What is the treatment for low ferritin levels?

Treatment for Low Ferritin Levels

Oral iron supplementation is the first-line treatment for low ferritin levels, with intravenous iron reserved for cases of poor oral absorption, intolerance, or when rapid correction is needed. 1, 2

Diagnosis and Assessment

• Low ferritin is defined as:

  • <30 µg/L for healthy adults >15 years old 3
  • <15 µg/L for children 6-12 years old 3
  • <20 µg/L for adolescents 12-15 years old 3
  • <45 µg/L in individuals with anemia 1

• Important considerations:

  • Inflammatory conditions may mask iron deficiency with falsely normal ferritin levels (usually <100 µg/L) 1
  • Transferrin saturation <20% supports diagnosis of iron deficiency 2
  • Common symptoms include fatigue, difficulty concentrating, exercise intolerance, and restless legs syndrome 2

Treatment Algorithm

First-Line: Oral Iron Supplementation

• Dosing:

  • Ferrous sulfate 325 mg daily or on alternate days 2
  • Reasonable elemental iron content (28-50 mg) to minimize side effects 3
  • Take on an empty stomach for optimal absorption 1

• Enhancing absorption:

  • Take with vitamin C (500 mg) to improve absorption 1
  • Take with meat protein if possible 1
  • Avoid tea, coffee, calcium, and fiber around iron intake 1

Second-Line: Intravenous Iron

Indicated when:

• Oral iron is not tolerated (gastrointestinal side effects) 2

• Poor absorption (celiac disease, bariatric surgery) 2

• Chronic inflammatory conditions (CKD, heart failure, IBD) 2

• Ongoing blood loss 2

• Need for rapid correction 4

• Dosing:

  • IV iron sucrose 200 mg twice weekly has been shown effective and safe for correcting ferritin levels 5
  • Repeat doses until total calculated iron deficit is administered 1

Special Populations

Chronic Kidney Disease

• Higher ferritin targets (>200 ng/mL) and transferrin saturation >20% are recommended 1
• IV iron may be more effective than oral iron in CKD patients 1

Athletes

• Regular monitoring recommended (once yearly for males, twice yearly for females) 1
• Iron-rich diet with emphasis on highly bioavailable sources (meat, seafood) 1

Pregnant Women

• Iron deficiency affects up to 84% of women in the third trimester 2
• IV iron may be considered during second and third trimesters 2

Monitoring Response

• Repeat ferritin and hemoglobin tests 8-10 weeks after initiating treatment 6
• Do not measure ferritin immediately after IV iron infusion (falsely elevated) 6
• For patients with repeatedly low ferritin, consider intermittent oral supplementation and long-term follow-up every 6-12 months 3

Important Cautions

• Avoid iron supplementation in patients with normal or high ferritin levels 6
• Do not exceed ferritin levels of 500 µg/L, especially in children and adolescents, to avoid iron overload toxicity 1
• Long-term daily oral or IV iron supplementation with normal/high ferritin is potentially harmful 3
• Serum ferritin >1000 µg/L increases risk of cirrhosis and may require specialist referral 6

Dietary Recommendations

• Increase consumption of iron-rich foods, particularly heme iron sources (red meat) 1
• For vegetarians/vegans, focus on non-heme iron sources with vitamin C to enhance absorption 1
• Limit foods that impair iron absorption during meals containing iron 1

Iron deficiency treatment should be tailored based on ferritin levels, presence of anemia, underlying causes, and patient-specific factors, with the primary goal of improving quality of life and preventing complications related to iron deficiency.