Lupus Research, Clinical Care, Outcomes, and Socioeconomics: It's Complicated

Noa Schwartz, M.D., M.S., an assistant professor in the department of medicine (rheumatology), and director of the Montefiore Einstein Institute for Lupus Care and Research, was drawn to rheumatology because it's not one organ system but many. It allows her to see the interconnectedness of things -- whether it is joint inflammation, lymph node enlargement, rashes, or eye conditions -- and build a clinical picture that informs a diagnosis, which she finds intriguing.

Systemic lupus erythematosus, Dr. Schwartz’s specific area of interest, is a chronic autoimmune disease that can affect any organ in the body, from skin and joints to blood vessels, kidneys, heart, and brain, causing pain and inflammation. Basically, the body is attacking itself.

Lupus affects an estimated 1.5 million Americans, according to the Lupus Foundation of America, the majority of whom are women between the ages of 15 and 45 and mostly women of color.

Dr. Schwartz plays many roles in the field: researcher, clinician, and educator.

We recently spoke with her about some of the many things she is doing.

First, what causes lupus?

It is thought that there are underlying genetic tendencies that get triggered by environmental factors. For example, a person genetically predisposed may develop lupus due to an environmental trigger like sunlight, smoking, infections, or even some medications.

Why does lupus disproportionately affect women of color?

Noa Schwartz, M.D., M.S.

Noa Schwartz, M.D., M.S.

It's due to a combination of things. We know that Black women are three to five times more likely to develop lupus, and their symptoms and disease progression are often more severe and resistant to treatment compared to other groups. Some genetic variants and epigenetic changes that confer increased risk for lupus and specific organ involvement have been shown to be more prevalent among people of African descent, but we know that much of the racial disparities that we are seeing is not driven by genetics, but rather by socioeconomic status. Unfortunately, despite scientific and medical progress, patients coming from disadvantaged and marginalized communities still have worse disease and higher death rates.   

Health disparities persist. The Bronx has nearly twice the poverty rate of Manhattan. Many of our patients are the primary providers and caregivers for multigenerational families, making it difficult to keep up with frequent doctor visits, medical testing, and medications with complex regimens and side effects. My colleagues and I often see patients whose unmanaged lupus has progressed to irreversible damage because of insurance ineligibility or limitations, an inability to get to regular follow-up visits because of job demands or insufficient transportation options, or a lack of family support or housing insecurity. So, it is not necessarily that the disease presents differently in patients of color; it's just that, in addition to a chronic disease, they are also battling a societal system stacked against them.

Are you optimistic about where lupus research and clinical care are headed?

Yes, both for lupus and rheumatology in general. There have been major advances in diagnosis and treatment that have dramatically increased lupus survival rates from 50% at five years in the 1970s to 90% at 10 years today. During the last 10 years, three new medications were approved to treat lupus when for over 50 years prior the field of lupus medications was practically static.

We know a lot more about cytokine responses, B and T cells, antibodies, and other components of the immune system that are important in developing targeted biologics for the treatment of lupus and other autoimmune diseases.

Still, there is a lot more to be done. 

Tell us about an aspect of your research.

One exciting area we are investigating is identifying intracellular pathways that are related to neuropsychiatric lupus with the goal of manipulating or inhibiting these pathways to improve symptoms.

Using mass spectrometry and phosphoproteomics, we have identified several potential pathways that we are still in the process of validating. Many of these pathways already have inhibitors that have been developed for other reasons, mainly for cancer treatments. So, the medications are out there, and we hope that their use can be effective in treating the chronic manifestations of neuropsychiatric lupus, such as cognitive dysfunction and mood disorders.

Importantly, our preliminary studies suggest that acute inflammation that happens in the brain in the setting of lupus triggers neurodegenerative processes that contribute to the persistent, non-inflammatory cognitive dysfunction we often see in patients. These findings are especially  important, even beyond the field of lupus, since they can be relevant to other situations that cause brain inflammation with chronic sequelae, like long COVID.

Final thoughts

When I began my career, my goal was to be a physician-scientist and focus on clinical care as well as research. And, yes, research in all its forms is still of the utmost importance for me. But as I started caring for the patients of our community, my focus began to shift toward more immediate means to help and support them. We still have much room to improve not just survival but also people's quality of life. But to do this, it will take more than medical interventions. We need to build a strong infrastructure to support patients while they're navigating the treatment process. Addressing the social and economic barriers to care is critical because all the treatment advances in the world won't help patients who can't access them. This is exactly where we envision the Institute for Lupus Care and Research to come in and make a significant impact on patients' lives.