Do you need to reduce twice daily iron supplements if ferritin (iron storage protein) levels are elevated?

From the Guidelines

You should reduce or stop twice daily iron supplements if your ferritin levels are elevated, as elevated ferritin indicates your body already has sufficient or excess iron stores, and continuing supplementation could lead to iron overload.

Key Considerations

• If your ferritin test shows levels above the normal range (typically 20-250 ng/mL for women and 30-400 ng/mL for men, though reference ranges vary by laboratory), consult your healthcare provider before continuing any iron supplements 1.
• They may recommend stopping supplements completely, reducing to once daily, or switching to a lower dose formulation such as ferrous gluconate (which contains less elemental iron than ferrous sulfate) 1.
• Do not stop prescribed iron without medical guidance, especially if you're taking it for a specific condition like iron deficiency anemia.
• Excess iron can accumulate in organs like the liver, heart, and pancreas, potentially causing serious damage over time 1.
• Your body has limited mechanisms to eliminate excess iron, making it important to avoid unnecessary supplementation when iron stores are already adequate.

Monitoring and Adjustments

• The goal of iron therapy is to improve erythropoiesis, not to attain specific levels of TSAT and/or serum ferritin 1.
• Monitoring the TSAT and serum ferritin at least once every 3 months can help optimize erythropoiesis in hemodialysis patients by adjusting the pro-rated weekly dose of IV iron to maintain adequate iron status 1.
• If the TSAT remains < 20% and/or the serum ferritin < 100 ng/mL, another course of IV iron (100 to 125 mg per week for 10 to 8 weeks) is recommended 1.

Safety Concerns

• The major safety concerns with intravenous iron administration relate to infusion reactions and iron overload 1.
• Organ damage in hemochromatosis is reported to occur in patients with dramatically higher ferritin levels than observed in the general dialysis population 1.
• It is estimated that 420 g of excess iron is necessary to result in organ damage, an amount that few dialysis patients receive in their lifetime 1.

From the Research

Reducing Iron Supplements with High Ferritin Levels

• When ferritin levels are high, it may be necessary to reduce or stop iron supplements to avoid iron overload and potential toxicity 2, 3.
• The decision to reduce iron supplements should be based on individual patient factors, including the underlying cause of high ferritin levels and the presence of any inflammatory conditions 4, 5.
• In patients with chronic kidney disease, high ferritin levels may be associated with increased risk of iron overload and toxicity, and reducing iron supplements may be necessary to minimize these risks 6, 3.

Monitoring Ferritin Levels

• Regular monitoring of ferritin levels is essential to ensure that iron supplements are adjusted accordingly 2, 6.
• Ferritin levels should be interpreted in conjunction with other markers of iron status, such as transferrin saturation and serum transferrin receptors 4, 5.
• In patients with inflammatory conditions, ferritin levels may not accurately reflect iron status, and alternative markers such as transferrin saturation may be more useful 4.

Adjusting Iron Supplements

• When reducing iron supplements, it is essential to monitor patient response and adjust the dosage as needed to avoid iron deficiency or overload 2, 6.
• In patients with high ferritin levels, reducing iron supplements may involve switching to a lower dose or frequency of supplementation, or stopping supplements altogether 3.
• The goal of adjusting iron supplements is to maintain optimal iron status while minimizing the risk of iron overload and toxicity 2, 3.