With an increasing worldwide SLE prevalence,4 our study, which reports the current prevalence of SLE and coexisting autoimmune disease in Puerto Rico, is particularly relevant. Our data revealed prevalence rates consistent with the increasing trend seen worldwide.13 Also, similar to previous studies, our data had an expected marked distinction between rates of SLE in males and females, with a female-to-male ratio of 6:1.3,4
It should also be noted that the years analyzed in this study coincide with a particularly vulnerable period for the Puerto Rican healthcare system. In 2017, Hurricane Maria devastated the island, leaving millions without access to electric power and safe water sources, contributing to a 62% increase in mortality rate.14 In 2018, the health infrastructure in Puerto Rico was in the process of being rebuilt. Rodríguez-Madera et al.15 suggests that the hurricane created even more vulnerabilities in an already damaged healthcare infrastructure. For example, approximately 3,000 deaths can be directly attributed to the prolonged inability to access medical care post-Hurricane Maria. Within our dataset, we observed that the number of individuals insured by government-sponsored health insurance was markedly less in 2018 than in 2019 and 2020, consistent with the decreased access to health services post-Hurricane Maria. The peak prevalence observed in 2019 may be partly due to the restoration of essential infrastructures, such as communication systems, electricity, and transportation, which would allow increased access to care. We should also consider stress as a likely contributor to this increase in prevalence in 2019. The etiology of autoimmune diseases, such as SLE, is multifactorial, and both physical and psychological stress have been implicated as a trigger to their development and onset.16 Although we were not able to include data from years prior to Hurricane Maria, which took place in late 2017, literature has demonstrated that Puerto Ricans experienced higher than typical rates of stress and mental health disorders after this event.17 Given the synergistic relationship between stress and SLE, it is possible that the stress associated with Hurricane Maria may have contributed to the peak prevalence we observed in 2019. In 2020, we saw a downward trend of cases. Interestingly, this corresponds to the first year of the COVID-19 pandemic, where access to health services decreased due to the imposed restrictions. However, literature that examines the impact of COVID-19 on access to healthcare in Puerto Rico is limited.18 Therefore, it is essential to follow the data into the coming years to understand the impact of the COVID-19 pandemic on these rates.
We believe that this is the first work to explore the frequency of coexisting autoimmune diseases in patients with SLE in Puerto Rico. In our study, 3.6% of patients with SLE had at least one additional autoimmune comorbidity. This rate closely approximates the rate of developing an autoimmune disease in the general population (4.5%).12 We expected that given the high rates of SLE in Puerto Rico, the frequency of coexisting autoimmune diseases would be higher than in other regions. It is, however, much lower than the rate reported by a small retrospective study of patients in a United Kingdom clinic, which determined that up to 30% of their patients with SLE had at least one additional autoimmune condition.19 Of note, 72 of the 78 Puerto Rican municipalities have been classified as medically underserved areas, in part due to specialty physician shortages.20 Therefore, future research should also include the specialty of the diagnosing physician as a possible factor that may impact the frequency of coexisting autoimmune diseases. Including this in an analysis may reveal a more subtle effect of patients' socioeconomic status, as access to specialty care is further restricted by the number of physicians on the island that have the training to identify other, possibly rarer autoimmune conditions.
Among the autoimmune comorbidities we studied, the prevalence of autoimmune thyroiditis (1.11%) in SLE patients was similar to previous reports.8,9 However, the coexistence of SLE and rheumatoid arthritis (1.13%) and SLE and discoid lupus erythematosus (1.74%) was less in our study.8,9 The most common comorbidities seen in our study were mainly non-autoimmune and included: essential hypertension (33.7%), type 2 diabetes mellitus (19.5%), and hypothyroidism (18%). These were also among the most common comorbidities in the 2007 Puerto Rico SLE prevalence study.3 Of note, our study demonstrated an uptrend in rates of depressive disorders since 2018, particularly in 2020, the first year of the COVID-19 pandemic.
Studies assessing the risk factors that predispose individuals with autoimmune diseases to the development of other autoimmune diseases are also limited.11 Here, we report that female patients, patients within the age group of 35 to 54, and patients with corticosteroid use were more likely to have an additional autoimmune disease. Various molecular-genetic studies have demonstrated that spontaneous autoimmune disease occurs secondary to suppression of T regulatory cells (Tregs).21-23 Certain classes of immunosuppressive medications, like the corticosteroids often used to manage symptoms of SLE, alter Treg function. Furthermore, recent data shows that the mechanism of action of glucocorticoids, a subclass of corticosteroids, relies on Tregs to reduce autoimmune inflammation.24 Although this mechanism of action is beneficial to reducing flares in an acute setting, it is unclear what long-term effects this modulation may have on Tregs, especially in cases where there is prolonged corticosteroid use. In clinical practice, the European Alliance of Associations for Rheumatology (EULAR) recommends minimizing the medium-to-long-term use of glucocorticoids in SLE patients to <7.5 mg/day for less than six months with an early transition to other maintenance medications, such as hydroxychloroquine, to prevent the known adverse effects of long-term glucocorticoid use.25 In our study, we were unable to assess the duration and dosage of corticosteroid use; however, we determined that corticosteroid use was more common in patients with SLE and at least one additional autoimmune comorbidity. It is unclear whether the use of corticosteroids in these individuals results from increased SLE flares or is part of the management plan for the other autoimmune disease. Therefore, it would be interesting to analyze whether long-term corticosteroid use increases the risk of developing additional autoimmune diseases. We recommend that future studies assess this critical question with varying durations and dosages of corticosteroids. Our findings incentivize screening for coexisting autoimmune diseases in SLE patients and promote an individualized approach to their clinical care.
Limitations of our study included the underprediction or misclassification of specific comorbidities due to inconsistent use of ICD classification by physicians (e.g., autoimmune thyroiditis was included in autoimmune comorbidities while unspecified hypothyroidism was included in other comorbidities). Due to these discrepancies in coding, we decided to report both autoimmune and non-autoimmune comorbidities. In the specific case of the coexistence of SLE and rheumatoid arthritis, it is crucial to observe that they have overlapping symptoms (e.g., joint pain and swelling), which may result in underreporting.
There were limitations with the database used, PRHIA. For example, the database only includes individuals enrolled in government-sponsored health insurance. According to the most recent report published by the U.S. Centers for Medicaid & Medicare Services (August 2021), there are 1.5 million adults and children, or approximately half of the island's population (3.5 million in 2020), enrolled.26,27 We could not access data from private insurances because the Transparency and Open Data Law28, which requires digitalization and publication of data, only regulates government agencies to access such information, effectively obscuring data for half of the population. Another limitation of PRHIA was the restricted number of searchable categories and data filters, which prevented us from obtaining the patient’s ethnicity and education level. Given that autoimmune diseases like SLE are multifactorial in etiology, these demographic variables are vital to understanding the development and progression of the illness. Additionally, we were not granted access to data prior to 2018, meaning we couldn’t assess trends before Hurricane Maria and the COVID-19 pandemic.
With all this information in mind, our study highlights the need to have an interconnected repository of healthcare data. Ideally, it should include the medical records of patients serviced by the public and private sectors to foster continuous, sustainable research, and innovation in health care initiatives and policies that could benefit the entire Puerto Rican population.