From the Guidelines
The patient should be treated with oral iron supplementation, considering the low transferrin saturation of 4.7% despite elevated ferritin levels, and the presence of fatigue, which is a common symptom of iron deficiency anaemia 1. To manage this patient, it's crucial to understand that ferritin levels up to 100 µg/L in the presence of inflammation may still reflect iron deficiency, and measurement of transferrin saturation can be helpful in such cases 1. Given the patient's ferritin level of 481 and low transferrin saturation, it suggests that the patient may have iron deficiency anaemia despite the elevated ferritin level. The patient's fatigue could be attributed to the iron deficiency anaemia, and treating the iron deficiency is essential to improve the patient's quality of life and reduce fatigue 1. According to the British Society of Gastroenterology consensus guidelines, iron tablets should not be used in those with active inflammatory disease, but in this case, since the patient's iron deficiency is likely contributing to the fatigue, oral iron supplementation can be considered, starting with a lower dose of no more than 100 mg elemental iron daily 1. It's also essential to investigate and treat any underlying inflammatory conditions that may be contributing to the elevated ferritin level and to monitor the patient's response to treatment by rechecking iron studies after 3 months of therapy 1. Key considerations in the treatment plan include:
- Starting with a lower dose of oral iron supplementation to minimize gastrointestinal side effects
- Monitoring the patient's response to treatment and adjusting the dose as needed
- Investigating and treating any underlying inflammatory conditions that may be contributing to the elevated ferritin level
- Rechecking iron studies after 3 months of therapy to assess the patient's response to treatment 1.
From the Research
Patient Presentation
The patient is a 65-year-old female presenting with fatigue, elevated ferritin levels (481), low iron levels (10), low TIBC (211), and low transferrin saturation (4.7).
Diagnostic Considerations
- Ferritin is an iron storage protein, and its concentration in plasma or serum reflects iron stores 2.
- Elevated ferritin levels can indicate iron overload, but ferritin is also an acute-phase protein that can be elevated in inflammation and infection 2.
- The patient's low iron levels and low transferrin saturation suggest iron deficiency, despite the elevated ferritin levels.
Treatment Recommendations
- The diagnosis and treatment of iron deficiency vary widely across indications, and guidelines recommend a concentration for serum ferritin to define iron deficiency 3.
- For iron deficiency, treatment targets include an increase in hemoglobin concentrations and serum ferritin >100 μg/L or 200 μg/L 3.
- However, in cases where ferritin levels are elevated, as in this patient, treatment should focus on addressing the underlying cause of the elevated ferritin, such as inflammation or iron overload 4.
- Intravenous iron supplementation may be considered in patients with chronic kidney disease or chemotherapy-induced anemia, but its use in this patient would depend on the underlying cause of the iron deficiency and elevated ferritin levels 3.
Key Laboratory Findings
- Ferritin: 481
- Iron: 10
- TIBC: 211
- Transferrin saturation: 4.7
- These findings suggest iron deficiency, despite the elevated ferritin levels, and require further evaluation to determine the underlying cause of the elevated ferritin.
Further Evaluation
- Additional laboratory tests, such as C-reactive protein or erythrocyte sedimentation rate, may be helpful in determining if inflammation is contributing to the elevated ferritin levels 2.
- A thorough medical history and physical examination are necessary to identify any underlying conditions that may be contributing to the iron deficiency and elevated ferritin levels 5.