A 48-year-old woman complains of persistent fatigue and daytime sleepiness. Her other medical problems include hypertension and rheumatoid arthritis. Her medications include naproxen, enalapril, and a multivitamin supplement with iron. She has no known drug allergies. Vital signs are within normal limits. Examination shows conjunctival pallor and bilateral hand joint deformities with tenderness to palpation at metacarpophalangeal joints. Stool testing for occult blood is negative. Laboratory results are as follows:
Which of the following would be the most appropriate next step in managing this patient's anemia?

Question

A 48-year-old woman complains of persistent fatigue and daytime sleepiness.  Her other medical problems include hypertension and rheumatoid arthritis.  Her medications include naproxen, enalapril, and a multivitamin supplement with iron.  She has no known drug allergies.  Vital signs are within normal limits.  Examination shows conjunctival pallor and bilateral hand joint deformities with tenderness to palpation at metacarpophalangeal joints.  Stool testing for occult blood is negative. Laboratory results are as follows:
 Which of the following would be the most appropriate next step in managing this patient's anemia?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c163_1891_8f63_3944eea29597_MD0005_00 Anemia of chronic disease (ACD, anemia of chronic inflammation) is a common complication of rheumatoid arthritis and other inflammatory diseases. The precise etiology is not fully understood but is generally thought to be due to suppression of hematopoiesis by inflammatory cytokines. Hematologic studies typically show a low serum iron, elevated ferritin levels, and normal transferrin saturation (approximately 25% of ACD patients may have low transferrin saturation). Mean corpuscular volume is usually low-normal to mildly decreased. ACD is usually a relatively mild anemia, but approximately 20% of patients may have hemoglobin <8 g/dL. In these more severe cases, clinicians should rule out additional concurrent causes of anemia such as iron deficiency, myelodysplasia, and thalassemia. The foundation of treatment for ACD is addressing the underlying inflammatory disorder. In rheumatoid arthritis, anti-TNF-α antibody (eg, infliximab) infusions have been shown to lessen the severity of anemia. If patients have low or inappropriately normal erythropoietin levels, they may respond to injections of erythropoietin or darbepoetin. Patients with appropriately elevated erythropoietin levels (especially >500 mU/mL) do not respond. Those who have severe, symptomatic anemia who do not improve with initial measures may need periodic red cell transfusions. (Choice A) Folinic acid (leucovorin) is a folic acid derivative. It can be given orally or parenterally to counteract the effects of antifolate drugs such as methotrexate used in autoimmune disorders and cancer. Folinic acid would not be helpful in this patient, who is not on methotrexate. (Choice C) Iron supplementation may be useful in patients with rheumatoid arthritis and ACD who have co-existing iron-deficiency anemia, which can result from gastrointestinal bleeding secondary to drug therapy or decreased absorption of dietary iron. If oral supplementation is not adequately absorbed, as may occur in patients with rheumatoid arthritis, parenteral iron may be needed. However, supplemental iron would not be helpful in patients such as this who have adequate iron stores. (Choice D) Plasmapheresis is used to reduce levels of circulating autoantibodies in conditions such as Guillain-Barré syndrome, myasthenia gravis, and thrombotic thrombocytopenic purpura. It has been used historically for rheumatoid arthritis but is no longer recommended and is not a standard treatment for anemia of chronic disease. (Choice E) Splenectomy can be considered in patients with hypersplenism and hemolytic anemia (eg, autoimmune hemolytic anemia, hereditary spherocytosis). ACD, however, is not due to hypersplenism or hemolysis, and splenectomy would not be helpful. Educational objective: Anemia of chronic disease (anemia of chronic inflammation) is a common complication of inflammatory conditions such as rheumatoid arthritis. Management generally involves treating the underlying condition and ruling out concurrent causes of anemia. Anti-TNF-α agents improve anemia of chronic disease in patients with rheumatoid arthritis. References: Anaemia in inflammatory rheumatic diseases. (http://www.ncbi.nlm.nih.gov/pubmed/23147894)

A 48-Year-Old Woman Complains of Persistent Fatigue and Daytime Sleepiness