From the Guidelines
Increasing dietary iron alone is not sufficient to treat iron deficiency anemia in an 84-year-old male with low iron levels but normal ferritin (143 ng/mL). This presentation suggests anemia of chronic inflammation rather than true iron deficiency, as indicated by the normal ferritin level 1. In this condition, iron is adequately stored but not properly utilized for red blood cell production. The underlying cause needs to be identified and addressed. A complete workup should include:
- CBC with differential
- Peripheral blood smear
- Reticulocyte count
- Vitamin B12 and folate levels
- Inflammatory markers like CRP and ESR Further investigation for occult blood loss, malignancy, or chronic inflammatory conditions is warranted. Treatment typically focuses on the underlying condition rather than iron supplementation. If iron supplementation is deemed necessary after proper evaluation, oral ferrous sulfate 325 mg once or twice daily between meals would be typical, but this should only be initiated after determining the true cause of anemia 1. Unnecessary iron supplementation in elderly patients can cause gastrointestinal side effects and may be harmful if the patient has conditions like hemochromatosis or if inflammation is preventing proper iron utilization. According to the most recent guidelines, a ferritin cut-off value of 45 mg/dL is recommended for diagnosing iron deficiency, but in patients with inflammatory conditions, a higher cut-off value may be necessary 1.
In patients with normal ferritin levels, such as in this case, the focus should be on identifying and treating the underlying cause of anemia, rather than solely relying on iron supplementation. The recent American Gastroenterological Association (AGA) guideline recommends a multidisciplinary approach to managing iron deficiency anemia, including evaluation of dietary iron intake, review of menstrual blood losses, and a search for gastrointestinal conditions leading to poor iron absorption or blood loss 1.
Given the patient's age and normal ferritin level, it is essential to rule out other causes of anemia, such as chronic diseases, malignancies, or medication-induced anemia. A thorough diagnostic workup and consultation with a hematologist or gastroenterologist may be necessary to determine the best course of treatment. The goal of treatment should be to improve quality of life and decrease the risk of complications related to anemia, while also addressing the underlying cause of the condition 1.
From the Research
Iron Deficiency Anemia Treatment
- Increasing dietary iron may not be sufficient to treat iron deficiency anemia in an 84-year-old male with low iron levels but normal ferritin (serum ferritin level of 143 ng/mL) 2.
- The patient's normal ferritin level suggests that iron stores are adequate, but the low iron level indicates a problem with iron utilization or absorption 3.
- Causes of iron deficiency should be identified and treated, and oral iron is typically first-line therapy for most patients 2.
Diagnostic Considerations
- Ferritin levels can be elevated in inflammation and infection, which may affect the diagnosis of iron deficiency 3.
- A thorough evaluation of the gastrointestinal tract to identify a source of bleeding is necessary, as gastrointestinal diseases that do not usually cause bleeding are frequently associated with iron deficiency anemia in patients without gastrointestinal symptoms 4.
Treatment Options
- Oral iron is typically first-line therapy, but intravenous iron may be indicated for patients with oral iron intolerance, poor absorption, or chronic inflammatory conditions 2, 5.
- The management of anemia requires a comprehensive approach, including the development of a specialist service, education of healthcare professionals, and transfer of skills from areas of good practice 5.
Anemia of Inflammation
- Anemia of inflammation (AI) is a common comorbidity in patients with chronic inflammatory disorders, and iron dysregulation plays a major role in its pathophysiology 6.
- Therapeutic strategies for AI include treating the underlying disease, using erythropoiesis-stimulating agents, and managing iron deficiency 6.