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Arthritis and Rheumatism

RA or low iron anemia - Part 2



I am still confused because my ferritin came back normal. But I decided to take iron pills any way. I have been on them for 2 weeks now. I actualy felt more tired then I use to. I don`t know how long I would have to take iron before I should notice a difference. If I don`t feel any better or my anenia doesn`t get better then I will stop taking the iron. I am taking Enbrel, Methotrexate and Prednisone for my RA. Tiazac and Coversyl for my high blood pressure. Could any of them interact with the iron and make me feel worse?

Previous Question: I just got back from seeing my GP. My hemoglobin was low, it was 9.0. I knew that it would be low because I have been anemic for 2 years. He thinks that my iron is low. He talked about my ferratin level that I had checked last year and that was fine. He also told me that the size of my red blood cells are getting smaller and my periods are heavy that is why he thinks that my iron is low and wants me to take iron pills. But My old GP, a doctor of internal medicine and my rheumatologist nurse said that it is because of my arthritis and that it will get better when my arthritis get better. I don`t want to take any more medications. I asked him about what will happen if I didn`t take any thing. He said that you will be tired. No really health problems if I don`t take it. Take it to get more energy which I got back when I started Enbrel. Take more medications that does not do any thing. I will be fine with out it. I see my rheumatologist on Tuesday and I will ask him. He is the only person that I have not asked yet. I will let him know my test results and see what he says. I hate taking medications. Can you explain to me who to believe and why?

Previous Answer: Actually both physicians may be correct as you may have a combination of iron deficiency anemia and anemia of chronic disease due to rheumatoid arthritis. Laboratory testing should help sort out which anemia or anemias you have. In iron deficiency anemia, the ferritin level is low with low iron levels and elevated total iron binding capacity. The MCV (size of red blood cells) is low. In anemia of chronic disease due to rheumatoid arthritis, the ferritin, iron levels and total iron binding capacity are all low with normal MCV. Ferritin may not be accurate reflection of iron stores if there is active rheumatoid arthritis since it will be elevated as an acute phase reactant. Therefore, if your rheumatoid arthritis is active, your ferritin may be normal even though there is iron deficiency anemia.


To clarify my previous answer re: ferritin, normally in iron deficiency anemia the ferritin is low and in rheumatoid arthritis the ferritin is normal if there is no active flare and elevated if there is active flare. Therefore, a normal ferritin may be due to rheumatoid arthritis in the setting of no active disease or due to combination of iron deficiency anemia- lowering ferritin and active rheumatoid arthritis- elevating ferritin with combined effect resulting in normal ferritin.

Iron supplements will improve energy levels and anemia after couple of months rather than couple of weeks. Although the medications you are on do not interfere with iron, methotrexate itself can affect the bone marrow and also cause anemia. You may be feeling more tired if your rheumatoid arthritis is flaring up rather than due to the iron supplements.

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Response by:

Johnny  Su, MD Johnny Su, MD
Formerly, Assistant Professor of Medicine
School of Medicine
Case Western Reserve University