Do corticosteroids (steroids) lower hemoglobin (Hb) levels?

Do Steroids Lower Hemoglobin Levels?

Corticosteroids can cause anemia by various mechanisms, and this is recognized as a potential side effect in clinical practice guidelines. 1

Evidence from Guidelines

The Society for Immunotherapy of Cancer (SITC) toxicity management guidelines explicitly list anemia as a potential adverse effect of corticosteroid therapy. According to these guidelines, anemia is categorized by hemoglobin levels:

• Grade 1: Hemoglobin < lower limit of normal - 10.0 g/dL
• Grade 2: Hemoglobin < 10.0-8.0 g/dL
• Grade 3: Hemoglobin < 8.0 g/dL; transfusion indicated
• Grade 4: Life-threatening consequences requiring urgent intervention 1

The British Association of Dermatologists' guidelines for pemphigus vulgaris management also list anemia as a principal side effect of mycophenolate mofetil, which is often used in combination with corticosteroids, noting that patients may experience "lymphopenia; anemia; neutropenia; thrombocytopenia" 1

Mechanisms of Steroid-Induced Anemia

Corticosteroids can lower hemoglobin levels through several mechanisms:

1. Bone marrow suppression: Prolonged corticosteroid use can affect the bone marrow's ability to produce red blood cells
2. Increased red blood cell destruction: Steroids may occasionally trigger immune-mediated hemolysis
3. Gastrointestinal bleeding: Steroids increase the risk of peptic ulceration, which can lead to blood loss and subsequent anemia
4. Nutritional deficiencies: Long-term steroid use may impair absorption of nutrients necessary for red blood cell production

Clinical Significance and Monitoring

The degree of hemoglobin reduction with corticosteroid therapy varies based on:

• Dose and duration of steroid therapy
• Patient's baseline hemoglobin level
• Presence of comorbidities
• Concurrent medications

For patients on long-term corticosteroid therapy, regular monitoring of complete blood counts is recommended to detect anemia early. This is particularly important for patients with pre-existing anemia or risk factors for developing anemia.

Special Considerations

Paradoxical Effects in Certain Conditions

In some hemolytic conditions, corticosteroids may actually increase hemoglobin levels by suppressing immune-mediated destruction of red blood cells. A study in children with hereditary spherocytosis found that steroid therapy was effective in augmenting hemoglobin levels during hemolytic crises 2.

Rare Immune-Mediated Hemolysis

In rare cases, corticosteroids themselves can trigger drug-induced immune hemolytic anemia. A case report documented acute hemolysis due to hydrocortisone administration, suggesting an immune-mediated mechanism 3.

Management Recommendations

For patients on corticosteroid therapy who develop anemia:

1. Monitor hemoglobin levels regularly, especially in high-risk patients
2. Investigate other causes of anemia (iron deficiency, B12/folate deficiency, chronic disease)
3. Consider dose reduction if clinically feasible
4. Provide supportive care as needed (iron supplementation, transfusion for severe cases)
5. Evaluate for gastrointestinal bleeding if anemia develops rapidly

Conclusion

While corticosteroids can lower hemoglobin levels through various mechanisms, the clinical significance varies among patients. Regular monitoring of complete blood counts is important for patients on long-term steroid therapy to detect and address anemia early.