Undiagnosed Anemia Common With Chronic Illness

Pathology and hematology professor Lawrence Tim Goodnough, MD, asserts that anemia, a reduction in the number of red blood cells, occurs surprisingly more often than medical professionals and patients recognize. Consequently, many people who suffer its symptoms—fatigue, lack of concentration, irritability and headaches, among others—do not benefit from available treatments.

In an article published Thursday in the New England Journal of Medicine, Goodnough details a particular area of concern in the lack of anemia diagnoses: the prevalence and severity of anemia as a side effect of such chronic diseases as rheumatoid arthritis, cardiovascular disease, cancer and diabetes. The paper, which was co-authored with Guenter Weiss, MD, of the Medical University of Innsbruck, grew in part from Goodnough's research on how the inflammation that occurs during these chronic diseases contributes to anemia by interfering with the production of erythropoietin, the hormone that stimulates red blood cell production in the bone marrow.

Anemia is also caused by a dietary deficiency of iron, folate or vitamin B12, all of which are needed to produce healthy red blood cells. Iron deficiency is the most common cause of nutritional anemia.

In people over the age of 75 the rate of anemia approaches 30 percent. One-third of the cases in the elderly are due to heart, kidney and other chronic inflammatory diseases.

It is critical to identify and treat anemia in the elderly, said Goodnough, as it has been shown that there is a direct relationship between anemia and loss of day-to-day functioning in this group. "Once an elderly person becomes progressively more sedentary, it becomes this downward spiral going from independence to dependence," Goodnough said. Small studies have shown that treating anemia can reverse this spiral.

For patients with certain conditions such as chronic kidney disease or cancer, the treatment of anemia has been shown to improve their quality of life, such as overall energy level and ability to participate in daily activities. In addition, for patients with chronic kidney disease, when anemia is treated, there is an improvement in the patients' survival time.

In the article, Goodnough, who directs the transfusion service at Stanford, reviews how anemia caused by chronic disease can be treated with blood transfusion and drugs that stimulate the production of red blood cells, as well as treating the chronic disease itself. Anemia caused by nutritional deficiencies can be reversed by improving diet and taking vitamin supplements.

In general, Goodnough explained, physicians don't pay enough attention to the reduction in quality-of-life issues that accompanies anemia. Many anemic people may not mention that they are fatigued, have shortness of breath and have difficulty pursuing such daily activities as taking care of their kids and going to work. That problem is exacerbated among chronic disease patients, who often think those symptoms are a result of their disease or treatment rather than the accompanying anemia. They also may have cut back so much on activities that they lack symptoms because they are doing nothing but sitting around.

The problem goes beyond the segment of patients discussed in the article. "I am of the view that anemia is a public health problem," Goodnough said.

Up to 20 percent of pre-menopausal women are anemic—the rates for black and Hispanic women are higher than for Caucasians—due to the monthly losses of blood, which is not compensated for by their intake of iron in their diet. "To me, a menstruating woman is iron-deficient until proven otherwise," Goodnough said.

Unfortunately, screening for anemia—taking a blood count—doesn't happen as often as Goodnough believes is needed. A blood count looks at the number of red blood cells, white blood cells and platelets and identifies anemia by a lower than normal red blood cell count.

"In the general population, physicians are not screening at all, because Medicare does not reimburse for a blood count as a screening test," he said, also noting that none of the major medical organizations recommend that providers routinely do such screens.As a result, many people find out unexpectedly that they have anemia when they have a routine blood count before scheduled elective surgery. Donating blood is another common way that anemia is discovered, because a blood count is required before blood is drawn.

"I am a big fan of community blood donation because it not only benefits the greater good of the community by enhancing blood in the inventory, but it also is an effective way of screening young women for anemia who might very well benefit from iron supplementation," he said.

Given the frequency of the condition, Goodnough thinks that a simple blood count should be a part of any general physical exam. "If someone comes in with a complaint . . . why not order a blood count?" Goodnough said. "The cost is trivial, and they will never know how much better they would feel if you don't make the diagnosis first."