For some time before I was diagnosed with RA, I was either anemic or borderline anemic. There is a blood test that checks this and the normal range is 12.0 to 15.5 grams per deciliter. I was usually in the 10.0 to barely 12.0 area. Nothing seemed to solve the issue. I’d take iron supplements of all kinds. I took desiccated liver pills. I did whatever I or my doctor could think of to get my results back up to normal.
Few things seemed to work and the worse my blood count was, the worse I felt. Among others, fatigue is a major symptom common to both RA and anemia. So the mind-numbing fatigue I felt was put down to my anemia.
Fellow contributor, Angela Lundberg, wrote an excellent article on the fact that anemia and RA often go together. Had I had this information then, I might have made the connection. As with many people, I experienced RA symptoms for a period of time before being diagnosed. I suspect now that my feeling ill was associated with RA, as was my increased anemia.
The type of anemia commonly associated with RA is called anemia of chronic disease or anemia of inflammation and chronic disease (ACD or AI/ACD). RA isn’t the only chronic disease associated with this condition. Other inflammatory diseases such as irritable bowel disease (IBD) and Lupus are also linked to AI/ACD.
What causes this?
There are generally two things that happen to cause this. The first is that the body can’t efficiently use iron to make appropriate levels of red blood cells. This is a major reason that taking iron supplements doesn’t improve AI/ACD.
A second thing that can happen to people with RA is that their bodies don’t respond normally to the hormone that stimulates the bone marrow to produce red blood cells. Over time, this can lower the number of red blood cells, contributing to anemia.
There is some good news in all of this.
It appears that two of the inflammatory culprits, called cytokines, that contribute to RA also play a key role in developing AI/ACD. These two cytokines are interleukin-6 (IL-6) and tumor necrosis factor alpha (TNF-α). It stands to reason, therefore, that the biologics inhibiting IL-6 and TNF-α should also improve anemia. In fact, a study that looks at patients going back to the 1960’s shows a marked decrease in AI/ACD since the new biologic drugs have been used for treating RA. The first biologic, Enbrel, was introduced in 1998.
Most recently I found a large-scale study of anemia markers in more than 150,000 patients with RA. The researchers looked at a number of treatments and found that those receiving an IL-6 inhibitor improved substantially more than any other identified treatment group. The treatment was tocilizumab, better known to RA patients as Actemra. Until recently Actemra was the only IL-6 medication on the market, although a new one, Kevzara was introduced earlier this year (and since it’s new, was not included in the study).
Patients who were on other biologics were the next most-improved group, although the improvement wasn’t clinically meaningful. Patients on other treatment plans had no significant changes.
These studies are exciting to me because they continue to show how RA and comorbid conditions like anemia are connected. They could be caused by the same agent, so targeting the treatments could help control multiple conditions.
That being said, I have to temper my excitement with the knowledge that these studies have been done on historical data. They weren’t designed specifically to test improvements in anemia using different treatment options. However, they provide future researchers with incredible insights and can lead to more meaningful studies and, hopefully, treatment breakthroughs.