Struggling with Fatigue? Rheumatoid Arthritis and Iron Deficiency Might Be to Blame

Let’s talk about something I see a lot in my clinic — rheumatoid arthritis and iron deficiency. If you’re living with RA, and you’re feeling unusually tired (like more than your usual flare-up fatigue), you might be surprised to learn your iron levels could be to blame. It’s a topic I often dive into with patients who think it’s “just the arthritis” causing their exhaustion. And hey, I get it — when everything hurts, it’s easy to chalk it all up to inflammation. But trust me, there’s more to the story.

How Rheumatoid Arthritis Messes with More Than Just Joints

When people think about rheumatoid arthritis, they often picture joint swelling, pain, and stiffness. And yes, that’s a big part of it. But what gets missed in the conversation — and even in some doctor’s offices — is how systemic RA really is. It’s not just your joints in the crosshairs. Your whole body is involved, including your blood.

I’ve seen patients struggle with low energy, brain fog, and shortness of breath for months, only to find out they’re severely iron deficient. The catch? It doesn’t always show up as classic anemia. RA creates a type of chronic inflammation that can mess with how your body uses and stores iron. So, even if you’re “eating right,” it might not be enough.

But Wait — Can RA Really Cause Iron Deficiency?

Absolutely. It’s not just about blood loss or poor diet. Inflammatory diseases like RA can block the normal pathways that allow your body to absorb and transport iron. This leads to what we call “anemia of chronic disease” — and it’s sneaky. Your labs might look borderline normal, or just slightly off, but the fatigue you’re feeling is very real.

• Hepcidin Overdrive: Inflammation increases a hormone called hepcidin, which tells your body to trap iron in storage and not release it into the bloodstream.
• Impaired Iron Absorption: The gut becomes less efficient at pulling in iron from food.
• Decreased Red Blood Cell Production: Your bone marrow slows down, even though it’s trying to fight back against inflammation.

And here’s a little insight from my own practice — I often check ferritin levels (your body’s iron storage protein) along with hemoglobin. Why? Because in RA, ferritin can be falsely elevated due to inflammation, which tricks people into thinking their iron is fine. But it’s not about just how much iron is there — it’s about whether your body can use it.

Symptoms That Might Not Be ‘Just RA’

Fatigue is the most common symptom I hear about, and it’s usually brushed off. “I’m always tired, it’s just the RA.” But when it becomes debilitating — like needing a nap after folding laundry — it’s time to look deeper.

Here are some sneaky signs of iron deficiency in people with RA:

1. Extreme fatigue that doesn’t improve with rest
2. Shortness of breath or racing heart with mild activity
3. Headaches or trouble concentrating
4. Pale skin or dark circles under the eyes
5. Brittle nails or hair thinning (this one surprises people!)

I once had a patient who swore her “RA brain fog” was just part of the disease — turns out, her iron levels were tanked. A few months into treatment, she told me it was like someone turned the lights back on in her head.

Understanding the Iron Panel: What Your Labs Are Really Saying

So you get your labs back — what are you looking for? Here’s a quick breakdown:

• Hemoglobin (Hgb): This is your oxygen-carrying protein. Low levels = classic anemia.
• Ferritin: Your iron storage. High can be falsely reassuring in RA due to inflammation.
• Serum Iron: Actual circulating iron. Often low in both iron deficiency and chronic disease.
• Total Iron Binding Capacity (TIBC): If this is high, it means your body is trying to grab more iron.
• Transferrin Saturation: A low percentage here is a red flag for true iron deficiency.

I always tell patients: don’t just glance at the hemoglobin and assume you’re fine. Ask your provider to look at the full iron panel — especially if you’re dealing with stubborn fatigue that doesn’t make sense.

Managing Iron Deficiency When You Have RA

Alright, so now that we’ve unpacked how rheumatoid arthritis and iron deficiency are more connected than most people realize, the next logical question is — what do you actually do about it?

First things first, you don’t want to just start popping iron supplements off the shelf without understanding your labs. I’ve had patients do that before, and honestly, it’s a mixed bag. Some feel a bit better, sure — but others end up with stomach cramps, constipation, or worse, not absorbing anything at all. With RA in the mix, the approach has to be more tailored.

Diet Isn’t Everything, But It Helps

I’ve had plenty of patients ask, “Can I fix this with food?” The honest answer? Sometimes. But it depends on why you’re iron deficient. If your gut isn’t absorbing properly because of chronic inflammation, or your hepcidin levels are sky-high, even the best diet won’t cut it alone.

Still, it’s a good starting point. I usually suggest working in a mix of:

• Heme iron sources: Think red meat, chicken liver, turkey — this form of iron is the easiest to absorb.
• Non-heme iron: Spinach, lentils, pumpkin seeds, fortified cereals — not as easily absorbed, but still useful.
• Vitamin C: Helps your body actually use that iron. Add bell peppers, oranges, or strawberries to your meals.
• Avoid tea and coffee during meals: Tannins interfere with iron absorption — I know, it’s a bummer!

One of my patients, a lovely woman with RA for 12 years, kept trying to “eat her way” out of anemia. She was vegetarian, super disciplined with her diet, and yet her levels wouldn’t budge. We ended up adding a gentle supplement with vitamin C — and boom, three months later, her energy was finally back.

Supplements and Infusions: When Food Isn’t Enough

There are several different ways to go when food just doesn’t cut it. I like to walk through all the options with my patients so they feel in control of the decision. Here’s what I usually explain:

1. Oral iron supplements: Over-the-counter ferrous sulfate is common, but can be harsh on the stomach. I often recommend slower-release or lower-dose options like ferrous bisglycinate.
2. IV iron infusions: For people with significant inflammation or absorption issues, this bypasses the gut altogether and can be incredibly effective.
3. Combining with RA meds: Treating the underlying inflammation helps your body respond better to iron therapy — so don’t skip those DMARDs or biologics!

Something that’s come up often in my practice — folks worry about taking “too much” iron or mixing it with other meds. That’s where a personalized plan comes in. I always review medications for interactions (like calcium supplements blocking absorption) and space out dosages if needed. It’s all about making the treatment actually work for the real-life person, not just the textbook.

Why Your Fatigue Deserves Real Attention

Here’s the truth: chronic illness fatigue is wildly misunderstood. A lot of my patients feel brushed off — “You’re just tired,” or worse, “It’s probably depression.” While mood definitely plays a role, we can’t ignore the biological contributors, especially iron deficiency.

I’ve had countless conversations where patients tear up because someone finally validated what they were feeling. That it wasn’t all in their head. That needing to nap after unloading groceries wasn’t laziness. When we treat the iron deficiency alongside RA management, it’s like giving someone their life back — they’re sharper, stronger, more like themselves again.

Here’s a little list I share with my patients to help them track when fatigue feels “off” and might need lab work:

• Needing more than 9 hours of sleep and still waking up drained
• Fatigue worsening despite stable RA meds
• Frequent headaches, dizziness, or cold hands/feet
• Cravings for ice (yes, that’s a real iron deficiency symptom!)
• Not bouncing back from activity like you used to

Remember: fatigue is a symptom, not a diagnosis. If it’s dragging down your quality of life, let’s figure out why.

Talk to Your Provider — But Come Prepared

If there’s one piece of advice I can give after years in Rheumatology, it’s this — be your own advocate. Not every provider automatically connects the dots between RA and iron deficiency. Come in with a list, ask for iron studies, and don’t settle for “your labs look fine” if you feel like garbage.

We’re here to help, but sometimes we need a nudge. I love when a patient walks in informed and ready to partner with me — it leads to better care every time.

When to Dig Deeper: Is It More Than Just Iron Deficiency?

So let’s say you’ve ruled in iron deficiency. You’ve tackled it with diet, maybe a supplement, or even an infusion. But… you still feel off. Yep, I’ve seen that, too. Rheumatoid arthritis and iron deficiency often don’t travel alone. Other deficiencies can ride shotgun — and sometimes they’re the real culprit behind lingering fatigue, brain fog, or that constant blah feeling.

In clinic, I often check for:

• Vitamin B12: Low B12 can mimic iron deficiency symptoms and is super common in folks with autoimmune diseases.
• Folate: Another key player in red blood cell production. And yes, methotrexate (a common RA med) can deplete it.
• Vitamin D: While not linked to anemia, low D can make fatigue and joint pain worse — and I’d say at least half my RA patients run low here.

One of my patients, a retired nurse with aggressive RA, had been on top of her iron but still felt completely wiped. Her B12 was borderline and her vitamin D was practically nonexistent. Once we addressed those, her entire outlook shifted — literally said it was the first time in years she could get through her day without a nap.

Tracking Progress Without Losing Your Mind

Managing RA is already a full-time job, so adding another layer — like iron deficiency — can feel like a lot. I always tell patients: pace yourself, and track the things that matter to you. Don’t just chase normal lab values — chase how you feel.

Here’s what I recommend tracking for a few weeks:

1. Energy levels throughout the day (maybe a 1–10 scale in a notebook or app)
2. Sleep quality and restfulness
3. Physical stamina — are stairs still killing you?
4. Mental clarity — are you able to focus better?
5. Symptoms like palpitations, dizziness, or lightheadedness

When you bring that data into your appointments, it helps paint a fuller picture. I’ve found that patients who track their trends, even loosely, feel more confident in their care — and they’re more likely to catch changes early. It’s not about perfection; it’s about patterns.

What to Ask at Your Next Rheumatology Appointment

It can be hard to advocate for yourself in a busy clinic setting — I get that. As someone who’s been on both sides of the exam table, here’s a little cheat sheet I share with my patients before they head into an appointment:

• “Can we check a full iron panel, not just hemoglobin?”
• “Could my fatigue be related to low iron, B12, or something else?”
• “What’s the safest way for me to get more iron — supplement or IV?”
• “Is it possible my RA meds are affecting my iron or nutrient levels?”
• “Can we set up a plan to recheck labs in 8–12 weeks?”

Even if your provider hasn’t brought it up, these questions can open the door to a better, more targeted conversation. And honestly, we appreciate it — it shows you’re engaged, aware, and ready to work as a team.

Living Better with RA and Less Fatigue

Managing rheumatoid arthritis and iron deficiency isn’t about quick fixes. It’s about stacking small wins: figuring out what your labs are actually telling you, nourishing your body the best way you can, and fine-tuning medications and supplements along the way.

One thing I always emphasize is this: your fatigue is valid. You don’t have to “tough it out” or feel guilty for needing rest. But you also don’t have to accept it as your new normal — especially if there’s a fixable issue like iron deficiency hiding behind the scenes.

Over the years, I’ve watched patients transform — from barely making it through the day to feeling energized enough to join a walking group or plan a vacation again. It’s not magic. It’s just the right information, the right care, and a provider who listens.

Helpful Resources

• American College of Rheumatology
• National Heart, Lung, and Blood Institute
• Centers for Disease Control and Prevention

Disclaimer

This article is for informational purposes only and based on my personal experience as a Rheumatology nurse practitioner. It is not intended to replace professional medical advice, diagnosis, or treatment. Always consult your healthcare provider before making any changes to your medical care or treatment plan.

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.