How to manage a patient with iron deficiency and mild hypoferritinemia?

Management of Iron Deficiency with Mild Hypoferritinemia

Based on the laboratory values showing ferritin of 30 μg/L with normal iron levels (162), oral iron supplementation is recommended to replenish iron stores, even in the absence of anemia. 1, 2

Interpretation of Laboratory Values

• Ferritin 30 μg/L: This indicates low body iron stores according to British Society of Gastroenterology guidelines, which define values <30 μg/L as generally indicative of low body iron stores 1
• Iron 162: Normal serum iron level
• Cortisol 29.3: Within normal range
• Lymphs (absolute) 3.8: Within normal range

This pattern represents non-anaemic iron deficiency (NAID), characterized by depleted iron stores (hypoferritinemia) but normal hemoglobin levels.

Treatment Approach

First-Line Treatment

• Oral iron supplementation: Ferrous sulfate 324mg (65mg elemental iron) daily 3
  • Take between meals or on an empty stomach for optimal absorption
  • Consider divided doses (1-2 tablets daily) to minimize gastrointestinal side effects
  • Continue treatment for 3-6 months to replenish iron stores

Dietary Recommendations

• Increase consumption of iron-rich foods:
  • Red meat, poultry, fish
  • Beans, lentils, spinach
  • Iron-fortified cereals
• Enhance iron absorption:
  • Consume vitamin C-rich foods with meals
  • Avoid tea, coffee, and calcium supplements within 2 hours of iron intake

Monitoring

• Check ferritin and hemoglobin after 8-10 weeks of therapy 2
• Target ferritin level: >100 μg/L 2
• Long-term follow-up with basic blood tests every 6-12 months to monitor iron stores 4

Special Considerations

For Premenopausal Women

• Evaluate for menstrual blood loss as the likely cause 1
• GI investigation generally not warranted in premenopausal women without other risk factors 1
• Screen for celiac disease 1

For Men and Postmenopausal Women

• Lower threshold for GI investigation as the prevalence of significant underlying GI pathology is higher 1
• Upper and lower GI investigations should be considered unless there is a history of significant non-GI blood loss 1

Common Pitfalls to Avoid

• Misinterpreting ferritin cutoffs: The traditional cutoff of <15 μg/L is too low and misses many cases of iron deficiency 2, 5
• Overlooking non-anemic iron deficiency: Iron deficiency without anemia still requires treatment 4
• Inadequate treatment duration: Short courses of iron therapy may not fully replenish iron stores 2
• Ignoring GI side effects: These can lead to poor adherence; consider lower doses or alternate-day dosing if side effects occur 2
• Excessive IV iron: Intravenous iron should be reserved for specific indications (intolerance to oral iron, inflammatory conditions, etc.) 2, 4

When to Consider Alternative Approaches

• If no improvement after 4-8 weeks of adequate oral therapy
• If GI side effects prevent adherence to oral therapy
• If inflammatory conditions are present that might impair iron absorption

Remember that even without anemia, iron deficiency can cause fatigue and affect cognitive function and physical performance, making treatment important for quality of life 4.