From the Guidelines
Autoimmune disorders can cause persistent low hemoglobin through several mechanisms, and the most effective approach to management involves identifying and treating the underlying autoimmune condition, as well as addressing the anemia itself with targeted supplementation and monitoring. The most common autoimmune causes of anemia include autoimmune hemolytic anemia, rheumatoid arthritis, lupus, and pernicious anemia. According to the European Consensus on the diagnosis and management of iron deficiency and anaemia in inflammatory bowel diseases 1, iron deficiency may be caused by continuous blood loss, malnutrition, or impaired iron uptake, and the distinction between iron deficiency anaemia and anaemia of chronic disease is crucial for guiding treatment. In terms of diagnostic work-up, the American Society of Clinical Oncology clinical practice guideline 1 recommends a comprehensive evaluation, including history and physical examination, blood chemistry, CBC, LDH, haptoglobin, bilirubin, reticulocyte count, and autoimmune serology. Key considerations in the management of autoimmune-related anemia include:
- Addressing the underlying autoimmune condition with immunosuppressants like prednisone, rituximab, or azathioprine
- Supplementation with iron, vitamin B12, or erythropoietin stimulating agents as needed
- Regular monitoring of complete blood counts, typically every 1-3 months
- Evaluation for underlying causes of anemia, including iron deficiency, vitamin deficiencies, and hemolysis. Overall, a comprehensive and targeted approach to diagnosis and management is essential for improving outcomes in patients with autoimmune-related anemia.
From the Research
Autoimmune Disorders and Continuous Low Hemoglobin (Hgb)
- Autoimmune hemolytic anemia (AIHA) is an acquired disorder resulting in the presence of antibodies against red blood cell (RBC) antigens, causing hemolysis 2.
- AIHA can occur as a part of the systemic lupus erythematosus (SLE) spectrum, and warm autoimmune hemolytic anemia as the initial manifestation of SLE is extremely rare 2.
- The diagnosis of AIHA can be made with a stepwise approach that aims to identify laboratory and clinical evidence of hemolysis and then determine the immune nature of hemolysis with the direct anti-globulin test 3.
Relationship Between Autoimmune Disorders and Low Hgb
- Autoimmune hemolytic anemia at any time can be distinguished from patients with other causes of anemia, because they are more likely to have elevated titers of IgG anticardiolipin antibodies and thrombosis 4.
- Autoimmune hemolytic anemia at the onset of SLE was independently associated with renal involvement, thrombocytopenia, and possibly thrombotic episodes during follow-up 4.
- Haematological manifestations in SLE are frequently observed and range from mild to severe, requiring different treatment approaches 5.
Management of Autoimmune Disorders and Low Hgb
- Rituximab is now the preferred second-line treatment for primary warm AIHA and first-line treatment for primary cold agglutinin disease (CAD), either as monotherapy or combined with bendamustine 3.
- Complement inhibitors have shown utility in stabilizing AIHA patients with acute severe hemolysis 3.
- Personalized medicine aims to find the most optimum drugs for a patient, and recognizing the drugs based on genetics and molecular profile of patients needs a comprehensive protocol 6.