Lupus in Hispanics: A matter of serious concern
ABSTRACTSystemic lupus erythematosus in US Hispanics is a serious disease with devastating consequences. Prompt diagnosis is of paramount importance to prevent early organ damage and death. The authors review the salient features of lupus in US Hispanics and its short-term and long-term impact in order to raise physician awareness.
KEY POINTS
- Amerindian genes contribute to a greater susceptibility to lupus, although there is an interplay between genetic and nongenetic factors in its etiology and expression.
- In large studies, disease activity and organ damage were greater in African Americans and in Hispanics from Texas than in Caucasians and Hispanics from Puerto Rico.
- Hispanics of primarily Amerindian ancestry (which includes Aztec, Mayan, Quechuan, Aymaran, and other Central and South American groups) have a lower survival rate than patients in other ethnic groups, but poverty is the responsible factor.
- The need to control disease activity with corticosteroids must be balanced against the risk of overtreatment and organ damage.
- Antimalarial drugs such as chloroquine and hydroxychloroquine should be prescribed from the outset to all patients with lupus, according to current guidelines designed to avoid ocular toxicity.
HISPANICS HAVE MORE COMORBIDITIES
Obesity, hypertension, diabetes, and metabolic syndrome are more common in US Hispanics, particularly those of Amerindian ancestry, than in the majority population of non-Hispanic Caucasians.23,24 The potential deleterious effects of glucocorticoids in patients already predisposed to these conditions need to be considered, balancing adequate disease control against the potential adverse effects.22
QUALITY OF LIFE IS WORSE WITH LUPUS
Whether it is measured with a generic instrument such as the Short Form 36 (SF-36), as it was in LUMINA,25 or with a disease-specific tool such as the Lupus-Pro, quality of life is significantly worsened by lupus. Furthermore, Fernandez et al26 found that a low level of health-related quality of life, as measured by the SF-6D version of the SF-36, was predictive of poor outcomes in LUMINA patients.
POVERTY, NOT ETHNICITY, ACCOUNTS FOR HIGHER MORTALITY RATE
As yet, we have no population-based data comparing survival in US Hispanic patients with lupus vs that of other population groups.
At first inspection, data from LUMINA indicate that Hispanics of primarily Amerindian ancestry have a lower survival rate than patients in other ethnic groups (Figure 1).6 However, when all other factors are taken into consideration, poverty, not ethnicity, is the major contributing factor (Table 2).6,27
This finding illustrates the important interplay between genetic and nongenetic factors in the course and final outcome of lupus, as already alluded to, although the exact relationship between them is not clear. It remains to be determined whether poverty is only a proxy for other population characteristics such as illiteracy, limited access to specialized care, limited access to medications, or cultural beliefs that may interfere with proper care.
ANTIMALARIAL DRUGS INCREASE SURVIVAL
Using statistical analysis that adjusts for confounding by indication, we and others28–30 have shown that antimalarial drugs exert an independent and important protective effect on survival in lupus (Figure 2).
Important also is the protective effect of antimalarials on organ damage and the possibility of using them from disease outset in Hispanic patients at risk of early and rapid damage accrual,11 renal damage, and even lupus nephritis.31,32 This has very practical implications for the adequate and prompt management of these Hispanic patients.
PRACTICAL IMPLICATIONS
Lupus in US Hispanics is a serious disease with devastating consequences. Prompt diagnosis is paramount to prevent early organ damage and to prolong survival.
The disease may present in many different and unexpected ways, but joint pain, sun-sensitive rashes, renal involvement, cytopenias, and other manifestations should prompt the clinician to consider lupus in the differential diagnosis. Patients are often dismissed as having “arthritis” without being asked about other manifestations that may suggest a systemic connective tissue disease such as lupus. The same goes for skin rashes or unusual central nervous system manifestations.
The diagnosis of lupus is clinical, but some laboratory studies are essential to rule in or rule out renal or hematologic abnormalities and determine the level of disease activity. Tests usually ordered in patients suspected of having lupus include antinuclear antibody, complement levels, a complete blood cell count and differential, and a urinalysis. The need for additional tests depends on the results of the tests listed.
Once the disease is diagnosed, treatment should be tailored to the severity and type of clinical manifestations present. In general, glucocorticoids should be used at the smallest possible dose, antimalarials should be prescribed from the outset to all patients (following current guidelines in order to avoid ocular toxicity),33 and immunosuppressants and other treatments should be considered in certain instances. In parallel, consideration should be given to sun protection, adequate exercise, tobacco avoidance, osteoporosis and atherosclerosis prevention, planned conception, and compliance.
The goal in these people at risk is to control their lupus manifestations without causing undue damage, to preserve their quality of life, and to prevent an early demise.
