Can Rheumatoid Arthritis Cause Internal Bleeding? The Scary Truth

Can rheumatoid arthritis cause internal bleeding? This question comes up more often than you’d think—especially in my clinic, where patients are understandably concerned about the seriousness of their symptoms and the possible side effects of their treatments. As a Rheumatology nurse practitioner, I’ve seen firsthand how confusing this disease can be. It’s not just about joint pain. It can affect so many systems in the body, sometimes in unexpected ways. Let’s talk about what you really need to know—without the fluff and in plain English.

Understanding Rheumatoid Arthritis: It’s More Than Just Achy Joints

RA, as we often shorten it in clinic, is a chronic autoimmune condition. That basically means the immune system gets a little too enthusiastic and starts attacking your own tissues—mainly the joints. But here’s the kicker: it doesn’t stop there. Over time, this inflammation can creep beyond the joints and affect things like your blood vessels, lungs, heart, and even eyes. The body’s inner terrain becomes a sort of battlefield.

Now, when we bring up internal bleeding in this context, people are usually taken aback. The phrase itself sounds intense, even scary. And understandably so. Most folks don’t connect a “joint disease” with bleeding inside the body. But the link is real, and we’ll unpack it here—layer by layer—because you deserve to know the full picture.

Can Rheumatoid Arthritis Cause Internal Bleeding? Let’s Break It Down

Medication Side Effects: The Usual Suspects

This is usually the first place I start when talking with patients. A lot of the meds we use to manage RA—like NSAIDs (nonsteroidal anti-inflammatory drugs), corticosteroids, and DMARDs—can increase the risk of internal bleeding. It’s not necessarily the RA itself causing the bleeding directly, but the tools we use to fight it. Here’s how:

• NSAIDs like ibuprofen or naproxen can irritate the stomach lining. Taken long-term (as many RA patients do), they can lead to ulcers and even gastrointestinal bleeding.
• Steroids (think prednisone) can thin out your blood vessels and reduce the body’s ability to repair minor damage—making bleeding more likely.
• Biologics and other DMARDs may suppress the immune system to such an extent that they make infections more dangerous—and some infections can cause bleeding, especially in the gut or lungs.

I’ve had a patient once—a lovely woman in her late 50s—who came in complaining of dark stools and lightheadedness. Turns out, she had a slow GI bleed from years of consistent NSAID use. It was a wake-up call for both of us. We switched her to a different med and added a protective stomach drug. It’s all about finding that delicate balance.

RA-Related Blood Vessel Damage (Vasculitis)

This part’s a little less common but way more serious. Rheumatoid arthritis can lead to a condition called rheumatoid vasculitis. That’s when inflammation affects the blood vessels themselves. It can damage the vessel walls and cause them to leak—or in some cases, rupture. Yep, that can lead to internal bleeding too. Usually this shows up in more advanced or untreated cases of RA, and it’s often accompanied by other red flags like skin ulcers, nerve problems, or sudden changes in vision.

1. Bleeding into the skin (appears as small red or purple dots, or bruising)
2. Bleeding in the gastrointestinal tract
3. Even bleeding into the lungs in severe cases (rare, but not unheard of)

In my practice, I’ve only seen a few cases of vasculitis-related bleeding, but they stuck with me. These are the patients who end up needing a team approach—hematology, rheumatology, sometimes even surgery if it gets really intense.

Low Platelet Counts and Anemia

Another angle we can’t ignore: RA and its treatments can mess with your blood counts. Certain medications—like methotrexate—can cause bone marrow suppression. That can lead to lower platelet levels (which help your blood clot). Fewer platelets = higher risk of bleeding. Add that to a damaged gut lining or inflamed vessels, and you’re looking at a potential recipe for internal bleeding.

One of my long-time patients—a retired teacher—had been on methotrexate for years. She was feeling more tired than usual and bruising easily. Her labs showed both anemia and low platelets. We paused the meds, got her iron up, and tweaked her treatment plan. Monitoring labs isn’t just a formality—it can literally save lives.

Other Hidden Risks You Should Know About

There are a few lesser-known but important scenarios where bleeding risks can sneak in:

• Liver involvement: In rare cases, RA or its meds can impact liver function, leading to clotting issues.
• Infections: Immunosuppressive drugs increase infection risk, and some infections—like sepsis—can cause bleeding.
• Co-existing conditions: Many RA patients also deal with conditions like heart disease or hypertension, which may require blood thinners—adding another layer of bleeding risk.

So, while RA doesn’t directly “cause” internal bleeding in the same way a trauma or rupture might, it creates a complex web of risks that can lead there. The key is awareness and a proactive care plan.

How Do We Monitor for Internal Bleeding in RA Patients?

One of the most important parts of managing RA—especially with the bleeding risk—is keeping a close eye on labs and symptoms. In my clinic, we run routine bloodwork every few months. It’s not just to check a box—it’s to catch any early signs of problems before they become full-blown emergencies.

What are we looking for? Great question. Here’s a quick list of what we usually track:

• Complete Blood Count (CBC): Helps detect anemia, low platelets, or infection.
• Liver Function Tests: Especially if you’re on methotrexate or leflunomide—those meds can be hard on the liver.
• Stool Occult Blood Test: If there’s any concern about gastrointestinal bleeding, even if it’s not visible yet.
• Kidney Function: Because NSAIDs can put strain on those organs over time.

What I always tell my patients is this: “If something feels off—speak up.” Things like black, tarry stools, sudden dizziness, or unexplained bruises are not things to brush off. They’re clues. And in RA, we can’t afford to ignore clues.

Imaging and Specialist Support

There are also times when labs just aren’t enough. If someone is showing signs of deeper internal bleeding—especially in the lungs or GI tract—we’ll move on to imaging. That might mean a CT scan, endoscopy, or even a bronchoscopy. We work closely with GI docs, pulmonologists, and sometimes hematologists to get a full picture.

In one case I remember vividly, we had a gentleman in his early 60s, stable RA for years, suddenly develop shortness of breath and a bloody cough. Turns out, it was pulmonary hemorrhage—rare, but terrifying. The rapid coordination between rheumatology, pulmonology, and critical care made all the difference. He pulled through, but it was a serious reminder of just how complicated RA can be.

When Should You Be Worried? Red Flags That Deserve Attention

Sometimes people just aren’t sure when a symptom crosses the line into “serious.” Totally fair. Here are some warning signs I always tell my patients to watch for:

1. Dark or tarry stools – could mean bleeding in the upper GI tract
2. Unexplained fatigue – especially if it’s worse than your usual “RA tired”
3. Bruising easily or frequently – could signal platelet issues or medication side effects
4. Blood in urine or sputum – don’t ignore it, even if it’s just once
5. Feeling faint or dizzy – especially when standing up or after exertion

If any of these sound familiar, please don’t “wait and see.” I know life gets busy, but in my experience, early intervention saves headaches (and hospital stays) down the road.

Can Rheumatoid Arthritis Cause Internal Bleeding in Rare or Severe Cases?

Let’s circle back to the core question: Can rheumatoid arthritis cause internal bleeding? The short answer is yes—though it’s usually not the arthritis alone, but a combination of factors including meds, complications, and co-existing conditions.

That said, in severe or long-untreated cases, the disease itself can be destructive enough to trigger bleeding without much outside help. Rheumatoid vasculitis is a great example. It can affect not just skin and nerves, but internal organs and vessels. If a medium or large blood vessel becomes inflamed and damaged, bleeding can absolutely follow. And in some rare instances, the lungs can fill with blood—a life-threatening emergency.

I’ll never forget a patient I worked with in my early years as an NP. She had advanced RA, wasn’t tolerating meds well, and eventually developed systemic vasculitis. She came in one day looking pale, weak, and out of breath. Labs and scans revealed internal bleeding in her abdomen, likely due to ruptured blood vessels. She needed urgent care, blood transfusions, and a complete overhaul of her RA management. Scary stuff—but she pulled through with the right support.

Patients on Blood Thinners: Double the Risk

We can’t talk about bleeding without mentioning blood thinners. Many people with RA also have heart issues—some even have atrial fibrillation or previous blood clots. So they’re prescribed anticoagulants like warfarin or newer meds like apixaban. Helpful, yes—but they also raise the bleeding risk sky-high if not carefully balanced.

When I’m reviewing med lists with my RA patients, especially older adults, I always look for these combos. We may need to loop in cardiology or hematology to ensure we’re not accidentally setting someone up for an internal bleed. It’s all about coordination and individualizing care.

Can Diet or Supplements Influence Bleeding Risk in RA?

This question pops up a lot: “Are there foods or supplements I should avoid if I have RA and am worried about bleeding?” The answer is… maybe. Some natural products can actually thin the blood slightly or interact with your medications.

• Fish oil, turmeric, and garlic all have mild blood-thinning properties. Fine in small doses, but something to be mindful of if you’re also on meds like NSAIDs or anticoagulants.
• Vitamin E can increase bleeding risk if taken in high doses.
• Alcohol—besides irritating the stomach—can worsen liver function and interact badly with meds like methotrexate.

So while I’m all about natural approaches where appropriate, I always recommend running supplements by your provider first. One of my patients was taking high-dose fish oil for heart health but started bruising like crazy. A quick tweak in the dosage (and switching to a plant-based omega-3) fixed the issue without sacrificing her goals.

Managing the Risk: What Patients and Providers Can Do

So, what can we do to minimize the risk of internal bleeding in RA patients? From my experience, a proactive approach is key. Here are some strategies I’ve found effective:

• Regular Monitoring: Keeping up with routine blood tests helps catch potential issues early. This includes checking for anemia, platelet counts, and liver function.
• Medication Reviews: Periodically reviewing all medications with your healthcare provider ensures that combinations like NSAIDs and corticosteroids are used safely.
• Symptom Awareness: Educating patients about warning signs—such as unusual bruising, blood in stool or urine, and persistent fatigue—empowers them to seek timely medical attention.
• Lifestyle Adjustments: Encouraging a balanced diet, limiting alcohol intake, and avoiding smoking can support overall health and reduce complications.

In my clinic, I’ve seen patients benefit greatly from personalized care plans that address their unique risks and needs. Open communication between patients and providers is essential in managing RA effectively.

Real-Life Case: Navigating Complications

Let me share a case that highlights the importance of vigilance. A patient in her late 50s, with a long history of RA, came in complaining of fatigue and dark stools. She was on a regimen that included NSAIDs and low-dose prednisone. Recognizing the red flags, we conducted tests that revealed a bleeding gastric ulcer.

We collaborated with a gastroenterologist to manage the ulcer and adjusted her RA medications to reduce gastrointestinal risks. This case underscores how critical it is to monitor for signs of internal bleeding and to adjust treatment plans accordingly.

Final Thoughts: Staying Informed and Proactive

Rheumatoid arthritis is a complex disease that requires careful management to prevent complications like internal bleeding. By staying informed, maintaining open communication with healthcare providers, and being proactive about monitoring and lifestyle choices, patients can significantly reduce their risks.

Remember, if you notice any unusual symptoms or have concerns about your medications, don’t hesitate to reach out to your healthcare team. Early intervention can make a significant difference in outcomes.

References

• Increased Incidence and Impact of Upper and Lower Gastrointestinal Events in Rheumatoid Arthritis
• Rheumatoid Vasculitis: Symptoms & Treatment – Cleveland Clinic
• Rheumatoid Arthritis Treatment Options – Johns Hopkins Arthritis Center
• Can You Take Prednisone With Advil (Ibuprofen)? – Verywell Health
• Rheumatoid Arthritis: Diagnosis and Treatment – Mayo Clinic

Disclaimer

This article is for informational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment. Always consult your healthcare provider with any questions you may have regarding a medical condition. Do not disregard professional medical advice or delay seeking it because of something you have read here.

Tarra Nugroho

Tarra Nugroho is a dedicated Nurse Practitioner with a strong foundation in family and preventive care. She brings both compassion and clinical expertise to her practice, focusing on patient-centered care and health education. As a contributor to Healthusias.com, Tarra translates medical knowledge into clear, empowering articles on topics like women’s health, chronic disease management, and lifestyle medicine. Her mission is simple: help people feel seen, heard, and informed—both in the clinic and through the content she creates. When she’s not caring for patients, Tarra enjoys weekend hikes, plant-based cooking, and curling up with a good health podcast.