Many people with rheumatoid arthritis (RA) tend to develop anemia, but what causes RA-related anemia, and how can you get it under control?

Fast Facts

Symptoms of anemia include fatigue, weakness, and headache.

The type of anemia that is common with RA is called anemia of chronic disease. 

RA-related anemia can be treated directly, but keeping RA symptoms under control is the best way to address anemia.

Rheumatoid arthritis (RA) is an autoimmune disorder that causes chronic inflammation of the joints, as well as joint pain.

But you may be surprised to hear that anemia is also one of the most common symptoms of RA.

In fact, anemia can occur in up to 60 percent of people with rheumatoid arthritis. Because anemia-related fatigue contributes to the debilitating nature of the condition, it’s especially important to recognize and address RA-related anemia early.

What Is Anemia?

Anemia develops when your blood doesn’t produce enough red blood cells. Red blood cells are made up of hemoglobin, an iron-rich protein that transports oxygen from the lungs to the rest of your body. In some cases, people with anemia actually have enough red blood cells, but these cells contain abnormal or insufficient hemoglobin.

If you don’t have enough red blood cells or hemoglobin, your organs don’t get enough oxygen. Left untreated, anemia can cause fatigue and weakness. Other symptoms include headaches, pale skin, shortness of breath, a rapid heartbeat, and exercise intolerance — the decreased ability to work out at your regular intensity or duration.

Why Do People With Rheumatoid Arthritis Develop Anemia?

The most common type of anemia in RA patients is the anemia of chronic illness, also known as anemia of chronic disease (ACD), explains rheumatologist Robert W. Lightfoot, MD, a professor of medicine in the division of rheumatology at the University of Kentucky College of Medicine in Lexington. “Anemia tends to occur in many chronic illnesses, which includes RA,” he adds. (Other conditions in which anemia of chronic disease occurs include cancer and Crohn’s disease.)

The underlying causes of ACD are not well understood, but the inflammation that occurs throughout the body in RA may contribute to it. Inflamed tissues in the joints release proteins that compromise the body's ability to use iron and produce red blood cells, leading to a low red blood cell count.

Medications commonly used to manage RA, sometimes including non-steroidal anti-inflammatory drugs (NSAIDs) and steroids (also called corticosteroids), may also trigger anemia through a different mechanism of chronic blood loss. These drugs, especially the NSAIDs, can cause chronic irritation and bleeding of the stomach lining. This blood loss may be slow and not immediately noticeable, but over time, it can lead to anemia.

How Is RA-Related Anemia Treated?

Talk to your doctor if you’re experiencing symptoms of anemia like those noted above, or if you feel that your other RA symptoms aren’t under control. They will want to rule out non-RA related causes of anemia before recommending treatment, or changing your arthritis treatment plan if your medications could be contributing to anemia.

When it comes to treatment, iron therapy given by mouth or intravenously is often beneficial for people who have both RA and anemia and who have low blood levels of iron.

Powerful antacids, often given to people taking NSAIDs to protect their stomach lining, can diminish the absorption of iron from the intestines. This may lead to the need for intravenous rather than oral iron.

Injectable erythropoietin (a hormone involved in the production of red blood cells) was used in the past to manage anemia in rheumatoid arthritis patients. “It stimulates the bone marrow to increase the number of red blood cells, but the drug is expensive and the effect is minimal,” explains Dr. Lightfoot.

Typically, RA-related anemia doesn't respond well to standard treatments, he says. As a result, "it's important to treat the [underlying] inflammation caused by the RA” in order to manage anemia effectively.

Keeping rheumatoid arthritis symptoms under control is the best way to address your anemia. And managing the inflammation and swollen joints associated with RA should help alleviate your anemia and its symptoms. 

In chronically active RA inflammation, your doctor may ultimately recommend that you replace NSAIDs or steroids with one of the disease-modifying anti-rheumatic drugs (DMARDs), which are, says Lightfoot, “dramatically effective in remitting RA inflammation and, hence, eliminating ACD.”

An effective RA treatment regimen will improve both your joint symptoms and anemia, and you'll feel better all around.

Additional reporting by Cheryl Alkon.