From the Guidelines
Anemia in rheumatoid arthritis should be managed by controlling the underlying inflammation with disease-modifying antirheumatic drugs (DMARDs) as the primary treatment approach. The management of rheumatoid arthritis (RA) involves several principles, including drug treatment with DMARDs, non-steroidal anti-inflammatory drugs, and glucocorticoids, as well as non-pharmacological measures 1. Anemia is a common complication of RA, and its treatment primarily focuses on controlling the underlying RA inflammation.
Treatment Approaches
- DMARDs such as methotrexate, hydroxychloroquine, or biologics like TNF inhibitors are used to control RA inflammation 1.
- For symptomatic anemia, iron supplementation may be beneficial, particularly if iron deficiency coexists with anemia of chronic disease (ACD).
- Oral iron formulations are first-line, while intravenous iron may be necessary for those with poor absorption or intolerance.
- Erythropoiesis-stimulating agents like epoetin alfa can be considered for severe, symptomatic anemia unresponsive to other treatments.
Monitoring and Adjustment
- Regular monitoring of hemoglobin levels, iron studies, and inflammatory markers is essential to assess response and adjust therapy 1.
- The anemia typically improves as RA disease activity decreases, highlighting the importance of treating the underlying inflammatory condition rather than just the anemia itself.
The European League Against Rheumatism (EULAR) has formulated major objectives for the management of RA, including the use of DMARDs and biologics to control inflammation and improve patient outcomes 1. By prioritizing the control of underlying RA inflammation, healthcare providers can effectively manage anemia in patients with RA and improve their overall quality of life.
From the Research
Anemia in Rheumatoid Arthritis
- Anemia is a common condition in patients with rheumatoid arthritis (RA), affecting approximately 31.5% of patients 2.
- The pathogenesis of anemia in RA is complex and multifactorial, involving decreased iron absorption, decreased erythropoietin responsiveness, and ineffective erythropoiesis 3.
- The diagnosis of anemia in RA is made by exclusion, and iron deficiency is detected by transferrin, ferritin, and cellular indices after adaptation of their normal values 3.
Treatment of Anemia in Rheumatoid Arthritis
- Treatment of anemia in RA consists of antirheumatic treatment, and iron administration is not recommended as it may be counterproductive 3.
- Erythropoiesis-stimulating agents, such as human recombinant erythropoietin (EPO), have been used to treat anemia in RA, but the evidence is conflicting and the safety profile is unclear 4.
- Tocilizumab, an interleukin-6 receptor inhibitor, has been shown to be effective in treating anemia in RA patients, both in combination with methotrexate and other basic anti-inflammatory drugs and as monotherapy 5.
- Intensification of RA therapy, including the use of disease-modifying anti-rheumatic drugs (DMARDs) and biologic agents such as etanercept, can improve hemoglobin levels and reduce anemia in RA patients 6.
Prevalence and Severity of Anemia in Rheumatoid Arthritis
- Anemia occurs in 31.5% of patients with RA, with a U-shaped distribution that has minimal prevalence around 60 years of age 2.
- Severe chronic anemia (hemoglobin < 10 g/dl) is rare, affecting only 3.4% of RA patients 2.
- Renal function is impaired in patients with RA compared to those with noninflammatory rheumatic disorders, and estimated creatinine clearance is 9.8 ml/min lower in RA patients 2.