can occur alone, primary Sjogren syndrome, or in association with other rheumatic diseases, secondary Sjogren syndrome (sSS), such as Rheumatoid arthritis (RA). The occurrence of Sjogren syndrome with RA makes it course worse and increases high morbidity and mortality of RA. In this exploratory study we aim to determine the prevalence of sSS (diagnosed based on the revised version of American–European consensus Group Classification Criteria: AUCG-criteria), sicca symptoms (dry eye, dry mouth), positive autoantibody tests (Anti RO or Anti-LA antibodies), UWSFR (Unstimulated Whole Salivary Flow Rate), Schirmer and Lissamine test. In this cross-sectional study, eighty three consecutive RA patients (according to American College of Rheumatology criteria 1987) who were visited at rheumatology clinic of Razi General Hospital located in the north of Iran entered into our study. Our exclusion criteria was a positive history of past head and neck radiation treatment, Hepatitis C infection, acquired immunodeficiency disease (AIDS), pre-existing lymphoma, sarcoidosis, graft versus host disease, use of anticholinergic drugs (including neuroleptics, antidepressants, antihypertensive and parasympatholytics). They examined with UWSFR by a rheumatologist and with Schirmer test and Lissamine test by an ophthalmologist. Participants were 90.4% female with the mean age 48.3±13 years. Duration of RA was in 36.1% less than 5 years, in 22.9% 5-10 years, in 12.1% 11-15 years and in 28.9% more than 15 years. Our results demonstrated that the prevalence of sSS was 5.9% (CI:0.6%-10.5%). Number of 27.7% of RA patients positively responded to at least one question about sicca symptoms. Among objective tests, only Positive UWSFR and Lissamine test were significantly more common in RA patients with sSS in comparison to ones without sSS (P<0.001, P=0.01 respectively). In RA patients, we found a linear trend between sicca symptoms and aging (P=0.02). In patients with sicca symptoms, among tests that used for assessing decrease in saliva or tear production, only USWFR significantly more common (P=0.01). In conclusion: In RA population in North of Iran prevalence of sSS was less than 10%. In them, a significant linear trend existed between aging and sicca symptoms. Among objective tests of AUCG-criteria (except for lip biopsy that was not performed in the current study) only UWSFR and Lissamine test were significantly more common in patients with sSS in comparison ones without it.

Jonsson RSJB, Gordon TM. Sjogren's syndrome. In: Koopman WJ, Moreland LW, eds. Arthritis and Allied Conditions a Textbook of Rheumatology. 15th ed. Philadelphia: LWW, 2005:1681-705.

Gilboe IM, Kvien TK, Uhlig T, Husby G. Sicca symptoms and secondary Sjogren's syndrome in systemic lupus erythematosus: comparison with rheumatoid arthritis and correlation with disease variables. Ann Rheum Dis 2001;60:1103-9.

Ankor Shah EWSC. Rheumatoid Arthritis. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J eds. Harrison's Principles of Internal Medicine. New York, NY: McGraw-Hill Professional. 18th ed. 2012:2738-770.

Athanasios G. Tzioufas DIM, Moutospoulos HM. Sjogren Syndrome. In: Hochberg MC, Silman AJ, Smolen JS, Weinblatt ME, eds. Rheumatology. 5th ed. Philadelphia: Mosbey Elsevier 2011:1339-50.

Gabriel SE, Crowson CS, Kremers HM, Doran MF, Turesson C, O'Fallon WM, et al. Survival in rheumatoid arthritis: a population-based analysis of trends over 40 years. Arthritis Rheum 2003;48:54-8.

Turesson C, O'Fallon WM, Crowson CS, Gabriel SE, Matteson EL. Occurrence of extraarticular disease manifestations is associated with excess mortality in a community based cohort of patients with rheumatoid arthritis. J Rheumatol 2002;29:62-7.

Vitali C, Bombardieri S, Jonsson R, Moutsopoulos HM, Alexander EL, Carsons SE, et al. Classification criteria for Sjögren’s syndrome: a revised version of the European criteria proposed by the American-European Consensus Group. Ann Rheum Dis 2002;61:554-8.

Vitali C, Moutsopoulos HM, Bombardieri S. The European Community Study Group on Diagnostic Criteria for Sjogren's Syndrome. Sensitivity and specificity of tests for ocular and oral involvement in Sjogren's syndrome. Ann Rheum Dis 1994;53:637-47.

Whitcher JP, Shiboski CH, Shiboski SC, Heidenreich AM, Kitagawa K, Zhang S, et al. A simplified quantitative method for assessing keratoconjunctivitis sicca from the Sjogren's Syndrome International Registry. Am J Ophthalmol 2010;149:405-15.

Drosos AA, Lanchbury JS, Panayi GS, Moutsopoulos HM.Rheumatoid Arthritis in Greek and British Patients, A Comparative Clinical, Radiologic, and Serologic Study. Arthritis Rheum 1992;35:745-48.

Ioannidis JPA, Tarassi K, Papadopoulos IA, Voulgari PV, Boki KA, Papasteriades CA, et al. Shared epitopes and rheumatoid arthritis: Disease associations in Greece and meta-analysis of Mediterranean European populations. Semin Arthritis Rheum 2002;31:361-70.

Haga HJ, Naderi Y, Moreno AM, Peen E. A study of the prevalence of sicca symptoms and secondary Sjogren's syndrome in patients with rheumatoid arthritis, and its association to disease activity and treatment profile. Int J Rheum Dis 2012;15:284-8.

Vitali C, Bombardieri S, Moutsopoulos HM, Balestrieri G, Bencivelli W, Bernstein RM, et al. Preliminary criteria for the classification of Sjögren’s syndrome. Results of a prospective concerted action supported by the European community. Arthritis Rheum 1993;36:340-7.

Calguneri M, Ureten K, Ozturk MA, Onat AM, Ertenli I, Kiraz S, et al. Extra-articular manifestations of rheumatoid arthritis: Results of a university hospital of 526 patients in Turkey. Clin Exp Rheumatol 2006;24:305-8.

Uhlig T, Kvien TK, Jensen JL, Axell T. Sicca symptoms, saliva and tear production, and disease variables in 636 patients with rheumatoid arthritis. Ann Rheum Dis 1999;58:415-22.

Young A, Dixey J, Cox N, Davies P, Devlin J, Emery P, et al. How does functional disability in early rheumatoid arthritis (RA) affect patients and their lives? Results of 5 years of follow-up in 732 patients from the Early RA Study (ERAS). Rheumatology 2000;39:603-11.

Fujita M, Igarashi T, Kurai T, Sakane M, Yoshino S, Takahashi H. Correlation between dry eye and rheumatoid arthritis activity. Am J Ophthalmol 2005;140:808-13.

Carmona L, Gonzalez-Alvaro I, Balsa A, Belmonte MA, Tena X, Sanmarti R, EMECAR Study Group. Rheumatoid arthritis in Spain: occurrence of extra-articular manifestations and estimates of disease severi. Ann Rheum Dis 2003;62:897-900.

Antero DC, Parra AG, Miyazaki FH, Gehlen M, Skare TL.Secondary Sjogren's syndrome and disease activity of rheumatoid arthritis. Rev Assoc Med Bras 2011;57:319-22.

Massardo L, Aguirre V, García ME, Cervilla V, Nicovani S, González A, et al. Clinical Expression of Rheumatoid Arthritis in Chilean Patients. Semin Arthritis Rheum 1995;25:203-13.

Cimmino MA, Salvarani C, Macchioni P, Montecucco C, Fossaluzza V, Mascia MT, et al. Extra articular Manifestations in 587 Italian Patients with RA. Rheumatol Int 2000;19:213-7.

Baldini C, Talarico R, Tzioufas AG, Bombardieri S.Classification criteria for Sjogren's syndrome: a critical review. J Autoimmunity 2012;39:9-14.

Schneeberger E, Citera G, Heredia M, Cocco JM. Clinical significance of anti-Ro antibodies in rheumatoid arthritis. Clin Rheumatol 2008;27:517-9.

Furukawa H , Shimada K, Sugii S, Hashimoto A, Komiya A, Fukui N , et al. Association of Increased Frequencies of with the Presence of Anti-Ro/SS-A and Anti-La/SS-B Antibodies in Japanese Rheumatoid Arthritis and Systemic Lupus Erythematosus Patients. PLoS One 2013;8:e53910.

Rasmussen A, Ice JA, Li H, Grundahl K, Kelly JA, Radfar L, et al. Comparison of the American-European Consensus Group Sjogren's syndrome classification criteria to newly proposed American College of Rheumatology criteria in a large, carefully characterised sicca cohort. Ann Rheum Dis 2014;73:31-8.

Galvez J, Saiz E, Lopez P, Pina MF, Carrillo A, Nieto A, et al. Diagnostic evaluation and classification criteria in Sjogren's Syndrome. Joint Bone Spine 2009;76:44-9.

Hernandez-Molina G, Avila-Casado C, Nunez-Alvarez C, Cardenas-Velazquez F, Hernandez-Hernandez C, Luisa Calderillo M, et al. Utility of the American-European Consensus Group and American College of Rheumatology Classification Criteria for Sjogren's syndrome in patients with systemic autoimmune diseases in the clinical setting. Rheumatology (Oxford, England) 2015;54:441-8.

IssueVol 54, No 7 (2016) QRcode
Rheumatoid arthritis Secondary sjogren Sicca symptoms Autoantibodies

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How to Cite
Hajiabbasi A, Shenavar Masooleh I, Alizadeh Y, Banikarimi AS, Ghavidel Parsa P. Secondary Sjogren’s Syndrome in 83 Patients With Rheumatoid Arthritis. Acta Med Iran. 2016;54(7):448-453.