What is the management approach for a patient with iron deficiency and elevated ferritin levels?

From the Guidelines

The management of a patient with iron deficiency and elevated ferritin levels should prioritize identifying and treating the underlying cause of elevated ferritin, while also addressing the iron deficiency through oral or intravenous iron replacement therapy, with careful monitoring to avoid iron overload. The elevated ferritin level may indicate concurrent inflammation, liver disease, malignancy, or other conditions, and treatment should be tailored to address both the iron deficiency and the underlying cause of elevated ferritin.

Key Considerations

• Confirm true iron deficiency by checking additional iron studies, including transferrin saturation, which may be low despite high ferritin 1.
• Identify and treat the underlying cause of elevated ferritin through appropriate testing, which may include inflammatory markers, liver function tests, and genetic testing for hereditary hemochromatosis.
• Use oral iron supplements, such as ferrous sulfate 325 mg daily or every other day, as first-line therapy for iron replacement, taken on an empty stomach with vitamin C to enhance absorption.
• Consider intravenous iron formulations, like iron sucrose or ferric carboxymaltose, if oral iron is not tolerated or ineffective.
• Regularly monitor hemoglobin, ferritin, and transferrin saturation to assess treatment response and avoid iron overload, particularly in patients with genetic predispositions to iron accumulation 1.

Monitoring and Adjustment

• Monitor TSAT and serum ferritin at least once every 3 months to optimize erythropoiesis in patients with iron deficiency and elevated ferritin levels 1.
• Adjust the pro-rated weekly dose of IV iron to maintain adequate iron status, and temporarily withhold IV iron administration if TSAT or ferritin levels become too high.

From the Research

Interpretation of Low Iron and High Ferritin Levels

• Low iron levels in the presence of high ferritin levels can be indicative of anemia of inflammation, a condition where the body's inflammatory response leads to a decrease in iron availability despite adequate iron stores 2, 3.
• Ferritin is an acute-phase protein that increases in response to inflammation, making it a useful marker for inflammatory diseases 4, 5.
• In patients with chronic kidney disease, inflammation can lead to increased ferritin levels, making it challenging to diagnose iron deficiency anemia 3.
• The management approach for a patient with iron deficiency and elevated ferritin levels should take into account the underlying cause of the inflammation and the patient's overall clinical status 2, 3.

Diagnostic Approach

• A thorough clinical evaluation, including medical history, physical examination, and laboratory tests, is essential to determine the cause of high ferritin levels 5.
• Laboratory tests, such as transferrin saturation, can help identify hereditary hemochromatosis or other conditions associated with iron overload 5.
• Hepatic MRI can be used to assess hepatic iron concentration and guide diagnosis and treatment 5.

Treatment Considerations

• The treatment approach for iron deficiency anemia in patients with elevated ferritin levels should be individualized based on the underlying cause of the inflammation and the patient's clinical status 2, 3.
• Intravenous iron therapy may be necessary in patients with chronic kidney disease and inflammation, while oral iron therapy may be sufficient in patients without inflammation 3.
• Minimizing inflammation is crucial in the management of iron deficiency anemia in patients with chronic kidney disease 3.