High ESR Levels in Anemia and Ankylosing Spondylitis

Is it because I have anemia that my ESR is often elevated?

Hello Doctor: I am a patient with ankylosing spondylitis, 20 years old, and I have been diagnosed for over 2 years.
Recently, for the past 7 months, I have been taking Salazopyrin, and during my last two follow-up visits, my hsCRP levels were 0.2 and 0.4, with very mild symptoms (Salazopyrin has been much better for me compared to when I was on Humira).
However, I am troubled by one thing: my ESR levels were 39 and 56.
I would like to ask you, 1) Over the past 2 years, I have had my blood drawn 8 times, and my hemoglobin (Hb) levels ranged from 13.5 to 14.5, with a median of 14.05.
My mean corpuscular hemoglobin (MCH) was between 26.8 and 27.8, with a median of 27.25.
My red cell distribution width (RDW) was between 11.2 and 11.4, with a median of 11.3.
All other parameters were normal, but although these three values are within the normal range, they seem noticeably low.
Could this "slight" anemia be causing such high ESR levels? 2) Over the past 2 years, my ESR has ranged from 14 to 56, with a median of 36.
Doctors have said that occasional spikes are not a concern, but my last two results were quite high.
I have also observed that my ESR tends to remain elevated even when my CRP levels are low, which makes me wonder if it is truly acceptable to disregard it? Thank you, Doctor.

Xiang, 20~29 year old female. Ask Date: 2022/10/14

Dr. Zeng Guosen reply Internal Medicine

1.
Hemoglobin (Hb) levels of 13.5 to 14.5 are not the cause of abnormal erythrocyte sedimentation rate (ESR), as ESR can be influenced by many factors in the body.

2.
C-reactive protein (CRP) is more important than ESR for monitoring ankylosing spondylitis; symptoms and X-rays are also crucial.
If only the ESR is elevated while all other parameters remain stable, regular monitoring is sufficient.
However, if there are any abnormal changes in the values, further investigation is warranted.
Thank you for your question.

Reply Date: 2022/10/14

More Info

High ESR (Erythrocyte Sedimentation Rate) levels can be a source of concern for patients, especially those with chronic conditions like Ankylosing Spondylitis (AS). In your case, it is important to understand the implications of your ESR readings in the context of your overall health, particularly in relation to your anemia and the management of AS.

1. Understanding ESR and Anemia: ESR is a non-specific marker of inflammation in the body. It measures how quickly red blood cells settle at the bottom of a test tube; a faster rate indicates the presence of inflammation. In patients with anemia, ESR can be influenced by the reduced number of red blood cells. Your hemoglobin (Hb) levels, which range from 13.5 to 14.5 g/dL, are within the normal range, but you mentioned feeling that they are "slightly low." This perception could stem from the fact that even normal values can feel inadequate if you are experiencing symptoms of fatigue or malaise, which are common in anemia.
Anemia can indeed affect ESR levels. In some cases, the presence of anemia can lead to a higher ESR due to changes in the plasma protein composition, which can occur even when inflammation is not significantly present. However, your ESR levels of 39 and 56 mm/h are elevated and suggest that there may be ongoing inflammation, which could be related to your Ankylosing Spondylitis rather than solely due to anemia.

2. Interpreting High ESR in AS: It is not uncommon for patients with AS to have elevated ESR levels even when other inflammatory markers, such as hsCRP (high-sensitivity C-reactive protein), are low. This discrepancy can occur because ESR is influenced by various factors, including the presence of chronic inflammation, infection, and even certain medications. In your case, the fact that you are experiencing mild symptoms and have low hsCRP levels suggests that your AS may be well-controlled at the moment, despite the elevated ESR.

Your healthcare providers' advice to not overly concern yourself with occasional high ESR readings is generally sound, especially if your clinical symptoms are stable and you are responding well to treatment. However, it is essential to monitor these levels over time and discuss any significant changes with your rheumatologist.
3. Management and Follow-Up: Given your situation, it would be beneficial to maintain regular follow-ups with your rheumatologist. They can help determine whether the elevated ESR is a sign of active disease or if it is simply a reflection of your body's response to the chronic condition. If your symptoms remain mild and stable, and if your treatment regimen continues to be effective, the elevated ESR may not require immediate intervention.
In conclusion, while elevated ESR levels can indicate inflammation, they should be interpreted in the context of your overall health, symptoms, and other laboratory findings. It is crucial to maintain open communication with your healthcare team to ensure that your Ankylosing Spondylitis is managed effectively and to address any concerns you may have regarding your ESR levels and anemia. Regular monitoring and a comprehensive approach to your treatment will help you manage your condition more effectively.

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