What is the recommended treatment for a patient with low ferritin (iron storage) level and normal hemoglobin (H&H) and iron levels?

Treatment for Low Ferritin with Normal Hemoglobin and Iron Levels

Iron supplementation is recommended for patients with ferritin levels below 30 μg/L even when hemoglobin and serum iron are normal, as this represents iron deficiency without anemia that should be treated to prevent progression and improve quality of life. 1

Diagnosis Confirmation

• Low ferritin (<30 μg/L) with normal hemoglobin and iron levels represents non-anemic iron deficiency 1, 2
• Confirm absence of inflammation by checking C-reactive protein, as inflammation can falsely elevate ferritin despite iron deficiency 2
• This condition is common in:
  • Menstruating females
  • Adolescents
  • Athletes
  • Regular blood donors
  • Those with vegetarian/vegan diets 2, 3

Treatment Protocol

First-Line Approach:

1. Oral iron supplementation:

   • Ferrous sulfate 324 mg (65 mg elemental iron) once daily 1, 4
   • OR Ferrous gluconate 324 mg (38 mg elemental iron) once daily 5
   • Lower doses (28-50 mg elemental iron) may improve compliance by reducing gastrointestinal side effects 2

2. Optimize absorption:

   • Take on empty stomach
   • Add vitamin C 250-500 mg with iron to enhance absorption 1
   • Avoid calcium, tea, coffee, and dairy products within 2 hours of iron intake 1

3. Duration of treatment:

   • Continue for at least 3 months to replenish iron stores 1
   • Monitor ferritin after 8-10 weeks of treatment 2

Treatment Monitoring:

• Repeat ferritin and hemoglobin after 8-10 weeks of treatment 2
• Target ferritin >100 μg/L and transferrin saturation >20% 1
• Long-term follow-up with basic blood tests every 6-12 months for patients at risk of recurrent iron deficiency 2

Special Considerations

• Caution: Unnecessary iron supplementation when not indicated can lead to gastrointestinal side effects and potentially iron overload 1
• Referral: Consider gastroenterology referral to rule out gastrointestinal malignancy, especially in patients with unexplained iron deficiency 1
• Intravenous iron: Consider only in exceptional cases such as malabsorption, intolerance to oral preparations, or need for rapid repletion 1, 2
• Dietary counseling: Recommend regular intake of iron-rich foods (red meat, dark leafy greens, legumes, nuts) 1

Common Pitfalls

1. Undertreatment: Failing to treat non-anemic iron deficiency can lead to fatigue, reduced cognitive function, and decreased physical performance 2
2. Inadequate duration: Not continuing treatment long enough to replenish stores (minimum 3 months) 1
3. Missing underlying causes: Not investigating potential causes of iron deficiency (blood loss, malabsorption, dietary insufficiency) 1
4. Overtreatment: Continuing daily supplementation despite normal or high ferritin levels can be harmful 2
5. Poor compliance: Not addressing gastrointestinal side effects that lead to treatment discontinuation 2

For this specific case with ferritin of 15 μg/L and normal hemoglobin and iron, treatment is indicated as this level falls below the recommended threshold of 30 μg/L for adults, indicating depleted iron stores despite normal hemoglobin 1, 2.