Anemia is a common comorbidity (co-occurring condition) in people with psoriasis, psoriatic arthritis (PsA), or other inflammatory conditions. Anemia due to iron deficiency or other causes is a major contributor to fatigue, which can dramatically affect quality of life. Because fatigue is a common symptom of inflammatory diseases, it may be overlooked as a sign of anemia as well.
Anemia is a condition that occurs when the blood cannot carry enough oxygen to meet the body’s needs. In anemia, the blood has low levels of hemoglobin, a protein found in red blood cells that carries oxygen.
Anemia can occur for several reasons. You may develop anemia if your body:
The most common types of anemia with psoriasis are iron deficiency anemia and anemia of chronic disease. In some cases, people with psoriasis may experience pernicious anemia.
Your body needs iron to make hemoglobin for new blood cells. Iron deficiency anemia can occur if you do not eat enough iron, have poor iron absorption in the gut, or experience blood loss.
Anemia of chronic disease, also called anemia of inflammation, can occur in people with conditions that cause chronic inflammation, such as psoriasis, chronic kidney disease, and rheumatoid arthritis.
Anemia of chronic disease can prevent the normal production of red blood cells in several ways. Chronic inflammation can shorten the life span of red blood cells. Chronic inflammation can also cause iron to accumulate in macrophages (white blood cells that destroy aging red blood cells), making the iron unavailable to create new hemoglobin.
Additionally, chronic inflammation can decrease iron availability by increasing levels of hepcidin, a hormone that controls iron storage and transport. Inflammation causes high levels of cytokines in the body, which raises levels of hepcidin as well.
Pernicious anemia is a rare type of autoimmune anemia that sometimes occurs in people with psoriasis or PsA. Your body needs vitamin B12 to make red blood cells. Pernicious anemia causes vitamin B12 deficiency due to poor gastrointestinal absorption of B12.
Intrinsic factor is a protein produced in the stomach that is needed to absorb vitamin B12. Pernicious anemia occurs when the immune system attacks and destroys intrinsic factor or the cells that make it. Without enough intrinsic factor, the body cannot absorb enough vitamin B12 to make the amount of red blood cells it needs.
Other conditions can also cause vitamin B12 deficiency and anemia. These include celiac disease and inflammatory bowel disease, as well as surgeries affecting the stomach and small intestine.
Anything that prevents hemoglobin from being made, prevents red blood cells from being made, or destroys blood cells can cause anemia. Research has found that people with psoriasis tend to have poor iron storage — especially people with low body mass. It is not understood how psoriasis causes abnormal iron metabolism and storage, but researchers believe it is not connected to the inflammation associated with psoriasis.
Chronic inflammation can also cause anemia in psoriasis. Chronic inflammation can decrease the production of erythropoietin, a protein produced by the kidneys that stimulates the production of red blood cells. Additionally, chronic inflammation can decrease the life span of red blood cells and prevent the recycling of iron to create more hemoglobin and red blood cells.
If you have psoriasis, it’s a good idea to know the signs and symptoms of anemia in case you begin to experience them. Symptoms of all types of anemia can include:
Iron deficiency anemia can cause additional symptoms, including:
Pernicious anemia can also cause symptoms of:
Fatigue is typically the most common symptom of anemia. The more severe the anemia, the more symptoms a person will generally experience. People with very mild anemia may not experience any symptoms at all.
Learn more about other causes of fatigue in psoriasis.
Anemia can be diagnosed with a blood test. A complete blood count (CBC) is used to measure hemoglobin levels and the amount of red blood cells in blood. Results of a CBC also include other information that can help identify causes of anemia.
Anemia is defined as having a hemoglobin level less than 13.5 grams per deciliter (gm/dL) in men or 12.0 gm/dL in women. Additional tests can help your doctor diagnose the type and cause of anemia, including blood tests for iron, folate (folic acid or vitamin B9), and vitamin B12.
MyPsoriasisTeam members report that treating anemia has improved their well-being. As one member said, “I’m feeling better now that I’m not anemic anymore.”
Treatment for anemia typically depends on the cause. In the case of anemia with psoriasis, treating your underlying condition can often help improve anemia. Other approaches can also help you manage anemia.
Treating the underlying cause of inflammatory disease is an important part of treating anemia of chronic disease. Some biologic drugs used to treat psoriasis and PsA can help improve anemia.
Research has shown that tumor necrosis factor alpha inhibitors can improve anemia in people with PsA, ankylosing spondylitis, and related diseases. These drugs include etanercept (Enbrel), adalimumab (Humira), infliximab (Remicade), and golimumab (Simponi).
Iron deficiency can often be treated with dietary changes or iron supplements.
Foods that are rich in iron include:
Eating foods rich in vitamin C — such as citrus fruits, broccoli, peppers, strawberries, melons, and tomatoes — can also help improve iron absorption.
Eating a balanced, nutritious diet can help prevent iron deficiency. Over-the-counter or prescription iron supplements may be needed to restore healthy iron levels as well. Intravenous iron can also be used to treat iron deficiency, especially in people who cannot tolerate or absorb oral iron supplements.
Learn more about the diet strategies for psoriasis.
Supplemental vitamin B12 or folate is often used to treat anemia in people with deficiencies in these vitamins. People who cannot absorb vitamin B12 well, such as those with pernicious anemia, may need synthetic vitamin B12 injections to raise B12 levels.
MyPsoriasisTeam members report that B12 shots have been effective. “My B12 depletes and I have a series of three shots, which bring my B12 levels up for a year or two, it seems,” said one member. Another said, “I was having some general blood tests and have since discovered a vitamin B12 deficiency. I have a regular injection quarterly and my psoriasis is 80 percent better.”
In some cases, erythropoietin-stimulating drugs may be used to increase the production of red blood cells. These are usually prescribed for people with low levels of red blood cells due to chronic inflammation, cancer, or chemotherapy.
Severe anemia that is potentially life-threatening may require a blood transfusion. A transfusion of red blood cells is typically only used to treat extremely low hemoglobin levels (less than 7 gm/dL, or about half of the normal minimum hemoglobin levels). A transfusion may also be used for severe anemia that has not responded to other treatments.
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