CMScript: Focus on Lupus and Other Auto-Immune Conditions

Living with a chronic illness can be challenging, particularly when symptoms are difficult to recognise or are mistaken for other conditions. This is often the case with autoimmune diseases, which occur when the body’s immune system mistakenly attacks healthy tissues and organs, causing inflammation and damage. These complex, lifelong conditions can affect many parts of the body and may be difficult to diagnose. One of the better-known autoimmune diseases is Systemic Lupus Erythematosus (SLE), commonly known as lupus.

SLE is included on the Chronic Disease List (CDL) under the Prescribed Minimum Benefits (PMBs), which means medical scheme members are entitled to certain healthcare benefits for the diagnosis, treatment and ongoing management of the condition. This edition of the CMScript provides information on lupus, the PMB cover available for the condition, and the steps members may need to follow to access the care and support that is needed.

What is lupus?

Systemic Lupus Erythematosus (SLE), commonly known as lupus, is a chronic autoimmune disease that can affect different parts of the body, including the joints, skin, kidneys, heart, lungs, blood and nervous system.

Although anyone can develop lupus, around 90% of people diagnosed with the condition are women, with symptoms commonly developing between the ages of 15 and 44.

Signs and symptoms to look out for

Symptoms can range from mild to severe and often require ongoing medical care and management. Common signs and symptoms include:

• Extreme tiredness (fatigue), joint pain, swelling and muscle aches.
• Fever, chest pain or shortness of breath, headaches, sensitivity to sunlight, memory or concentration problems.
• Hair loss, skin rashes, including a butterfly-shaped rash across the cheeks and nose
• Kidney problems, such as swollen legs or blood in the urine

If you experience symptoms that concern you, speak to a healthcare professional for appropriate assessment and advice.

Risks and How to Manage Your Health

The exact cause of lupus is not fully understood. However, certain factors may increase the risk of developing the condition, including:

• Being female and having a family history of autoimmune disease.
• Certain genetic factors and hormonal influences.
• Environmental triggers, such as infections or sunlight exposure.
• Smoking.
• Certain medications and ongoing stress.

There is currently no known way to completely prevent lupus. However, people living with lupus can help reduce flare-ups and complications by:

• Attending regular medical follow-up appointments and taking medication as prescribed.
• Managing stress, eating a healthy, balanced diet, getting enough rest and exercising regularly.
• Avoiding excessive sunlight and using sunscreen.
• Treating infections early.
• Stopping smoking.

How is lupus diagnosed?

There is no single test that confirms lupus. Your healthcare provider may consider a combination of:

• Your medical history.
• A physical examination, blood tests, urine tests and imaging tests, where necessary.
• An assessment of your symptoms over time.

Blood and laboratory tests may include an antinuclear antibody (ANA) test, full blood count, kidney function tests, urine analysis and inflammatory markers. A rheumatologist may be involved in confirming the diagnosis and managing the condition.

Your Cover under Prescribed Minimum Benefits (PMBs)

Systemic lupus erythematosus (SLE) is included in the Chronic Disease List (CDL) of the PMB regulations. This means medical schemes must fund the diagnosis, treatment, and care for lupus in accordance with the PMB regulations and applicable treatment guidelines.

Your medical scheme may use:

• Medicine formularies – lists of approved medicines.
• Designated Service Providers (DSPs).
• Treatment protocols and care plans.
• Basket of care arrangements, which may include a specified number of consultations, blood tests, scans, or other services needed to manage the condition.

If additional care is clinically necessary, your medical scheme cannot simply refuse funding. Your treating doctor may need to submit a clinical motivation explaining why the additional treatment or service is medically necessary.

Remember to contact your medical scheme to confirm the requirements for chronic medicine registration, PMB processes, DSPs, medicine formularies and pre-authorisation. Using medicines or healthcare providers outside your scheme’s approved arrangements may result in a co-payment.

Read the full CMScript here.