How to Manage, Treat Anemia of Inflammation in Patients with Rheumatic Disease

Rheumatologists must consider anemia of inflammation, drug-induced anemia and other possibilities when evaluating their patients.
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Anemia is common in patients with systemic rheumatic disease, yet it may not get the attention it deserves. Anemia can result from chronic inflammation, treatment side effects or other disease factors, or it may signal an unrelated condition. Although diagnosis and treatment of anemia are sometimes challenging, clinicians must do their utmost to rigorously investigate the cause of anemia and treat where appropriate. With new drugs on the horizon to treat the anemia of inflammation, clinicians may soon have new treatment options to manage this condition.¹

Background

Many patients with systemic rheumatic disease have anemia of inflammation (sometimes called anemia of chronic disease) as a secondary result of their condition. However, many other kinds of anemia occur in rheumatic patients. If clinicians simply assume anemia is due to disease inflammation, they can miss other important medical conditions, such as chronic gastrointestinal bleeding and malignancy.¹

Anemia of inflammation seems to correlate with disease severity and disease activity. In studies of quality of life in patients with rheumatoid arthritis, resolution of anemia often correlates with resolution of symptoms and improved quality of life.² Hemoglobin levels also correlate with the risk of certain comorbidities like cardiovascular disease.³ Yet it is something of an open question as to how much low-level anemia directly affects patients’ quality of life, disease morbidity and mortality. It may serve more as an indicator of overall disease status.

Guenter Weiss, MD, is professor of medicine and biochemistry and director of the Department of Internal Medicine II, Infectious Diseases, Immunology, Rheumatology and Pneumology at the Medical University of Innsbruck, Austria. He says, “We have very limited information on the effect or persistence of anemia on the quality of life of such patients, as well as on the course of the underlying rheumatic disease.”

Prevalence varies among different rheumatic diseases. Factors influencing prevalence rates include treatment status, nutritional intake, age, gender, gene polymorphisms and iron homeostasis. Rates of 10–66% have been cited in rheumatoid arthritis patients, with rates on the lower end of this scale in modern patients who have been aggressively treated.^1,4

Causes of Anemia in Rheumatic Disease

Iron-deficiency anemia is the most common type worldwide, but anemia of inflammation is historically a more common cause of anemia in rheumatic patients with inflammatory disease.⁵ However, in certain groups of patients with well-controlled disease, anemia from iron deficiency may actually be more common. For example, a 2011 study of rheumatoid arthritis patients in the U.K. found more patients with iron-deficiency anemia than anemia from inflammation.⁴