People with rheumatoid arthritis can sometimes feel extremely tired and weak, and they may think that this is a normal part of the disease. Chronic RA can cause fatigue and weakness, but these could also be warning signs of anemia.
Rheumatoid arthritis can actually commonly get blood disorders, including iron-deficiency anemia. Having low iron levels in the blood means that the blood will become not only less in number but also smaller in size. These effects make it harder for the blood to transport important oxygen to various tissues in the body. This causes feelings of weakness and fatigue.
Anemia is the most common blood disorder associated with rheumatoid arthritis
It turns out that most cases of anemia in rheumatoid arthritis are known as anemia of chronic disease. This type of anemia is common in many other chronic illnesses too and has to do with how chronic disease affects the body’s ability to access iron stores. The result is that the bone marrow cannot produce as many red blood cells, and the cells that are produced are lower in quality. Blood cells produced in this disorder tend to live a shorter lifespan as well. All these factors lead to a poor oxygen delivery in the bloodstream and resulting tiredness and muscle fatigue.
Clues that might indicate anemia
Have you noticed any weird cravings? By weird, we mean cravings for ice, clay, and paper – things that aren’t normally yummy or have any nutritional value. This is a phenomenon called “pica”, and nobody knows why anemic people develop this craving.
Besides feeling tired and lack of energy, there are other symptoms that may indicate anemia. For example, some people might feel like they can’t breathe well when doing any physical activity. Weight loss, infections, spontaneous bleeding, and clotting can also result from chronic anemia.
These symptoms of anemia are generally pretty mild and vague, so anemia might be kind of difficult for someone to notice. Worse yet, it is very gradual, so someone might get used to how it feels to be anemic and not realize something is wrong.
Factors that can contribute to the development of anemia
Besides being an anemia of chronic disease, some drugs used to treat rheumatoid can make anemia worse. For example, the disease-modifying anti-rheumatic drugs including methotrexate, leflunomide, and sulfasalazine are common culprits that can cause anemia. They do this by acting directly on the bone marrow, decreasing its ability to produce blood cells. This direct suppression results in something called pancytopenia, which is when all blood cell lines are suppressed. This includes not just red and white blood cells, but platelets too. Some doctors also refer to this as aplastic anemia.
Another drug-related effect is the use of nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen. These are common pain-relieving drugs used for rheumatoid arthritis pain, but can also contribute to anemia too. They can do this by causing gastrointestinal bleeding. NSAIDs are associated with a higher risk of such bleeding, including gastric ulcers. Losing blood from the gut is a way that can promote anemia. Another way NSAIDs can further increase anemia is by affecting the kidneys. It’s been long known that these drugs can cause chronic kidney disease, and the kidney makes a very important hormone known as erythropoietin. This hormone is needed to promote red blood cell production within the bone marrow. If NSAIDs are affecting the kidneys, it reduces the amount of erythropoietin being made thus causing the bone marrow to produce less red cells. Both these mechanisms are ways that NSAIDs can worsen anemia in rheumatoid patients.
Other risk factors that make anemia more likely for an RA patient
The risk of getting anemia is even higher in rheumatoid patients who are women or elderly patients. Furthermore, it’s not exactly clear how the disease increases the risk of anemia, but there seems to be a direct correlation between how bad the rheumatoid is and how likely you will get anemia. It works in reverse too. When you treat the rheumatoid, you often see an improvement in the anemia as well.
How do doctors treat anemia of chronic disease?
There isn’t really an exact science to treating people who have anemia of chronic disease. Because of that, most doctors choose to tackle the root of the problem by treating the chronic disease itself. In this case, it would be the top priority to treat the rheumatoid first. Usually, by improving rheumatoid arthritis, you inadvertently also improve the anemia.
If treating the rheumatoid fails to improve the anemia, there are some drugs out there that can help. These drugs work to stimulate the bone marrow directly, making it produce more red blood cells. You might think that taking iron pills or extra vitamins can help, but doctors advise that this never works. Instead, the only way to really reverse severe anemia of chronic disease is to give transfusions.
Anemia of chronic disease can be tricky to evaluate. Pinpointing the culprit is key to successful treatment. For example, if it turns out that the medications are what’s causing the anemia, stopping these medications is the most effective way to reverse this side effect. If the anemia is due to a gastrointestinal bleed, treating and managing the bleed is not only most important to potentially save lives, but will also effectively treat the anemia.
Furthermore, there are some vitamin deficiencies besides iron that can worsen anemia of chronic disease. For example, Vitamin B12 and folate deficiencies have also been known to superimpose on anemia of chronic disease. It's not surprising to find a severely ill rheumatoid arthritis patient who may be deficient in multiple different vitamins and nutrients. Careful evaluation of nutritional status is always helpful in these cases.
When anemia is very severe, it might be necessary to resort to a blood transfusion. Though it’s rarely needed, some cases of severely low hemoglobin will require this drastic treatment in order to save lives. It’s really important to maintain at a certain number of red blood cells in the bloodstream because it’s the minimum required to maintain vital organs like the brain and heart. That’s why transfusions, though rare, are sometimes necessary.
Anemia isn’t the only blood disorder that RA patients can get
Besides anemia, rheumatoid arthritis puts patients at risk for thrombocytopenia too. This is a condition of low platelets, and though it’s less common than anemia, it's just as dangerous. Low platelets can become so severe that patients start to bleed internally. Blood cancers are also more common in patients with rheumatoid because the chronic inflammation that happens increases this risk.
Another rare blood disorder that can complicate rheumatoid arthritis is Felty’s syndrome. Patients who get this syndrome have an enlarged spleen, low white cell count, lymphoma, and leukemia. Felty’s syndrome is a very serious complication that most commonly strikes people who have had rheumatoid arthritis untreated for very long periods of time.
What to do if you’re a rheumatoid patient who develops a blood disorder
The best thing to do if you’re someone living with rheumatoid arthritis is to be aware of the risks. Knowing that your risk for blood disorder is increased is the first step to learning the signs you should look out for. It’s important to catch any complication early, and it’s no different with anemia and the other blood disorders. Most people end up doing very well if they get into the doctor’s office right away for evaluation and treatment. Your doctor should regularly get blood work and monitor your labs for any changes. This is especially important if you’re taking any disease-modifying anti-rheumatic drugs.