What is the treatment for a patient with a ferritin level indicating iron deficiency?

Treatment of Iron Deficiency with Ferritin Level of 5

Oral iron supplementation should be initiated immediately for patients with a ferritin level of 5 ng/mL, which indicates severe iron deficiency anemia requiring prompt treatment to restore hemoglobin levels and replenish iron stores. 1

Diagnosis Confirmation

A ferritin level of 5 ng/mL confirms absolute iron deficiency, as it falls well below the diagnostic threshold of <30 ng/mL. This extremely low level indicates depleted iron stores and requires immediate intervention 1, 2. Additional testing that may be helpful includes:

• Complete blood count (hemoglobin, MCV)
• Transferrin saturation (typically <20% in iron deficiency)
• TIBC (typically elevated in iron deficiency)

Treatment Algorithm

First-Line Treatment: Oral Iron Therapy

For most patients with uncomplicated iron deficiency:

1. Standard oral iron supplementation:

   • Ferrous sulfate 324 mg (65 mg elemental iron) once daily 3
   • Alternative dosing: One tablet every other day if daily dosing causes gastrointestinal side effects 1
   • Continue treatment for 3 months after correction of anemia to replenish iron stores 4

2. Expected response:

   • Hemoglobin should increase by approximately 2 g/dL after 3-4 weeks 4
   • If no response after 4 weeks, consider IV iron or investigate for ongoing blood loss 1

3. Monitoring:

   • Check hemoglobin and ferritin after 8-10 weeks of treatment 5
   • Once normalized, monitor every 3 months for one year, then annually 4

Alternative: Intravenous Iron Therapy

Consider IV iron as first-line in these specific scenarios:

1. Clinically active inflammatory bowel disease 4
2. Previous intolerance to oral iron 4
3. Hemoglobin below 10 g/dL 4
4. Patients requiring erythropoiesis-stimulating agents 4
5. Malabsorption conditions (celiac disease, post-bariatric surgery) 2
6. Ongoing blood loss exceeding oral absorption capacity 6

Dietary Recommendations

While supplementation is essential, dietary modifications can help:

• Increase consumption of iron-rich foods:

  • Heme iron sources: Red meat, poultry, fish
  • Non-heme iron sources: Beans, lentils, spinach, fortified cereals

• Enhance iron absorption:

  • Consume vitamin C-rich foods with meals
  • Avoid tea, coffee, and calcium supplements with meals as they inhibit iron absorption

• Avoid iron-blocking foods during supplementation:

  • Calcium-rich foods
  • Phytate-containing foods (whole grains, legumes)
  • Polyphenols (tea, coffee)

Investigating Underlying Causes

A ferritin level of 5 warrants investigation for the underlying cause of iron deficiency:

• Menstruating women: Assess menstrual blood loss
• All patients: Evaluate for gastrointestinal blood loss
  • Upper endoscopy and colonoscopy for men and postmenopausal women 4
  • Consider small bowel evaluation if initial endoscopy is negative 4
• Dietary assessment: Evaluate for inadequate iron intake
• Medical history: Screen for malabsorption conditions

Common Pitfalls to Avoid

1. Inadequate duration of treatment: Continue iron supplementation for 3 months after hemoglobin normalizes to replenish stores 4

2. Failure to investigate underlying cause: A ferritin of 5 indicates significant iron deficiency requiring investigation for potential serious underlying conditions 2

3. Inappropriate ferritin cutoffs: Traditional laboratory reference ranges may underdiagnose iron deficiency, especially in women 7

4. Overlooking non-anemic symptoms: Iron deficiency can cause fatigue, restless legs syndrome, and cognitive issues even before anemia develops 2

5. Ignoring poor response: Failure to achieve hemoglobin increase of 2 g/dL after 4 weeks requires reassessment 1

By following this algorithm, patients with severe iron deficiency can be effectively treated while investigating and addressing the underlying cause of their condition.