Rheumatoid arthritis anaemia

Anaemia often becomes a characteristic feature of several chronic diseases, such as rheumatoid arthritis. In most instances this can be linked to lower than normal endogenous serum EPO levels (although in some cases a deficiency of iron or folic acid can also represent a contributory factor). Several small clinical trials have confirmed that administration of EPO increases haematocrit and serum haemoglobin levels in patients suffering from rheumatoid arthritis. A satisfactory response in some patients, however, required a high-dose therapy that could render this therapeutic approach unattractive from a cost benefit perspective. 

Pathophysiologically normochromic and normo-cytic anaemia, as occurs in many clinical syndromes exemplified by renal failure, a number of cancers, rheumatoid arthritis and systemic lupus erythematosus, is typical. Initially erythrocytes are of normal size and degree of haemoglobinization. However, persistent impairment of iron supply, especially from mitochondria to globin in the cytoplasm, leads to them becoming hypochromic and microcytic. 

It is indicated in renal transplantation, severe active rheumatoid arthritis unresponsive to other therapy, certain autoimmune diseases, chronic active hepatitis, idiopathic thrombocytopenic purpura and acquired haemolytic anaemia. 

Patients with rheumatoid arthritis may also suffer from wide range of symptoms which affect other parts of the body. These symptoms may include anaemia, dry eyes, osteoporosis and nodules, among other things. 

Q10 Maria appears to be suffering from pernicious anaemia, which is due to failure of B12 absorption. In her case the underlying problem may be her rheumatoid arthritis, a chronic autoimmune, inflammatory condition. In autoimmune diseases the immune system attacks and damages normal tissues, including both joints and the stomach mucosa, which produces the intrinsic factor needed for Bi2 absorption. 

So the ESR is not diagnostic in itself, but is an indicator that there is an ongoing inflammatory process in the body. It is not useful in diagnosing the presence or type of anaemia but, taken together with the previous diagnosis of rheumatoid arthritis and the blood test results, it helps to support the diagnosis of pernicious anaemia. 

Autoimmune haemolytic anaemia Idiopathic thrombocytopenic purpura Rheumatoid arthritis Scleroderma... 

Drugs. Antiepilepsy drugs, particularly phenytoin, primidone and phenobarbital, occasionally cause a macrocytic anaemia that responds to folic acid. This may be due to enzyme induction by the antiepileptics increasing the need for folic acid to perform hydroxylation reactions (see Epilepsy) but other factors such as reduced absorption may be involved. Administration of folic acid causes a recurrence of seizures in some patients. Some anti-malarials, e.g. pyrimethamine, may interfere with conversion of folates to the active tetrahydrofolic acid, causing macrocytic anaemia. Methotrexate, another folate antagonist, may cause a megaloblastic anaemia especially when used long-term for leukaemia, rheumatoid arthritis or psoriasis. 

Diseases in which immunosuppression may be useful include tissue transplantation, inflammatory bowel disease, rheumatoid arthritis, chronic active hepatitis, systemic lupus erythematosus, glomerulonephritis, nephrotic syndrome, some haemolytic anaemias and thrombocytopenias, uveitis, myasthenia gravis, polyarteritis, polymyositis, systemic sclerosis, Behcet s syndrome. 

Ramselaar AC, Dekker AW, Huber-Bruning O, Bijlsma JW. Acquired sideroblastic anaemia after aplastic anaemia caused by D-penicillamine therapy for rheumatoid arthritis. Ann Rheum Dis 1987 46(2) 156-8. 

Fishel B, Tishler M, Caspi D, Yaron M. Fatal aplastic anaemia and liver toxicity caused by D-penicillamine treatment of rheumatoid arthritis. Ann Rheum Dis 1989 48(7) 609-10. 

Omer, A., and Mowat, A. G., Nature of anaemia in rheumatoid arthritis. IX. Folate metabolism in patients with rheumatoid arthritis. Ann. Rheum. Dis. 27, 414-424 (1968). 

In 1941, Fenz used this antitubercular drug to treat rheumatoid arthritis (RA), since it was thought that arthritis also had an infectious etiology. He found that intravenous doses of 0.01-0.1 g (2-20 mg of Cu) gave modest results, but exceptional results were claimed with some patients given 0.2 g (40 mg of Cu) per injection three times per week with a Umit of 2.5-6 g (475-1140 mg of Cu) per treatment course [229, 230]. Fenz also reported an additional antianaemia effect on anaemias associated with RA which was consistent with observations reported by others, who had found that anaemic... 

The pharmacokinetics of methotrexate are unaffected by sulfasalazine. Clinical studies in patients with rheumatoid arthritis suggest that the combination of methotrexate and sulfasalazine may not improve therapeutic efficacy and may result in folate-de-flciency anaemias. 

In conditions where there is dyserythropoiesis, with or without hyperplasia, the ELP is greatly increased as has been demonstrated using either N or C-labelled glycine. Examples include peinicous anaemia [386,387], thalas-saemia [387,388], shunt hyperbilirubinaemia [389], sideroblastic anaemia [387,390] and anaemia of rheumatoid arthritis [391]. 

Diseases in which the body produces antibodies against its own components. Among the diseases which are thought to have an autoimmune basis are primary myxoedema, thyrotoxicosis, pernicious anaemia, Addison s disease, Goodpasture s syndrome, myasthenia gravis, some haemolytic anaemias, primary biliary cirrhosis, active chronic hepatitis, ulcerative colitis, Sjogren s syndrome, rheumatoid arthritis and systemic lupus erythematosus. See separate entries for some of these diseases. 

A case is reported of red cell aplasia in a patient with Wilson s disease, who had been treated for 14 years with up to 2 g penicillamine daily (16 ). The erythropoiesis rapidly recovered after discontinuation of penicillamine. The serum copper concentration was 5/ug/dl (normal 80-150 jug/dl). Another case report concerns a patient who died from aplastic anaemia, which was thought to be drug-induced (17, 21 ). This patient had been treated for rheumatoid arthritis... 

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