What is the treatment for a patient with low ferritin (iron) levels but a normal Complete Blood Count (CBC)?

From the Guidelines

Treatment for low ferritin with normal CBC typically involves oral iron supplementation, usually with ferrous sulfate 325 mg taken 1-3 times daily between meals with vitamin C to enhance absorption. This approach is supported by recent guidelines, including the 2024 AGA clinical practice update on management of iron deficiency anemia 1. The goal of treatment is to replenish iron stores and improve quality of life, while also investigating the underlying cause of iron deficiency, which may be due to inadequate dietary intake, poor absorption, or blood loss.

Some key considerations for oral iron supplementation include:

• Taking iron with vitamin C to enhance absorption
• Avoiding taking iron with calcium, dairy, coffee, tea, or antacids, which can reduce absorption
• Starting with a low dose and gradually increasing as needed and tolerated
• Monitoring for common side effects, such as constipation, nausea, and black stools

If oral supplements are not tolerated or effective, intravenous iron may be considered, particularly in patients with severe iron deficiency or conditions where oral iron may not be well absorbed 1. The choice of intravenous iron formulation and administration schedule will depend on the individual patient's needs and medical history.

It's also important to note that dietary changes can complement supplementation, including increasing intake of iron-rich foods like red meat, spinach, beans, and fortified cereals. Follow-up ferritin testing is recommended after 2-3 months of treatment to monitor response and adjust the treatment plan as needed 1.

From the FDA Drug Label

CONTAINS: Each tablet contains 324 mg of ferrous sulfate, equivalent to 65 mg of elemental iron, providing 362% of the U.S. recommended daily intake (RDI) of iron for adults and children 4 and older. The treatment for a patient with low ferritin (iron) levels but a normal Complete Blood Count (CBC) is iron supplementation.

• The patient can take ferrous sulfate (PO), which contains 65mg of elemental iron per tablet, providing 362% of the U.S. recommended daily intake (RDI) of iron for adults and children 4 and older 2.
• It is essential to note that iron supplements may cause gastrointestinal discomfort, nausea, constipation, or diarrhea 2.

From the Research

Treatment for Low Ferritin Levels with Normal CBC

• The treatment for a patient with low ferritin levels but a normal Complete Blood Count (CBC) typically involves iron supplementation 3, 4.
• According to a study published in the American Family Physician, supplemental iron may be given initially, followed by further workup if the patient is not responsive to therapy 3.
• The study also recommends that the underlying cause of iron deficiency should be treated, and oral iron therapy can be initiated to replenish iron stores 3.
• Another study published in the European Journal of Haematology suggests that oral iron supplementation is often the first-line treatment for the acute and chronic management of iron deficiency due to its ease and accessibility 4.
• However, the study also notes that there is no consensus on the optimal formulation or dosing strategy for oral iron supplementation, and that management of iron deficiency is complicated by the hepcidin-ferroportin iron regulatory pathway 4.

Diagnosis and Screening

• A study published in HemaSphere recommends that women should be screened for iron deficiency during pregnancy, and children should be screened at one year of age 5.
• The study also notes that men and postmenopausal women should not be screened, but should be evaluated with gastrointestinal endoscopy if diagnosed with iron deficiency anemia 5.
• Another study published in the Cochrane Database of Systematic Reviews found that serum or plasma ferritin concentration is a useful index of iron deficiency and overload, but that the diagnostic accuracy of ferritin concentrations can vary depending on the population being studied 6.

Iron Supplementation Protocols

• A study published in BMJ Open found that frequent whole blood donors have an increased risk of developing iron deficiency, and that oral iron supplementation can help to replenish iron stores 7.
• The study evaluated the impact of different iron supplementation protocols on ferritin and hemoglobin levels, gastrointestinal side effects, and donor return, and found that a daily low-dose or every-other-day dosing protocol may be effective in replenishing iron stores while minimizing side effects 7.