Kickas.org Forums Ankylosing Spondylitis General Discussion #1 AS Web Support Group Why do we become iron anemic

Hi Guys,
I just had a call from my G.P's office and my iron level is 5. That is really low, even though I eat meat daily and lots of high iron foods. I do know the A/S has been flared the past six months, and have read this can cause anemia. I would love for comments why this happens . I started iron pills three days ago, I don't think I will last long on these, they are wicked on my stomach, I guess the next choice will be injecting iron weekly. The strange thing my doctor asked me was " do you feel really tired" my reply was " I always feel really tired, no difference lately. I have noticed my heart pounding especially when I lay down however.

Janet

Hi, Janet:

Iron is not the solution for the type of anemia we ASers usually get.

If you are an 'indicator' (ESR increases with inflammation), you can notice that it is inversely proportional to RBC.

It is first necessary to get the inflammation under control and if anything would be injected, it should be B12 and supplementation with copper 3 days then zinc 3 days (they are antagonistic), folic acid (no more than 1mg/day), selenium, and plenty of EFAs, especially GLAs and DMAE during flare--10g/day or more unless eating plenty of fish.

Good luck to You,
John

hi
sorry to hear u r having problems with ur iron levels. if its any consolation, iron upsets my stomach too, i try and avoid taking it, or if it is really necessary in small doses. i do think dragonslayer has a very valid point tho.
take care
heather

Hi JOhn,
Thanks for the reply. I already inject monthly B12 and take B complex daily and the Omega 3's. My tests showe my RBC were too small so the complete Ferritn panel was done and this is what it showed/. So are you saying that it isn't "iron anemia " that we tend to get?

Janet

anemias are divided into three main categories (althought there can be some overlap) based on the size of the red cells - if cells are normal size, this is called normocytic, if red cells are small, this is called microcytic, and if red cells are large, this is called macrocytic.

If red blood cells are small, this MAY point to iron deficiency anemia. "Anemia of chronic disease" can be microcytic or can be normocytic.

For microcytic anemia, if it is due to iron deficiency in the face of NSAID use, the anemia may be based on some kind of hidden blood loss for example through an ulcer or other gastrointestinal source, this is something you may want to ask your doctors about directly.

Folate deficiency and B12 deficiency would cause macrocytic anemia, anemia where the red blood cells are larger than normal.

Here is a link to a really comprehensive review on the anemia of chronic disease:
http://www.ualberta.ca/~geriatri/ggr/handouts/h050426-ref2.pdf
Weiss G, Goodnough LT.
Anemia of chronic disease.
N Engl J Med. 2005 Mar 10;352(10):1011-23. Review.

"...The difference between anemia of chronic disease and iron-deficiency
anemia thus relates to the latter as an absolute iron deficiency, whereas the pathophysiology of anemia of chronic disease is multifactorial...

In both anemia of chronic disease and iron-deficiency anemia, the serum concentration of iron and transferrin saturation are reduced, reflecting absolute iron deficiency in iron-deficiency anemia and hypoferremia [low blood iron levels] due to acquisition of iron by the reticuloendothelial system in anemia of chronic disease...

...In patients with anemia of chronic disease, the proliferation and differentiation of erythroid precursors [red blood cell precursors] — erythroid burst-forming units and erythroid colony-forming units — are impaired and are linked to the inhibitory effects of interferon alpha, beta and gamma, and TNF-alpha and interleukin-1, which influence the growth of erythroid burst-forming units and erythroid colony-forming units....The underlying mechanisms may involve ... the down-regulation of the expression of erythropoietin receptors on progenitor cells, impaired formation and activity of erythropoietin, and a reduced expression of other prohematopoietic factors....."

my understanding of this reading is that with anemia of chronic disease, the body cannot properly utilize the iron that is taken in from the diet, and cannot properly make new red blood cells, as there are too few red blood cell precursor cells, and the precursor cells that are there are not being properly stimulated to grow and mature. The levels of hormones [i.e. erythropoeitin} which would make the red blood cell precursor respond are low, and the receptors which would respond to those hormones are low.

some more links on iron-deficiency anemia and on anemia of chronic disease in this previous post:
https://www.kickas.org/ubbthreads/showthreaded.php?Cat=0&Number=207918&page=&vc=1

Thanks so much, this was really helpful. I which I could blame it on NSAIDS but haven't taken them in 16 months, that's is why I am so flared now.

JAnet

Hi Janet,

You've gotten great advice hear already, and Evelyn's post is very informative, as I learned a couple new things about my anemia from it. I started to write this post a few hours ago at work and didn't get to finish it, so I copied it and then went back and reread the new replies in the time between when I started it and now. No one else who posted to you seems to be quite as worried about the possibility of bleeding as I do in the paragraphs below, but I decided to go ahead and leave my post as I wrote it anyhow, just in case some bleeding is going on. My post sounds almost like scare mongering compared to the others, which I definitely didn't intend to happen, so we'll just consider me the "worry wart, worst-case scenario guy" in thie group, ok? It sounds like you and your doctor have everyting under control, but maybe this info will help someone else in a similar situation. Good luck, and keep us posted on this, ok Janet?

Here's the original post I wrote

Hi Janet,

When you say your iron level is 5, do you mean that your hemoglobin level is that low? For my response here, I'll assume that is what you meant, so if I am wrong, you can just ignore thie note.

In women, hemoglobin is considered normal if it falls within this range: 12.1 to 15.1 gm/dl. Anything over 20 is considered the upper critical limit (or "panic value," as one site called it), while the lower critical limit is, well, 5. I can definitely understand why your doctor is asking you if you have been feeling tired, as that is a very, very low number. My dropped to 6-something once, and I felt as if I was carrying concrete blocks around my neck and wearing a couple more on my feet.

Did he ask you if you have had any stomach pain, or if you had thrown up any brown or red material that looked like coffee grounds? Or if your stool had turned black and tarry? As you probably already know, these questions are used to try to find out if the patient is experiencing internal bleeding in the gastrointestinal system, something AS and arthritis patients are especially susceptible to due to the powerful drugs we often take, such as NSAIDS, prednisone, methotrexate, and more. Frankly, with a hemoglobin level of 5, I would be quite surprise if he had not asked you these questions, at the very least. When I had that 6-something reading, my doctor called me at work as soon as he got the blood test back and ordered me to leave immediately and go right to the hospital. I was lucky that time--the bleeding had already stopped by the time I went to the doctor and then the hospital. I definitely had been bleeding, however, as I had thrown up old blood two weeks before that day (I just didn't know that dried blood looked brown, not red, or that it also looked like coffee grounds, which was a completely accurate description of what it DID look like).

Believe me, I am not telling you all this just to scare you--however, I do want to make sure that your doctor at least considered the possibility that you might be bleeding in your gastro tract and took the proper steps to either rule that out or diagnoe it and begin getting you treatment for it. Did the topic even come up in your visit? If not, I obviously can't tell you what to do, but I do know that if was me, and my hemoglobin was that low, I would at the very least go for a second opinion. If I was feeling weak, perhaps even faint at times, and I also had exhibited one or more of the bleeding symptoms, I would go to the hospital instead of waiting to get a second opinion in the coming days. We AS patients need to be very aware of potential stomach damage, and a low hemoglogin number is one indicator that shouldn't be ignored.

Best of luck Janet--please keep us updated on what happens in the coming days and weeks.

Brad

Brad,I agree, blood loss- including possible occult blood loss- is an important consideration for iron deficiency anemia. Iron deficiency anemia is one of the possible causes for anemia with low blood iron levels, the other being anemia of chronic disease. Sometimes the two can coexist, a person can have anemia with contributions of both iron deficiency and of anemia of chronic disease. Good luck Janet, and be sure to ask about blood loss, thanks Evelyn

Hi Janet,

Sorry I can't be of much help with this one as my problem has always been that I retain to much iron in my system making iron pills a no no for me. I do take B complex though to help with the tireness and stress.

Brent

Hi Brad,
Thanks for the ocncern, but it is my iron level not my Hgb level. I am very aware of all the points you have made, however I have had no NSAIDS in 16 months, so I can rule that out. I also had a scope about three months ago which ruled out an ulcer. I only get stomach discomfort if I start the NSAIDS again, so I have given up on taking these for the past 16 months. I am waiting too be approoved for Embrel and hope the iron anemia will improove to supplements.

Nice to have folks who really show concern for each other.


Janet