Treatment for Low Ferritin Levels
For patients with low ferritin levels, oral iron supplementation should be recommended as first-line treatment in those with iron deficiency without anemia or with mild anemia whose disease is clinically inactive and who have not been previously intolerant to oral iron. 1
Diagnosis and Assessment
Low ferritin levels indicate depleted iron stores, which may progress to iron deficiency anemia if left untreated. The diagnostic criteria depend on the presence of inflammation:
- In patients without inflammation: serum ferritin <30 μg/L indicates iron deficiency 1
- In patients with inflammation: serum ferritin up to 100 μg/L may still be consistent with iron deficiency 1
- Transferrin saturation (TSAT) <20% indicates inadequate iron available for erythropoiesis 1
Treatment Algorithm
First-Line Treatment: Oral Iron
- Standard dosing: 100-200 mg elemental iron per day in divided doses 1
- Alternative dosing: Consider alternate-day dosing which may improve absorption and reduce gastrointestinal side effects 1
- Duration: Continue until ferritin levels normalize (50-100 μg/L) 1
- Administration: Take preferably after meals 2
- Monitoring: Check ferritin levels every 10-12 phlebotomies or treatments 1
When to Consider Intravenous (IV) Iron
IV iron should be used as first-line treatment in patients with:
- Clinically active inflammatory disease 1
- Previous intolerance to oral iron 1
- Hemoglobin below 100 g/L 1
- Patients requiring erythropoiesis-stimulating agents 1
- Poor absorption of oral iron (e.g., celiac disease, post-bariatric surgery) 3
- Ongoing blood loss 3
Special Populations
Hemodialysis Patients
- Oral iron is often inadequate to maintain iron stores in hemodialysis patients 1
- IV iron is generally required due to increased iron losses and demands of erythropoietin therapy 1
- Target ferritin levels: 100-500 μg/L 1
Iron Refractory Iron Deficiency Anemia (IRIDA)
- Initial treatment with oral iron or oral iron combined with ascorbic acid 1
- If inadequate response, switch to IV iron supplementation 1
- Monitor ferritin levels to avoid exceeding 500 μg/L 1
Important Considerations and Precautions
- Avoid excessive supplementation: Iron supplementation in the presence of normal or high ferritin values is not recommended and potentially harmful 1
- Vitamin C: Avoid supplemental vitamin C in iron-loaded patients, particularly those undergoing phlebotomy 1
- Monitoring for side effects: Common gastrointestinal side effects include constipation, diarrhea, and nausea 1
- Duration of treatment: Continue treatment until target ferritin levels are reached (50-100 μg/L) 1
- Maintenance therapy: After achieving target levels, consider maintenance therapy to prevent reaccumulation of iron deficiency 1
Response to Treatment
- With standard oral iron therapy, expect gradual improvement in ferritin levels after hemoglobin normalizes 4
- With higher doses, ferritin may rise temporarily within days but return to subnormal levels quickly if iron is discontinued 4
- Regular monitoring of ferritin levels is essential to assess response and adjust therapy 5
By following this treatment approach, most patients with low ferritin levels can achieve normal iron stores and prevent progression to iron deficiency anemia, thereby improving quality of life and reducing morbidity associated with iron deficiency.