How can low ferritin levels be increased?

Strategies to Increase Low Ferritin Levels

Oral iron supplementation is the first-line treatment for increasing low ferritin levels, with intravenous iron reserved for cases of severe deficiency, malabsorption, or intolerance to oral therapy. 1

Diagnosis and Assessment

Before initiating treatment, proper assessment of iron status is essential:

• A comprehensive panel should include:

  • Serum ferritin (primary marker of iron stores)
  • Transferrin saturation (TSAT)
  • Complete blood count with red cell indices
  • Mean Cell Hemoglobin (more reliable than MCV)
  • Red Cell Distribution Width (RDW >14% suggests iron deficiency) 1

• Diagnostic thresholds:

  • Absolute iron deficiency: serum ferritin <30 ng/mL in non-inflammatory conditions
  • In patients with inflammation or cancer: ferritin <100 ng/mL may indicate deficiency 2
  • Low transferrin saturation (<20%) can indicate iron deficiency even with normal ferritin 2

Treatment Options

1. Oral Iron Supplementation

• Dosing recommendations:

  • Standard dose: 60-120 mg of elemental iron daily 3
  • For optimal absorption, take on an empty stomach
  • Consider alternate-day dosing to improve absorption and reduce side effects 4

• Types of oral iron:

  • Ferrous sulfate (most common)
  • Ferrous gluconate (may cause fewer GI side effects)
  • Carbonyl iron (effective with potentially fewer side effects) 5

• Optimization strategies:

  • Take with vitamin C to enhance absorption
  • Avoid taking with tea, coffee, calcium supplements, or antacids
  • Avoid twice-daily dosing as it may not increase total iron absorption due to hepcidin response 4

2. Intravenous Iron

Indicated for:

• Patients who cannot tolerate oral iron
• Malabsorption conditions
• Need for rapid iron repletion

Available formulations:

• Ferric gluconate (maximum infusion dose: 125 mg)
• Iron sucrose (maximum infusion dose: 200-500 mg)
• Ferric carboxymaltose (maximum infusion dose: 20 mg/kg up to 1000 mg) 2

IV iron has shown superior efficacy in raising hemoglobin levels compared to oral iron (7-10 g/L vs. 4-7 g/L increase) in patients with ferritin <100 ng/mL 2

3. Dietary Modifications

• Increase consumption of iron-rich foods:

  • Heme iron sources (more bioavailable): red meat, seafood
  • Non-heme iron sources: leafy greens, beans, iron-fortified cereals
  • Include vitamin C-rich foods with meals to enhance non-heme iron absorption 1

• Avoid iron absorption inhibitors with meals:

  • Tea and coffee
  • Calcium-rich foods
  • Whole grain cereals (high in phytates) 2, 1

Special Populations

Pregnant Women

• Higher iron requirements (18 mg/day in North America, 14.8 mg/day in UK)
• Iron supplementation recommended even for non-anemic pregnant women with low ferritin 6
• Supplementation prevents postpartum iron deficiency 7

Athletes (especially females)

• Regular monitoring recommended (twice yearly for female athletes)
• Iron deficiency common (15-35% in female athletes, 5-11% in male athletes)
• Diet rich in iron, particularly red meat, recommended when ferritin is low 2

Monitoring Response

• Recheck hemoglobin after 4 weeks of treatment to confirm response
• Monitor ferritin levels to ensure target achievement:
  • During induction phase: measure monthly or after every 4th treatment
  • During maintenance: measure every 6 months 2
• Continue treatment for at least 3 months after normalization of hemoglobin to replenish iron stores 1

Common Pitfalls

1. Overlooking underlying causes: Address the source of iron deficiency (blood loss, malabsorption, dietary insufficiency)

2. Inappropriate supplementation: Avoid iron supplementation in patients with hemochromatosis or iron overload conditions 2

3. Inadequate duration of therapy: Continue treatment beyond normalization of hemoglobin to replenish iron stores

4. Ignoring side effects: GI side effects are common with oral iron and may lead to non-adherence; consider alternative formulations or dosing schedules

5. Vitamin C overuse: While vitamin C enhances iron absorption, excessive supplementation should be avoided, especially in patients with iron overload 2

By following these evidence-based strategies, low ferritin levels can be effectively increased, improving oxygen-carrying capacity, reducing fatigue, and enhancing overall quality of life.