Anaemia in rheumatoid arthritis: can we afford to ignore it?

Abstract

INTRODUCTION Anaemia is common in rheumatoid arthritis (RA). Clinicians may focus on rheumatological issues and assume anaemia of chronic disease (ACD). This study challenged this assumption and investigated the causes of anaemia in a large cohort of RA patients to assess its implications. METHODS The hospital where the study was conducted monitors regular full blood count and erythrocyte sedimentation rate (ESR) monthly in all RA patients on disease modifying drugs to assess efficacy and safety. A computerised system identifies and records abnormal results. The database for 2009 was interrogated to find all patients with two consecutive haemoglobin values <11&emsp14;g/dl. Using a proforma, patients were defined as having iron deficiency anaemia (IDA), ACD, macrocytic anaemia (MCA) or another cause. All results of further tests investigating the anaemia were recorded. RESULTS Among 2000 RA patients on the system, 199 (10%) were identified as having anaemia over a year. Of these, 90 had IDA, 78 had ACD, 25 had MCA, and 6 had postoperative anaemia. Among 90 patients with IDA, investigations were performed in 53, with 23 normal. An explanation for IDA was found in 30: gastrointestinal bleeding in 25, gynaecological blood loss in 3, and urinary bleeding in 2. Among 78 patients with ACD, response to intensification of RA treatment occurred in 45, but erythropoietin therapy was required in 9. Within the 25 patients with MCA, 12 had unrecognised vitamin B(12) deficiency, 4 drug induced changes, 3 myeloid malignancy, 2 hypothyroidism, and 2 alcoholism. CONCLUSIONS Anaemia in RA is common, multifactorial, and potentially both serious and correctable. Established malignancy was present in 10 patients and premalignancy in a further 10 (10% of total). Treatable causes were commonly identified. Clinicians need to investigate the nature and cause of persistent anaemia, and must not assume it to be simply ACD without evidence.

Differential Diagnosis of Anemia in Patients with Rheumatoid Arthritis

“…The Hb concentration in the COMBI anemia patients (97.39±5.03 g/l) was lower than in the IDA (100.51±5.43 g/l) and ACD groups (103.47±5.54 g/l), whereas the color index level and mean erythrocyte volume were lower in the IDA patients (0.68±0.06; 5.96±0.24 mcm 3 ) than in the ACD (0.92±0.04; 7.73±0.23 mcm 3 ) and COMBI groups (0.72±0.06; 6.38±0.83 mcm 3 ) (Table 1). Additionally, the TIBC in the IDA patients (79.34±3.02 mmol/l) showed a propensity toward increased values compared with the ACD group (52.27±5.36 mmol/l), but no statistically significant differences were noted between the IDA and COMBI (67.34±15.53 mmol/l) patients.…”

“…2 In particular, anemic syndrome is a very common manifestation of rheumatoid inflammation. According to literature study by Bloxham et al, 3 anemia develops in 30-70% of patients with RA. Different types of anemia, including iron deficiency anemia (IDA), anemia of chronic disease (ACD), the combination of IDA and ACD (COMBI) anemia, megaloblastic anemia, and hemolytic anemia, have been seen in patients with RA.…”

Thirty-day complications in rheumatoid patients following total knee arthroplasty

“…Stundner et al evaluated 351,103 TKA patients and found a blood transfusion risk approximately 50 % higher for RA patients (23 vs. 17 %; p<0.001) [15]. Anemia of chronic disease, iron deficiency anemia, and bone marrow suppression secondary to medications, which are common findings in patients with RA, are thought to play a role in this increased requirement [16,17]. Similar to the present study, Stundner et al and Elke et al found that the total length of surgical stay was significantly higher in rheumatoid patients (mean of 3.6 vs. 3.5 days, and median of 25 vs. 23 days; p<0.05) [18][19][20][21][22][23].…”

The relationship between hemoglobin level and disease activity in patients with rheumatoid arthritis

“…3 In particular, anemic syndrome is a very common manifestation of rheumatoid inflammation that could increase RA activity and decrease patient's quality of life. 4 Unfortunately, anemia is not considered a major problem in rheumatoid arthritis RA by the vast majority of physicians. This statement is based on the fact that studies on anemia in RA are sparse, with few systemic reviews, and no extensive literature on its prevalence and effect on various clinical and functional outcomes, including morbidity, mortality, and quality of life.…”