Quarterly Medical Review
Challenges for lupus management in emerging countries

https://doi.org/10.1016/j.lpm.2014.04.002Get rights and content

Summary

In emerging countries, systemic lupus erythematosus (SLE) has been associated with several unfavorable outcomes including disease activity, damage accrual, work disability and mortality. Poor socioeconomic status (SES) and lack of access to healthcare, especially in medically underserved communities, may be responsible for many of the observed disparities. Diagnostic delay of SLE or for severe organ damages (renal involvement) have a negative impact on those adverse outcomes in lupus patients who either belong to minority groups or live in emerging countries. Longitudinal and observational prospective studies and registries may help to identify the factors that influence poor SLE outcomes in emerging countries. Infection is an important cause of mortality and morbidity in SLE, particularly in low SES patients and tuberculosis appears to be frequent in SLE patients living in endemic areas (mainly emerging countries). Thus, tuberculosis screening should be systematically performed and prophylaxis discussed for patients from these areas. SLE treatment in the developing world is restricted by the availability and cost of some immunosuppressive drugs. Moreover, poor adherence has been associated to bad outcomes in lupus patients with a higher risk of flares, morbidity, hospitalization, and poor renal prognosis. Low education and the lack of money are identified as the main barrier to improve lupus prognosis. Newer therapeutic agents and new protocols had contributed to improve survival in SLE. The use of corticoid-sparing agents (hydroxychloroquine, methotrexate, azathioprine and mycophenolate mofetif) is one of the most useful strategy; availability of inexpensive generics may help to optimize access to these medications.

Section snippets

Methods

Published studies were searched by querying PubMed, Medline, Embase, and Cochrane. The search process used the following keywords: systemic lupus erythematous, epidemiology, registry, diagnosis, treatment, prognosis, trials, emerging countries, and developing countries, challenges, with a specific look at publications from Africa, Asia, and Latin America. The search was performed with no date limit, and then focused on the last 20 years. The populations of the emerging countries were likened to

Epidemiology

SLE has been reported all over the world. Many epidemiological studies have detailed its incidence, prevalence, and mortality rates and their distribution according to gender, age, race, and disease presentation.

However, the epidemiology of SLE in developing countries remains largely unknown and probably underestimated, while that in developed countries is known through registries and cohorts. Some of these have contributed substantially to lupus research, especially on the differences in

Discussion

Both ethnicity and SES are independently associated with disease activity and overall organ damage. However, the components of poor SES, including less optimal medical care and insurance coverage, higher level of poverty, and lack of formal education, act synergistically with SLE, contributing to greater overall organ damage and lower survival rates among minority population groups and lupus patients from emerging countries, while ethnicity appears to play a minor role. This interaction with

Conclusion

The prevalence, morbidity, and mortality associated with lupus are highest among racial and ethnic minorities, the poor, and those lacking medical insurance and education. Lack of access to healthcare, especially in medically underserved communities, may be responsible for many of the observed disparities. Multinational collaboration can help SLE research to improve the medical technology and research methods in developing countries. Appropriate educational programs for healthcare providers and

Disclosure of interest

the authors declare that they have no conflicts of interest concerning this article.

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