What is the treatment for low ferritin levels?

Treatment of Low Ferritin Levels

Oral iron supplementation is the first-line treatment for low ferritin levels, with ferrous sulfate 325 mg daily or on alternate days taken on an empty stomach for optimal absorption. 1

Diagnosis and Assessment

• Low ferritin is defined as <45 µg/L in individuals with anemia 1
• Inflammatory conditions may mask iron deficiency with falsely normal ferritin levels (usually <100 µg/L)
• Consider measuring C-reactive protein to exclude acute phase reactions that could elevate ferritin despite iron deficiency 2
• Ferritin cutoffs for treatment:
  • Adults >15 years: <30 µg/L
  • Children 12-15 years: <20 µg/L
  • Children 6-12 years: <15 µg/L 2

Treatment Algorithm

First-Line: Oral Iron Therapy

1. Oral Iron Supplementation:

   • Ferrous sulfate 324 mg (65 mg elemental iron) daily or on alternate days 3, 1
   • Take on an empty stomach for optimal absorption
   • Consider lower doses (28-50 mg elemental iron) to minimize gastrointestinal side effects and improve compliance 2

2. Optimization Strategies:

   • Take with vitamin C (500 mg) to enhance absorption 1
   • Consume with meat protein to improve absorption
   • Avoid taking with tea, coffee, calcium supplements, or high-fiber foods 1

3. Dietary Recommendations:

   • Increase consumption of iron-rich foods, particularly heme iron sources (red meat)
   • 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

Second-Line: Intravenous Iron

Consider IV iron in cases of:

• Oral iron intolerance
• Poor absorption (celiac disease, post-bariatric surgery)
• Chronic inflammatory conditions (CKD, heart failure, IBD, cancer)
• Ongoing blood loss
• Second and third trimesters of pregnancy 4
• IV iron sucrose 200 mg twice weekly has been shown effective and safe 1

Monitoring and Follow-up

• Repeat ferritin and hemoglobin tests 8-10 weeks after initiating treatment 1
• Do not measure ferritin immediately after IV iron infusion (will be falsely elevated)
• Target ferritin level: 50-100 µg/L 5
• Regular monitoring is recommended (once yearly for males, twice yearly for females) 1
• Patients with repeatedly low ferritin will benefit from intermittent oral supplementation to preserve iron stores 2

Special Considerations

• Avoid iron supplementation in patients with normal or high ferritin levels
• Do not exceed ferritin levels of 500 µg/L to avoid iron overload toxicity, especially in children and adolescents 1
• In patients with hemochromatosis, phlebotomy rather than iron supplementation is the treatment of choice 5
• Vitamin C supplements should be avoided by iron-loaded patients 5

Common Pitfalls

1. Failing to identify the underlying cause of iron deficiency (bleeding, malabsorption, inadequate intake)
2. Not addressing dietary factors that inhibit iron absorption
3. Continuing iron supplementation despite normalized ferritin levels
4. Overlooking inflammatory conditions that may mask iron deficiency with falsely normal ferritin
5. Long-term daily oral or intravenous iron supplementation in the presence of normal or high ferritin values is not recommended and potentially harmful 2

Iron deficiency without treatment can lead to fatigue, irritability, depression, difficulty concentrating, restless legs syndrome, pica, exercise intolerance, and cognitive deficits in children that may not be fully reversible 4, 6.