What is the treatment for low ferritin (iron) levels found during an Esophagogastroduodenoscopy (EGD)?

Treatment for Low Ferritin Levels Identified During EGD

For patients with low ferritin levels identified during EGD, oral iron supplementation with 60-200 mg of elemental iron daily in 2-3 divided doses is the first-line treatment, continuing for 3-6 months after hemoglobin normalizes to replenish iron stores. 1

Diagnosis and Assessment

Before initiating treatment, it's important to confirm iron deficiency:

• Ferritin <45 ng/mL is diagnostic of iron deficiency anemia according to the American Gastroenterological Association (AGA) 2
• In patients without inflammation, ferritin <30 μg/L is diagnostic 1
• In patients with inflammation, ferritin up to 100 μg/L may still indicate iron deficiency 1
• Transferrin saturation <16% also indicates iron deficiency 1

Treatment Algorithm

Step 1: Identify and Treat Underlying Cause

• Bidirectional endoscopy (EGD and colonoscopy) is strongly recommended for:
  • Asymptomatic postmenopausal women and men with iron deficiency anemia 2
  • Conditionally recommended for asymptomatic premenopausal women 2
• Test for H. pylori and celiac disease with non-invasive testing first 2
• Treat any identified causes (e.g., bleeding lesions, H. pylori, celiac disease)

Step 2: Iron Replacement Therapy

1. Oral Iron (First-line):

   • Dose: 60-200 mg elemental iron daily, divided into 2-3 doses 1
   • Duration: 3-6 months after hemoglobin normalizes 1
   • Take on empty stomach to maximize absorption
   • Consider vitamin C co-administration to enhance absorption

2. Intravenous Iron (For specific situations):

   • Indications:
     • Malabsorption (e.g., celiac disease, inflammatory bowel disease)
     • Intolerance to oral iron
     • Ongoing blood loss exceeding oral absorption capacity
     • Severe anemia requiring rapid correction
   • Dosing based on body weight and hemoglobin level 1

Monitoring Response

• Check hemoglobin after 4 weeks of therapy 1
• Response defined as increase in hemoglobin of at least 1 g/dL within 4 weeks 1
• Monitor ferritin and hemoglobin after 8-10 weeks of treatment 1
• Once normalized, monitor every 3 months for one year, then annually 1

Common Pitfalls to Avoid

1. Misdiagnosis: Distinguishing iron deficiency anemia from anemia of chronic disease can be challenging, especially when they coexist 3

   • Use additional parameters like soluble transferrin receptor activity when needed

2. Inadequate Investigation: Failing to investigate the underlying cause of iron deficiency is a critical error 1

   • Iron deficiency without overt bleeding is associated with risk of GI malignancy 4
   • Never assume menstruation is the sole cause in premenopausal women without proper evaluation

3. Insufficient Treatment Duration: Stopping iron supplementation once hemoglobin normalizes without replenishing iron stores 1

4. Overlooking Absorption Issues:

   • Taking iron with foods that inhibit absorption (tea, coffee, calcium)
   • Not addressing underlying malabsorption conditions

5. Misinterpreting Lab Values:

   • In inflammatory states, ferritin can be falsely elevated 1, 5
   • Using outdated cutoffs (the AGA now recommends using ferritin <45 ng/mL rather than <15 ng/mL) 2

By following this structured approach to treating low ferritin identified during EGD, you can effectively address both the iron deficiency and its underlying cause, improving patient outcomes and quality of life.