What is the treatment for elevated ferritin levels?

Management of Elevated Ferritin Levels

The treatment for elevated ferritin levels should be directed at the underlying cause, with phlebotomy being the primary treatment for true iron overload when hemoglobin is >11 g/dL, targeting ferritin levels <100 μg/L. 1

Diagnostic Approach

Before initiating treatment, it's crucial to determine whether elevated ferritin represents:

1. True iron overload (characterized by TSAT >45% and ferritin consistently >1000 ng/mL)
2. Inflammatory response (characterized by TSAT <20% and elevated inflammatory markers)
3. Other secondary causes

Essential diagnostic workup includes:

• Complete iron studies (ferritin, TSAT, serum iron)
• Liver function tests
• Complete blood count
• Inflammatory markers (CRP, ESR)
• Assessment for hemolysis when indicated

Treatment Algorithm Based on Underlying Cause

1. True Iron Overload (High Ferritin + High TSAT)

• First-line treatment: Weekly therapeutic phlebotomy (removal of 500 mL blood) when hemoglobin >11 g/dL 1

  • Target ferritin level: 50-100 μg/L
  • Monitor hemoglobin and hematocrit before each phlebotomy
  • Check ferritin and TSAT every 3 months initially

• For patients developing anemia during phlebotomy:

  • Extend phlebotomy interval 2
  • Consider adjunctive erythropoietin therapy 2

• For patients unable to tolerate phlebotomy:

  • Consider iron chelation therapy with deferasirox or deferoxamine

2. Inflammatory Conditions (High Ferritin + Low TSAT)

• Primary approach: Treat the underlying inflammatory condition
• Avoid iron supplementation unless confirmed iron deficiency anemia is present 1
• Monitor ferritin levels as inflammatory markers improve

3. Liver Disease

• Address underlying liver disease according to etiology
• For alcoholic liver disease: complete abstinence from alcohol with nutritional support
• For non-alcoholic fatty liver disease: weight loss through dietary modification and increased physical activity

Special Considerations

Medication Safety

• Deferasirox may cause:

  • Bone marrow suppression (monitor blood counts) 3
  • Renal toxicity (monitor renal function) 3
  • Hepatic dysfunction (monitor liver enzymes) 3
  • Serious skin reactions 3

• Deferoxamine risks include:

  • Auditory and ocular toxicity with prolonged use 4
  • Respiratory distress syndrome with high IV doses 4
  • Growth suppression in pediatric patients 4

Dietary Modifications

For patients with confirmed iron overload:

• Limit iron-rich foods and iron-fortified products
• Avoid vitamin C supplements >200 mg/day with meals (enhances iron absorption)
• Restrict alcohol intake during iron depletion phase

Monitoring Recommendations

• Initial phase: Check ferritin and TSAT every 3 months
• As ferritin approaches normal range: More frequent monitoring
• Regular CBC monitoring: Every 1-2 months initially
• Liver function tests: Every 3 months
• Target parameters:
  • TSAT: ≥20%
  • Ferritin: ≥100 ng/mL (but <500 μg/L to avoid toxicity, especially in children) 2
  • Hemoglobin: 11.0-12.0 g/dL

Common Pitfalls

1. Treating elevated ferritin without identifying the cause

   • Hyperferritinemia can result from various conditions including infections, malignancies, liver disease, and renal failure 5, 6
   • Multiple conditions often coexist in patients with markedly elevated ferritin 6

2. Initiating phlebotomy in anemic patients

   • Phlebotomy is contraindicated when hemoglobin <11 g/dL 1
   • May worsen symptoms in already anemic patients

3. Overlooking serum ferritin monitoring during treatment

   • Serum ferritin should not exceed 500 μg/L to avoid toxicity of iron overload, especially in children and adolescents 2

4. Continuing iron supplementation inappropriately

   • Avoid iron supplementation unless confirmed iron deficiency anemia is present 1

By following this structured approach to elevated ferritin, clinicians can effectively identify and manage the underlying cause while avoiding potential complications of inappropriate treatment.