Feature Articles

Monitoring Inflammation and Iron Deficiency Anemia in Rheumatoid Arthritis

February 11, 2009

Rheumatoid arthritis (RA) affects approximately 1.3 million people in the United States.1 While most people are aware that RA patients suffer from aching joints, many are not aware that they may also suffer from anemia. Anemia is very common in RA, occurring in 30-60% of patients.2-4 Since so many RA patients develop anemia, communication with your doctor and close monitoring for symptoms can help you keep anemia and its symptoms in check.

Dr. Daniel Furst, a Rheumatologist and Professor at the UCLA David Geffen School of Medicine stated that, “If you have RA, it is important to recognize and treat anemia; since correcting it can make you feel better, and may also improve your RA symptoms.” Studies have shown that treating anemia in RA patients leads to improvement in joint swelling and an increase in energy.4,5 Anemia treatment also had a positive effect on quality of life, measured as decreased fatigue and increased vitality and muscle strength.6

What causes RA-associated anemia?

The most common causes of anemia in patients with rheumatoid arthritis include inflammation and iron deficiency.

  • Inflammation: The inflammation associated with rheumatoid arthritis is the most common cause of anemia, affecting up to two-thirds of RA patients.7 Inflammation decreases the production of red blood cells by releasing small proteins that effect how your body uses iron and how your body produces erythropoietin, a hormone that controls production of red blood cells. Since your red blood cells carry oxygen, when there are not enough of them your body’s organs do not get enough oxygen.2 This can produce the symptoms you may feel when suffering from anemia, which are discussed below.

  • Iron Deficiency: Although inflammation is the most common cause of anemia, many RA patients also do not have enough iron available in their body to make enough healthy red blood cells. This iron deficiency is usually caused by menstrual bleeding, digestive tract bleeding or a problem getting the stored iron from within the bone marrow into the red blood cells. Some conditions that may cause this type of bleeding include stomach ulcers, growths in the intestines (polyps), colon cancer, and other less common conditions of the digestive tract. Drugs used to treat rheumatoid arthritis (nonsteroidal anti-inflammatory drugs, prednisone and other drugs) may be a cause of bleeding from the digestive tract.2 Dr. Furst emphasized, “Iron deficiency anemia (IDA) is not part of RA. Its the drugs we use to treat RA. It can also be from the effects from other conditions resulting in gastrointestinal blood loss.”

Symptoms of Anemia
  • Fatigue
  • Weakness
  • Pale skin
  • Brittle nails
  • Chest pain
  • Dizziness
  • Irritability
  • Coldness of hands or feet
  • Trouble breathing
  • Fast or irregular heartbeat
  • Headache
  • Fuzzy thinking
  • Loss of concentration
  • Depression
  • Loss of sex drive
  • Decreased work performance
  • Desire to eat ice or other peculiar things

Although RA medications may have side effects, taking them as recommended is an important way to reduce inflammation and help prevent and treat anemia. Additionally, if you notice blood in your stool, be sure to make an appointment with your doctor without delay.

What are the symptoms of anemia?

People with mild anemia may have no symptoms or may not notice the symptoms because they appear slowly. However, if the anemia is severe, the symptoms can increase and become more serious. RA patients with anemia may feel weak, easily tired, have problems carrying out routine activities, and can feel tired or experience shortness of breath with activity. Other symptoms include pale skin, chest pain, irritability, numbness or coldness in the hands and feet, a fast heartbeat, and headache.

If you’ve been feeling some of these symptoms and think you may have anemia, we recommend you see your healthcare professional. To help you tell your doctor about your symptoms which could be related to anemia, see the anemia Symptoms Quiz for you to fill out and take to your doctor. Close communication with your doctor will help him or her provide the treatment that is best for you based on what is causing the anemia.

A Few Healthy Lifestyle Tips
  • Staying as physically active as possible
  • Eating a healthy diet
  • Managing stress
  • Maintaining social support

How can I prevent anemia?

The best way to help prevent anemia in RA is to take care of yourself and to manage your RA. It is important to minimize inflammation by taking your RA medications and by adopting a healthy lifestyle.8 Regular exercise can help maintain muscle strength, joint mobility and flexibility. In addition, physical activity can help you reduce pain, sleep better, keep up your spirits and maintain a healthy weight.9

Good nutrition is another key for people who are at high risk for anemia, such as RA patients. RA patients should eat a variety of nutrient-packed foods every day; including lean meats, dairy products, fruits, vegetables and whole grains. For tips on healthy eating to prevent anemia visit the feature articles on Anemia and Nutrition: The Importance of Iron and The Importance of Essential Vitamins.

What treatments are available to help me?

Studies show people who have both rheumatoid arthritis and anemia tend to have more severe arthritis than people without anemia. They are more likely to have serious joint damage and to need anti-inflammatory drugs.4,6 The good news is that anemia can be treated, and benefits such as improved quality of life and increased energy and activity level can be achieved. Additionally, you’ll have a better chance of improving your RA symptoms.

The first principle of treating RA-associated anemia is to reduce inflammation by taking your medications as directed by your doctor. The anemia usually improves when inflammation has decreased. Iron deficiency may also occur along with inflammation-related anemia.10-13 Iron supplements along with erythropoietic stimulating agents (ESAs) have been useful in correcting anemia for RA patients.

Most anemias can be prevented or treated by reporting the signs and symptoms to your doctor. It is also important for your doctor to perform the correct tests to diagnose anemia and to follow specific treatment protocol. Several medications are approved to help correct anemia and we encourage close communication with your doctor.

Also, be sure to read the patient information handout for Anemia & Rheumatoid Arthritis. It is free to print our download. 


  1. Centers for Disease Control. National Center for Chronic Disease Prevention and Health Promotion. Arthritis types-Overview. Link. Accessed: January 23, 2009.
  2. Baer AN, Dessypris EN, Goldwasser E, Krantz SB. Blunted erythropoietin response to anaemia in rheumatoid arthritis. Br J Haematol. 1987 Aug;66(4):559-64. Link.
  3. Hochberg MC, Arnold CM, Hogans BB, Spivak JL. Serum immunoreactive erythropoietin in rheumatoid arthritis: impaired response to anemia. Arthritis Rheum. 1988 Oct;31(10):1318-21. Link.
  4. Peeters HR, Jongen-Lavrencic M, Raja AN, Ramdin HS, Vreugdenhil G, Breedveld FC, Swaak AJ. Course and characteristics of anaemia in patients with rheumatoid arthritis of recent onset. Ann Rheum Dis. 1996 Mar;55(3):162-68. Link.
  5. Murphy EA, Bell AL, Wojtulewski J, Brzeski M, Madhok R, Capell HA. Study of erythropoietin in treatment of anaemia in patients with rheumatoid arthritis. BMJ. 1994 Nov 19;309(6965):1337-38. Link.
  6. Kaltwasser JP, Kessler U, Gottschalk R, Stucki G, Möller B. Effect of recombinant human erythropoietin and intravenous iron on anemia and disease activity in rheumatoid arthritis. J Rheumatol. 2001 Nov;28(11):2430-36. Link.
  7. Wilson A, Yu HT, Goodnough LT, Nissenson AR. Prevalence and outcomes of anemia in rheumatoid arthritis: a systematic review of the literature. Am J Med 2004 Apr 5;116 Suppl 7A:50S-57S. Link.
  8. MayoClinic Health Library. Arthritis: Rheumatoid arthritis: a healthy lifestyle relieves on woman’s pain. Link. Accessed: January 23, 2009.
  9. WebMD. Arthritis Health Center. Rheumatoid Arthritis Health Center. Rheumatoid Arthritis Guide: Rheumatoid Arthritis: The importance of exercise. Link.
  10. Vreugdenhil G, Swaak AJ. Anaemia in rheumatoid arthritis: pathogenesis, diagnosis and treatment. Rheumatol Int 1990;9(6): 243-57. Link.
  11. Weiss G, Goodough LT. Anemia of chronic disease. N Eng J Med 2005 Mar 10;352(10):1011-23. Link.
  12. Chijwa T, Nishiya K, Hashimoto K. Serum transferrin receptor levels in patients with rheumatoid arthritis are correlated with indicators of anemia. Clin Rheumatol 2001;20(5):307-13. Link.
  13. Means RT Jr. Advances in the anemia of chronic disease. Int J Hematol. 1999 Jul;70(1):7-12. Link.