Exploring Differences in Sex and Race in Patients With Lupus

Men with systemic lupus erythematosus (SLE) are an understudied population, particularly given that SLE is 9 times more common in women than men in the United States. A recent study published in Arthritis Care & Research sought to explore and characterize differences between men and women with SLE. The authors noted that Black/African American and Hispanic or Latino individuals with SLE have higher disease activity and excess mortality compared with non-Hispanic or Latino White individuals. However, the impact of race on disease outcomes in men with SLE is incompletely understood.

In this study, Rice et al sought to characterize differences in SLE clinical manifestations, prescribed medications, and socioeconomic determinants of health, including health literacy and barriers to health care access and utilization, by sex and race among men with SLE. The study recruited participants from the National Institutes of Health All of Us Research Program (“All of Us”), a longitudinal study aimed at recruiting 1 million volunteers representative of the US population. Participants were adults 18 years of age or older who reside in the United States or a US territory. The study recruited individuals with SLE by identifying those with greater than or equal to 3 SLE diagnosis codes on separate occasions and who had ever been prescribed an antimalarial medication.

Participants were categorized as male or female based on self-reported biological sex assigned at birth. Organ-specific SLE disease involvement was determined for each participant using electronic health record data. Additional surveys were used, including the Brief Health Literacy Screen to assess health literacy and the Health Care Access & Utilization Survey to determine domains of health care access and utilization. The study identified 1462 participants with SLE, including 126 men (9% of the cohort). Approximately 41% of the cohort identified as White, and 73% were overweight or obese. The majority of participants were not employed, and approximately 45% of men and 54% of women had an annual household income less than $35,000.

When exploring differences by sex, the study found that men were more likely than women to have any cardiovascular event; there was a trend toward men having more lupus nephritis, but it did not reach statistical significance. Men had lower educational attainment than women. With regard to health literacy, a significantly larger proportion of men reported lack of confidence completing medical forms than women and more frequently reported requiring help reading health-related materials. The proportions of men and women with difficulty understanding written health information were similar. Finally, the authors found barriers to health care access leading to delays in care were common in both men and women, with no major difference in the rates by sex.

When exploring racial differences in health literacy, the study found Black/African American participants and those who identified as other race more frequently reported lack of confidence in completing medical forms, required help reading health-related materials, and had difficulty understanding written health information compared with White participants. Delays in care were common among all races but were more often reported by women of races other than Black/African American or White. Women who identified as other race reported more delays due to time constraints and transportation than Black/African American and White individuals. Compared with Black/African American and White women, women of other race also more often reported delaying care because their health care provider was different from them in race, ethnicity, sex, religion, beliefs, or native language. In contrast, the researchers found White woman reported more medication challenges due to cost barriers than Black/African American women and women of other race.

There are several limitations to the study, including low response rates and small sample sizes in men. The participants may not be representative of the entire US population with SLE. Additionally, the number of participants who identified as “other race” was large, likely reflecting a heterogenous racial background. The authors noted, however, that their study is one of the largest cohorts of men among studies that systematically examine sex differences in SLE. This study demonstrated several differences between men and women with respect to sociodemographic factors, health literacy, and disease manifestations. Barriers to health care access and utilization were common among both men and women. Men with SLE had disproportionately poorer health literacy compared with women, which may be a factor that exacerbates pre-existing disparities and barriers to care.

Reference

1. Rice C, Ayyala DN, Shi H, et al. Sex and racial differences in systemic lupus erythematosus among US adults in the All of Us Research Program. Arthritis Care Res. 2023. doi:10.1002/acr.25093