Dr. Weiss explains, “Primarily, we treat the underlying disease. Successful response often results in resolution of anemia if the underlying anemia is anemia of chronic disease.” Patients may need a new or added agent to bring their disease under control or a higher dose of an existing treatment.
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Explore This IssueDecember 2017
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Because of their mechanism, certain types of treatment may provide particular benefit in treating anemia of inflammation. Studies of TNF-α-blocking drugs have shown specific improvements, as have IL-6-blocking drugs such as tocilizumab. “These drugs act mainly by treating the underlying disease and reducing the inflammatory stimulus (via IL-6), which leads to the production of the master regulator of iron homeostasis, hepcidin,” explains Dr. Weiss. He notes that at this point the data do not support the use of one of these agents over any other.12,13
However, anemia may persist in some patients who do receive adequate treatment. Dr. Weiss explains, “It appears that a considerable number of patients with rheumatic diseases suffer from a combination of inflammatory anemia in association with true iron deficiency or vitamin deficiencies, which does not normalize after successful treatment of the rheumatic disease.” Because of this, he urges clinicians to gain a solid diagnostic understanding of the anemia and its underlying pathology.
It’s not clear in what specific situations iron, transfusions or erythropoietin-stimulating agents should be used. Clinicians may need to vary their therapeutic approach based on the underlying chronic condition, comorbidities & the specific needs of the individual patient.
Dr. Weiss emphasizes that the true cause of an iron deficiency must be evaluated. Any underlying iron deficiency should be treated with iron supplementation either orally or intravenously. Oral iron absorption can be limited in some patients with anemia of inflammation due to the inhibition of iron transfer from enterocytes to the circulation.1
Dr. Weiss notes, “If ferritin is low, then both options are feasible, because minute amounts of iron are absorbed under these circumstances, even when inflammation is present (as for example shown in patients with inflammatory bowel disease). Intravenous iron appears to be more appropriate in patients with normal ferritin and more inflammation; however, we are lacking pharmacokinetics and efficacy data of intravenous iron in this setting.”
Iron administration can also be used as a type of diagnostic measure in and of itself in differentiating anemia of inflammation from iron-deficiency anemia. “You can give supplemental iron and check their reticulocyte count about a week to 10 days later,” notes Dr. Koury. “If you see the retic count go up sharply, that would indicate a significant component of iron deficiency.”