Müdigkeit beim Sjögren-Syndrom – Therapeutischer Nihilismus oder sinnvolle Therapieoptionen?

Zusammenfassung

Die Müdigkeit ist ein hartnäckiges und schwierig zu beeinflussendes Problem vieler Sjögren-Patienten. Die Ursachen sind wahrscheinlich vielfältig und im Detail nicht geklärt. Die Vorstellungen zur Entstehung sind komplex, es existieren zahlreiche „black boxes”, die darüber hinaus miteinander in Wechselbeziehungen stehen. Entzündung (Zytokine), Depression und Ängste, Schonverhalten, chronische Schmerzen, schlechter Schlaf, mangelnde Krankheitsverarbeitung und fehlende körperlich Fitness tragen zur Genese bei und sind beim einzelnen Betroffenen unterschiedlich ausgeprägt. Ein vielschichtiges bio-psycho-soziales Betrachtungsmodell ist – wie beim Umgang mit chronischen Schmerzpatienten – sinnvoll, um therapeutische Ansätze zu erforschen und Behandlungsstrategien zu entwickeln. Therapien erbringen nicht immer den gewünschten Erfolg, sie gestalten sich für Patienten, aber auch für Ärzte oft mühsam. Ein diagnostischer und therapeutischer Nihilismus ist dennoch nicht angezeigt. Eine sorgfältige Anamnese und körperliche Untersuchung und gezielt weiterführende Untersuchungen helfen im Einzelfall behandelbare Ursachen (z. B. Anämie, Hypothyreose) zu evaluieren. Eine immunsuppressive Therapie einzig zur Behandlung der Müdigkeit (und auch der Sicca-Symptomatik) ist zum gegenwärtigen Zeitpunkt – mit Ausnahme der gut verträglichen Antimalariamedikamente – nicht zu empfehlen. Die konsequente Behandlung der Manifestationen des Sjögren-Syndroms (Trockenheitsbeschwerden der Augen, des Munde und der Scheide, Organmanifestationen, Lymphomfrüherkennung) trägt zu einer besseren Alltagsbewältigung bei und vermindert direkt oder über eine Reduktion der Depressivität die Müdigkeit. Besonders nächtliche Beschwerden in Form von Schmerzen, Sicca-Problemen, RLS, die durch Schlafstörungen die Müdigkeit noch verschärfen können, müssen symptomatisch behandelt werden. Medizinische Trainingstherapie, aktive Physiotherapie und Schulungen einschließlich verhaltenstherapeutischer Maßnahmen (Verarbeitungsstrategien) sind wertvolle Ergänzungen zur Verbesserung der Lebensqualität von betroffenen Patienten. Information und ein vertrauensvolles Arzt-Patienten-Verhältnis unterstützen nicht unwesentlich den täglichen Umgang mit der chronischen Krankheit.

Abstract

Fatigue is an obstinate problem for Sjögren's patients and difficult to influence. The causes seem to be multiple and have not been clarified in detail. The suggestions about the genesis are complex and there are many black boxes which even interact. Inflammation (cytokines), depression and anxiety, avoidance behaviour, chronic pain, poor sleep, inadequate coping strategies and lack of physical endurance contribute to its development with individually varying degrees of severity. A sophisticated bio-psycho-social model as practiced in the therapy for chronic pain patients is required to develop and investigate elaborate therapeutic strategies. Treatment attempts are often frustrating for both patients and physicians. However, a diagnostic and therapeutic nihilism is not appropriate. A careful medical history and a purposeful diagnostic procedure help to find individually treatable causes like anaemia or hypothyreosis. Immunosuppressive therapy for the treatment of isolated fatigue (and sicca symptoms) without systemic disease or internal organ involvement can currently not be recommended, with the exception of the well tolerated anti-malarial drugs. Consequent optimal care of the sicca symptoms (xerophthalmia, xerostomia, vaginitis sicca) and of internal organ complications contributes directly and/or indirectly via reduced depression to diminish fatigue. Aerobic exercise therapy, active physiotherapy and educational activities including cognitive behavioural measures are valuable supplements to create an acceptable quality of life. Information and a trustful patient-physician relationship should not be underestimated as a substantial contribution to establish adequate coping strategies.

Schlüsselwörter

Sjögren-Syndrom - Müdigkeit - Pathophysiologie der Müdigkeit - Therapie der Müdigkeit

Key words

Sjögren's syndrome - fatigue - pathophysiology of fatigue - therapy for fatigue

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