Anemia and RA

Anemia and RA

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Some medications used to treat RA may contribute to anemia.

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Worldwide, rheumatoid arthritis is the most commonly diagnosed inflammatory joint disease. In addition to causing pain and deformity in the joints, RA may involve a variety of other tissues and organs, including the lungs, heart, nervous system, blood vessels, eyes and bone marrow. In some people, the “extraarticular” manifestations of RA -- the symptoms caused by inflammation outside your joints -- are more disabling than the arthritis itself. Anemia, a condition where you have an insufficient number of healthy red blood cells in your circulation, is a common extraarticular manifestation of RA. Several factors contribute to anemia in people with RA.

Anemia of Chronic Disease

Anemia of chronic disease is a poorly understood condition that is common in people with chronic inflammatory disorders, such as cancer, lupus, HIV, kidney disease and RA. It is believed that inflammation somehow interferes with your body's ability to incorporate iron into hemoglobin, which is a critical step in red blood cell production. According to an April 2012 review in the “American Journal of Hematology,” the key player in anemia of chronic disease may be hepcidin, an iron-regulating protein that is released by your liver in response to inflammation. Among its other actions, hepcidin prevents the release of iron from places where it is stored, slowing the production of red blood cells in your bone marrow. The severity of this type of anemia is often directly related to the severity of joint inflammation in people with RA.

Iron Deficiency Anemia

Unlike anemia of chronic disease, which can occur even when you have sufficient iron stores in your body, iron deficiency anemia results from having too little iron. Without enough iron to meet your need for hemoglobin production, red blood cell manufacture slows and anemia follows. A study published in the October 2006 issue of “Rheumatology International” showed that nearly 50 percent of 214 people with RA in India had iron deficiency anemia. While iron deficiency is common in some parts of the world, a 2011 review in “Arthritis” attributed the high frequency of iron deficiency anemia in people with RA to hepcidin, which prevents iron absorption in the intestine.

Medication-Induced Anemia

Many of the medications used to manage RA can contribute, either directly or indirectly, to anemia. Corticosteroids, such as prednisone or methylprednisolone, and nonsteroidal antiinflammatory drugs, such as aspirin or ibuprofen (Advil, Motrin), can cause gastrointestinal bleeding, which can deplete your iron stores. Other drugs, such as methotrexate (Trexall, Rheumatrex) or hydroxychloroquine (Plaquenil), may cause anemia by suppressing bone marrow activity. Some of the newer biologic agents used to treat RA, such as infliximab (Remicade), have also been linked to anemia.


By worsening the fatigue often associated with RA, anemia may further impair your ability to perform your daily functions. Perhaps more importantly, anemia can aggravate potentially dangerous RA-related conditions, such as coronary artery disease. While anemia of chronic disease tends to follow disease activity and improves as joint pain improves, iron deficiency anemia or anemia due to bone marrow suppression can develop subtly and announce themselves unexpectedly with chest pain, heart palpitations or fainting. Regularly scheduled follow-up is an important part of managing RA, even if your joints are relatively quiet.