What is the treatment for an 84-year-old male with iron deficiency (low iron) but normal ferritin levels?

From the Guidelines

For an 84-year-old male with iron deficiency but normal ferritin levels, treatment with iron supplementation is not recommended due to the potential harm associated with it, as suggested by the most recent guideline 1. This presentation is unusual since ferritin typically decreases in iron deficiency. Further investigation is needed to confirm the diagnosis and identify the underlying cause, particularly focusing on gastrointestinal blood loss through colonoscopy and upper endoscopy. Some key points to consider in the management of this patient include:

• Confirming the diagnosis with additional tests including complete blood count, serum iron, total iron binding capacity (TIBC), and transferrin saturation.
• Identifying the underlying cause of iron deficiency, which may involve inflammatory conditions where ferritin acts as an acute phase reactant.
• Considering dietary counseling to increase iron-rich foods (red meat, beans, fortified cereals) as a complementary approach to medical therapy.
• If iron deficiency is confirmed and treatment is necessary, oral iron supplementation such as ferrous sulfate may be considered, but with caution and careful monitoring due to the potential for gastrointestinal side effects, as noted in 1 and 1. It's essential to prioritize the patient's safety and well-being, given the potential risks associated with iron supplementation in the presence of normal or high ferritin levels, as highlighted in 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.

16 HOW SUPPLIED Ferrous Sulfate Tablets are available as follows: Each tablet contains 324mg of ferrous sulfate, equivalent to 65mg of elemental iron, providing 362% of the U.S. recommended daily intake (RDI) of iron for adults and children 4 and older.

The FDA drug label does not answer the question.

From the Research

Treatment for Iron Deficiency with Normal Ferritin Levels

• The patient's condition, an 84-year-old male with low iron (41) but normal ferritin levels (143), suggests iron deficiency anemia 2, 3.
• According to the study by 2, the recommended diagnostic strategy for unexplained anemia with iron deficiency includes serological celiac disease screening and bidirectional endoscopy (gastroscopy and colonoscopy).
• The study by 3 also recommends bidirectional endoscopy as a highly sensitive and specific method for locating gastrointestinal lesions resulting in iron deficiency anemia.
• If the diagnostic assessment reveals a cause of anemia with iron deficiency, targeted treatment should be initiated, along with iron supplementation to normalize hemoglobin levels and replenish iron stores 2.
• Oral treatment with a 100-200 mg daily dose of elemental iron is recommended, with a lower dose if side effects occur, and 3-6 months of oral iron therapy may be required to achieve therapeutic goals 2.
• Intravenous iron therapy may be used if oral treatment lacks efficacy or causes side effects, or in the presence of intestinal malabsorption or prolonged inflammation 2.

Diagnostic Evaluation

• The study by 4 found that predictors of serum ferritin or transferrin saturation measurement included low hemoglobin concentration and a history of iron supplementation.
• A positive fecal occult blood test (FOBT) was a significant predictor of having an endoscopic evaluation 4.
• The study by 5 recommends that evaluation of asymptomatic patients with iron deficiency anemia usually begin with investigation of the colon, followed by evaluation of the upper gastrointestinal tract if necessary.

Ferritin Levels and Iron Deficiency

• The study by 6 suggests that a serum ferritin level of 22 microg/L can be used as a cutoff value for the diagnosis of iron deficiency in community-dwelling older adults.
• However, the patient's ferritin level is 143, which is above the suggested cutoff value, indicating that iron deficiency may not be the primary cause of anemia in this case 6.