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Rheumatoid Arthritis and Anemia BY HEIDI


Anemia of chronic disease, sometimes referred to as anemia of inflammation, is a common extra-articular (non-joint related) manifestation of rheumatoid arthritis (RA).1 Anemia of chronic disease is the second most common form of anemia worldwide, behind only iron-deficiency anemia.2

Anemia of chronic disease is characterized by normal or sometimes high levels of ferritin, the protein used to store iron, but low levels of iron within the bloodstream.3 This is believed to be caused by systemic inflammation triggered by the immune system. Anemia of chronic disease can be managed by treating underlying conditions like RA.

What Is Rheumatoid Arthritis?

Rheumatoid arthritis (RA) is an autoimmune, inflammatory disease that affects millions of people around the world. It is commonly believed that RA affects only the joints, but in reality, it is a systemic illness that can affect the whole body, from the skin to the heart and lungs and other areas.4

In RA, the immune system mistakenly identifies its own tissue as "foreign invaders," and sets off an inflammatory response that leads to painful swelling of various organs and joints throughout the body.5

While there is currently no cure for RA, there are many treatment options available that aim to decrease systemic inflammation and down-regulate the body's immune system. The most commonly used medications for RA are known as disease-modifying antirheumatic drugs (DMARDs), which can lead to decreased disease activity and sometimes even reversal of early joint damage.

What Is Anemia?

Anemia is a condition in which the body has fewer red blood cells (RBCs) than it's supposed to.3 The role of RBCs, which are made in the bone marrow, is to carry oxygen throughout the entire body, nourishing organs and tissue, while also capturing carbon dioxide and transporting it back to the lungs for release.6

While there are numerous different types of anemia that can occur, the main causes are typically due to excessive blood loss, decreased red blood cell production, or increased red blood cell destruction. Regardless of the specific type, the outcome is always the same: a lower than normal red blood cell count.

Without adequate gas exchange occurring throughout the body, the following symptoms may develop:


Rapid heartbeat

Dizziness or lightheadedness

Pale skin

Feeling cold

Shortness of breath


Identifying the root cause of anemia is critical to selecting the right treatment plan. Various autoimmune illnesses, cancer, chronic infections, and chronic kidney diseases are just a few of the conditions that can cause anemia.

Figuring out why a person's red blood count is low will ultimately determine how to bring their numbers back up.

How Are Rheumatoid Arthritis and Anemia Connected?

It has long been known that inflammation can wreak havoc on the body, and this includes the way in which red blood cells are produced, stored, and ultimately destroyed.

While iron-deficiency anemia is the most common form of anemia in the world, in patients with RA, anemia of chronic disease is dominant.3

Different Forms of Anemia Associated With RA

Some forms of anemia associated with RA include:

Anemia of chronic disease is when the body has an abundant amount of iron in its tissues, but not enough in the blood. In this case, systemic inflammation prevents the body from using stored iron to help make new RBCs.3 This leads to an overall decrease in RBCs. This type of anemia is also known to be normochromic (normal color RBCs) and normocytic (normal shaped RBCs) anemia, meaning the issue is not with the RBCs themselves, but rather with the process of producing new ones.

Iron-deficiency anemia develops when iron stores in both the tissue and bloodstream are depleted, ultimately leading to decreased new RBC production. This is the most common form of anemia worldwide. Oftentimes, iron deficiency anemia can develop from excessive bleeding in people with RA. It's important to note that certain medications used to treat RA, such as nonsteroidal anti-inflammatory drugs (NSAIDs), can lead to an increased risk of gastrointestinal bleeding.

Hemolytic anemia can be seen in people with RA, but it is the least commonly associated form. In hemolytic anemia, RBCs are destroyed at a much faster pace than normal, leading to low RBCs in the blood.7 In addition to RA, other conditions such as lupus, thalassemia, sickle cell disease, and infection can lead to hemolytic anemia.

How Are These Forms of Anemia Diagnosed?

Anemia is diagnosed by running a common blood test known as a complete blood count, or CBC.

In general, a CBC looks at white blood cell and red blood cell counts, hemoglobin and hematocrit counts, along with platelet values. It also looks at the size of RBCs, which can help differentiate different types of anemia.

Additional Lab Tests

If abnormalities are found on a CBC, additional labs can be ordered for further evaluation. These labs can include but are not limited to:2

Iron and ferritin levels

Iron binding capacity

Reticulocyte (premature RBC) counts

Sedimentation rate

In addition to lab work, obtaining a thorough medical history and physical examination can help healthcare providers narrow down the cause of anemia.

Abnormal CBC findings in a person with chronic uncontrolled symptoms of RA is more likely to be anemia of chronic disease, while lab abnormalities in a young, currently menstruating female is more likely to be iron deficiency anemia.

How Are These Forms of Anemia Treated?

Treatment of anemia is very specific to the type of anemia present, so it is critical to get an accurate diagnosis.

In the case of anemia due to chronic disease, specifically to RA, decreased inflammatory activity throughout the body can help restore proper red blood cell counts. This can be achieved through:

DMARD or biologic use

Anti-inflammatory dietary modifications

Stress reduction techniques

Once inflammation decreases, anemia of chronic disease tends to stabilize or improve.

If someone has developed iron deficiency anemia due to an active bleed, it's important to identify the source of the bleed and take measures to stop it. Depending on lab values, over-the-counter iron supplements or even intravenous (IV) iron infusions may be necessary.


Anemia is commonly seen in people with rheumatoid arthritis. Anemia of chronic disease, iron deficiency anemia, and more rarely hemolytic anemia have all been associated with RA. Regular lab testing is useful in the initial diagnosis and further management of anemia. Treating the underlying cause can lead to stabilization or improvement.