Real Men Get Lupus

Pamela Prete
Chief of Rheumatology 
Long Beach Veterans Administration Medical Center
There is a misconception that men don’t get system lupus erythematosus, a so-called “Women’s Disease” because lupus occurs 10-12 times more frequently in adult females than adult males.  However, lupus can occur in any sex at any age.  Some related forms of lupus such as discoid lupus, lupus confined to the skin and drug induced lupus are more frequent in males.  Men develop drug induced lupus more often than women, because many of the heart medications produce drug-induced lupus.  These drugs are used more frequently in men since more males than females suffer heart attacks.
When men do get lupus, their treatment may be affected by a physician’s relatively limited experience in treating men with lupus.  Little is known about the disease when it attacks men.  In fact, to date, the majority of the studies published about lupus have contained relatively few men, as little as 4% males, thus meaningful conclusions about the disease in men have not been made.
At present, most physicians believe that the disease is similar in males and females.  At least all the manifestations of systemic lupus erythematosus that can be seen in women are also seen in men.  However, some more recent studies have published the disturbing news that the disease may be even more serious when it affects males.  Several investigators show that the mortality for males with lupus may even be higher.  Whether or not this is related to the growing evidence that lupus seems to occur at an older age in males than females remains to be definitively evaluated.  There are many questions as yet to be answered about the lupus disease progression in males.
As Chief of Rheumatology, at Long Beach Veterans Administration Medical Center, I have been researching the gender differences in autoimmune disease expression for over 20 years, since first publishing the difference in immune response between males and females in an experimental animal model of lupus.  Clinical observations and anecdotal reports of the features of male systemic lupus erythematosus in the predominantly male Veterans Administration population over the years have suggested that this is an ideal population to study. The high male to female ratio would favor a preponderance of male patients in any lupus study.  In the collaboration with Azadeh Mohyi, M.D., staff physician in Adolescent Rheumatology at Children’s Hospital of Orange County and Stuart Gilman, M.D., at the Long Beach Veterans Administration Medical Center and with access to the information contained in the National Veterans Administration Data Registry, I hope that a study can finally be done with a sufficient number of male systemic lupus erythematosus patients as well as female patients to make important deduction about the disease.
Patients selected for the data bank were those who have had a diagnosis of systemic lupus erythematosus in any of the first five positions recorded on the Veterans Administration patient treatment files discharge record.  Discoid lupus and drug-induced lupus patients are not studied at this time.  This data is easily retrieved from the computerized file by accessing any record with medical diagnostic (ICDS-9 code of 7100) which represents systemic lupus erythematosus and its complications.  The first admission for lupus was identified by sorting all the SLE admissions and selecting the first admission in the database as Index Hospitalization.  At no time were any patient indentifiers retrieved, therefore, actual names of patients will never be known and confidentiality of the patient record will never be breached.
In their preliminary studies using these methods, I along with my colleagues developed a database that yielded 2,614 lupus patients; 2,188 males an 426 females, with an astonishing male to female ratio of 5:1.  Already we have learned that these male lupus patients first presented with their lupus symptoms at an average age of 55.5 years, whereas their female counterparts ranged in age from 24-71 with average age of 42.7 year at diagnosis.  Fifty percent of females with lupus were below 40 years of age at presentation and eighty percent of males were over 40 years.  These data help establish that males have a much later onset of their lupus symptoms than female patients with lupus.
Other information that can be learned from this study are the number of accompanying diseases called comorbidities that occur in male lupus and can determine disease outcome.  Knowledge about these accompanying diseases like cancer, heart attack, kidney thyroid disease, and anemia may have some prognostic value for the individual patient with lupus.  Preliminary results have confirmed that heart attacks which were long suspected to be more common in males with lupus than in females with lupus are indeed significantly more common in males.  The data that can be gathered from the VA National Registry are very important because this Registry receives reports of the disease and deaths of patients, even if the patients have moved to different parts of the United  States or changed health care systems.  The initial analysis of this very accurate data suggest that the lupus mortality at one year is greater for males than females with lupus as had been reported by previous investigators.
Many more manifestations of SLE can be examined and evaluated using sophisticated and descriptive analytic tools with this database.  My colleagues and I have presented some of our results at the American College of Rheumatology Western Regional Meeting held in San Diego, in March of 1997.  We hope that the conclusions drawn from examination of the large Veterans Administration data will yield significant improvement in the understanding and treatment of systemic lupus erythematosus in general and in particular, males with this disease.