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

Diagnosis of Iron Deficiency

• Low ferritin is defined as <45 µg/L in individuals with anemia 1
• For healthy adults >15 years, a ferritin cut-off of 30 µg/L is appropriate 2
• For children 6-12 years and adolescents 12-15 years, cut-offs of 15 µg/L and 20 µg/L respectively are recommended 2
• Note that inflammatory conditions may mask iron deficiency with falsely normal ferritin levels (usually <100 µg/L) 1

Treatment Algorithm

First-Line Treatment: Oral Iron

• Dosage: Ferrous sulfate 325 mg daily or on alternate days, taken on an empty stomach 1, 3
• Administration:
  • Take with vitamin C (500 mg) to enhance absorption 1
  • Avoid taking with tea, coffee, calcium, and fiber which inhibit absorption 1
  • Consume with meat protein to improve absorption 1

Second-Line Treatment: Intravenous Iron

Indicated for patients with:

• Oral iron intolerance (approximately 20% discontinue due to GI side effects) 4
• Poor absorption (celiac disease, post-bariatric surgery) 3
• Chronic inflammatory conditions (CKD, heart failure, IBD, cancer) 3
• Ongoing blood loss 3
• Need for rapid correction 1

IV Iron Administration:

• IV iron sucrose 200 mg twice weekly until total calculated iron deficit is administered 1
• Higher ferritin targets (>200 ng/mL) and transferrin saturation >20% are recommended 1

Monitoring and Follow-up

• Repeat ferritin and hemoglobin tests 8-10 weeks after initiating treatment 1
• Regular monitoring is recommended (once yearly for males, twice yearly for females) 1
• Serum ferritin levels should not exceed 500 µg/L to avoid toxicity of iron overload, especially in children and adolescents 5
• Patients with repeatedly low ferritin will benefit from intermittent oral supplementation and long-term follow-up every 6-12 months 2

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

Important Considerations and Precautions

• Avoid iron supplementation in patients with normal or high ferritin levels 1
• Long-term daily oral or IV iron supplementation with normal/high ferritin is not recommended and potentially harmful 2
• Serum ferritin >1000 µg/L increases risk of cirrhosis and may require specialist referral 1
• In patients with chronic inflammatory conditions, transferrin saturation (<20%) may be a more reliable indicator of iron deficiency than ferritin alone 6
• Regular blood donors are at high risk for iron deficiency and may benefit from prophylactic iron supplementation when ferritin levels fall below 15 µg/L 7

Special Populations

• Pregnancy: IV iron may be indicated during second and third trimesters 3
• Chronic kidney disease: IV iron may be more effective than oral iron 1
• Inflammatory bowel disease: IV iron shows better gastrointestinal tolerability than oral iron 4
• Rare genetic disorders: TMPRSS6 mutations can cause iron-refractory iron deficiency anemia requiring specialized management 6

Remember that treating the underlying cause of iron deficiency (such as blood loss or malabsorption) is essential alongside iron supplementation for optimal outcomes.