The Causes of Sjogren’s Fatigue: “The Laundry List”

Fatigue - Part 3

Note: To get the most out of this page, please read or review Part 1 and Part 2 of the fatigue series. On Sjogren’s Advocate, and on this post, “fatigue” refers to physical (somatic) fatigue, unless otherwise stated.  

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Causes of Sjogren's Fatigue: The Long List This page provides a detailed list ("laundry list") of the common causes of fatigue, serving as a foundational reference. This long list does not include all causes of fatigue, but it covers most of the important ones. Future posts will provide a framework to help you determine your unique faitgue profile and use it to communicate with your doctors about evaluation and management.  

Your Sjogren’s "Fatigue Profile"

People with Sjogren’s typically experience multiple, overlapping causes of fatigue. While fatigue is a core systemic feature of the disease, other factors, including Sjogren’s comorbidities. play a significant role.

Some causes are "sneaky" because they are difficult to distinguish from the baseline, immune-mediated fatigue that most patients live with daily. Identifying these specific drivers is the only way to move past "vague" symptoms and develop an effective, targeted treatment plan.

Why is Sjogren's Fatigue Under-Recognized?

Although fatigue is nearly as common as dryness in Sjogren’s, its impact is often underestimated by the medical community for several reasons:

• Lack of Objective Testing: There are no objective tests that directly measure fatigue. Clinicians must rely on and believe patient reports regarding the profound impact fatigue has on their lives.

• Diverse Presentations: Fatigue manifests in many different forms, some of which may not even be recognized as "fatigue" by the patient or their clinician.  

• Research Gaps: Historically, Sjogren’s research has largely ignored fatigue. When it is studied, different types of fatigue are usually lumped into a single vague category, despite having different biological causes.

• Clinical Constraints: Fatigue is a complex and time-consuming problem to manage. Most doctors do not have the time, specialized training, or resources to investigate it beyond a few basic screenings.

“Fatigue and cognitive dysfunction cause the greatest patent reported disability and remain a massive unmet need, poorly addressed and validated” ~ Vieira et al. (280)

The Causes of Sjogren’s Fatigue- “The Laundry List”

The following is a long (but partial) list of common causes of Sjogren’s fatigue. The yellow highlighted items identify conditions that can often be detected by routine screening tests, allowing for earlier treatment before they become obvious or severe. Others should be investigated based on your specific signs, symptoms, and individual risk factors.

Fatigue Caused Directly by Sjogren’s Disease. These are manifestations driven by the disease process itself:

• Baseline Sjogren’s Fatigue: Caused by immune dysfunction, abnormal regulation of inflammation, and metabolic changes.

• Pain-Related Fatigue: Caused by chronic muscle, joint, gastrointestinal, or neuropathic pain.

• Peripheral Nervous System Manifestations: Especially dysautonomia (autonomic nervous system dysfunction).

• Central Nervous System Manifestations: Such as migraines, demyelinating disease, or aseptic meningitis.

• Organ Involvement: Including lung disease and kidney disease.

  (On the kidney link, scroll down to the section titled “Kidney Function Tests”)

• Malignancies: Lymphoma or, less commonly, multiple myeloma.

• Gastrointestinal Manifestations: Malnutrition (and often pain) caused by gastritis or motility issues in the esophagus, stomach, or intestines (often misdiagnosed as IBS or an eating disorder).  

  Learn more about Gastrointestinal (GI) Manifestations 

• Other Manifestations: Vasculitis, serositis (including pericarditis), myocarditis, and anemia of chronic disease.
  

Fatigue Caused by Sjogren’s Comorbidities

Group 1: Usually Managed by your Primary Care Practitioner (PCP) Note: You may need to request specific screenings, as some PCPs may not be familiar with common Sjögren’s comorbidities.

• Iron deficiency (with or without anemia)

• Autoimmune thyroid disease (affects 15–30% of patients)

• Celiac disease (one screening test usually suffices)

• Diabetes

• Fatty liver disease (MASH/Metabolic Dysfunction-Associated Steatotic Liver Disease)

• Vitamin B12 deficiency and Pernicious anemia

• Chronic infections (e.g., recurrent sinusitis or urinary tract infections)

• SIBO (Small Intestinal Bacterial Overgrowth) or other dysbiosis

• Heart disease and stroke

• Sleep disorders (including Restless Legs Syndrome and Obstructive Sleep Apnea)

• Depression

Group 2: Usually Managed by your Rheumatologist

• Overlap Syndromes: Other systemic autoimmune rheumatic diseases such as Lupus, Rheumatoid Arthritis, or Systemic Sclerosis.

• Autoimmune Liver Diseases: Primary Biliary Cholangitis (PBC) and Autoimmune Hepatitis.

• Spondylitis Family: Psoriatic Arthritis and Axial Spondyloarthritis.

• Medication Side Effects: Fatigue resulting from Sjögren’s-specific treatments.

Fatigue Caused by Factors Unrelated to Sjogren’s

These are common medical or lifestyle factors that can affect anyone, regardless of a Sjogren’s diagnosis:

• Cancer and cancer treatments

• Hepatitis C and HIV (symptoms can overlap significantly with Sjogren’s.)

• Pregnancy and menopause

• Medications: Many drugs, especially antihistamines, can cause significant drowsiness or fatigue

• Nutritional Deficiencies: Resulting from eating disorders, gastric bypass surgery, or restricted eating (such as with GLP-1 drugs)

• Substance Use: Alcohol or drug use

Resources: How to Monitor Sjogren’s How My Doctors Monitor Me for Sjogren’s

Endnotes

1. Long COVID, Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS), and Mast Cell Activation Syndrome (MCAS) share many features with Sjogren’s. While these are important topics, they are too complex to include here and will be addressed separately in future posts.

2. Fibromyalgia: Read the post on fibromyalgia to learn why it is inappropriate to label Sjogren’s patients with "fibromyalgia," even when they exhibit many fibromyalgia-like symptoms. Mislabeling often leads to inadequate assessment of symptoms that are actually caused by Sjogren’s.