Why is my hemoglobin level dropping?

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Question from Joe:
After receiving iron intravenously for 6 weeks, my hemoglobin remained low until I received bortezomib (Velcade) with dexamethasone (Decadron) and then six cycles of rituximab (Rituxan). 

Answer from Dr. Leclair:
I think that the issue here is that, while iron is probably the most common cause of hemoglobin deficiency, it is not the only one. If the cells also originally appeared to be microcytic (smaller than they should be) and hypochromic (containing less hemoglobin than they should), then those are two additional indicators that iron deficiency might the cause. The proof that this was not the cause was the failure of the iron to correct the problem. So your physicians then knew that they had to move onto the other possible causes. 

Velcade with or without prednisone is the most common treatment for multiple myeloma, certain lymphomas and CLL.

You commented that your protein was high so I am going to assume that you have been diagnosed with myeloma? If I am correct, then this is the problem—the myeloma cells are making proteins that coat and then destroy red cells. No matter how quickly the marrow tries to keep up with the demand, those proteins kill off many more cells, causing a hemolytic anemia. The Velcade and prednisone attack those cells, both killing the cells or rendering them unable to make the protein in question.

Rituximab is an agent that attacks a structure on the cell membrane called CD20. If the cells that are making the protein also possess CD20, then the rituximab will continue to keep them supressed. Once these cells are suppressed, your red cell production can then "catch up" with demand. And your red cell count increases in number, and these cells contain more hemoglobin.

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you. 

Have a question for the experts? Send them to questions@patientpower.info.

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Page last updated on September 23, 2015