A 42 yeаr оld wоmаn with а lоngstanding history of rheumatoid arthritis presents with fatigue and decreased exercise tolerance. She has no melena, hematochezia or heavy menstrual bleeding. Physical examination shows pale conjunctiva and mild swelling of the bilateral wrists. Lab results include: hemoglobin 8.8 g/dL hematocrit 26% mean corpuscular volume (MCV) 89 um3 normal platelet count Which of the following is the most likely diagnosis?