Do I treat a patient with iron deficiency anemia (IDA) with low ferritin and iron saturation but normal hemoglobin (Hgb) levels?

Management of Iron Deficiency with Normal Hemoglobin

Yes, you should treat this patient with iron supplementation despite normal hemoglobin levels, as the very low ferritin (5) and iron saturation (8%) indicate iron deficiency that requires treatment to replenish iron stores. 1, 2

Diagnosis Confirmation

• Your patient has clear iron deficiency based on:
  • Ferritin of 5 (severely depleted; normal is 30-300 μg/L)
  • Iron saturation of 8% (severely low; normal is 16-45%)
  • Normal hemoglobin (indicating non-anemic iron deficiency)

Treatment Approach

First-Line Therapy

• Oral iron supplementation is recommended 1, 2:
  • Ferrous sulfate 200 mg three times daily (most cost-effective option)
  • Alternatives: ferrous gluconate or ferrous fumarate if better tolerated
  • Consider adding ascorbic acid (vitamin C) to enhance absorption if response is poor 1

Duration of Treatment

• Continue iron supplementation for three months after normalization of iron parameters to fully replenish iron stores 1, 2
• This is essential even though hemoglobin is normal, as iron stores need to be replenished to prevent future deficiency

Monitoring Response

• Check ferritin and transferrin saturation after 4-8 weeks of treatment
• Target values: ferritin >30 μg/L and transferrin saturation >16% 2
• Once normalized, monitor iron parameters every three months for one year, then after another year 1

Investigation of Underlying Cause

• While treating, investigate the underlying cause of iron deficiency:
  • For women: evaluate for heavy menstrual bleeding, pregnancy, or breastfeeding 1, 2
  • For men and postmenopausal women: gastrointestinal evaluation is mandatory (endoscopy) 3
  • Other causes: poor dietary intake, malabsorption, NSAID use, blood donation 2

Special Considerations

When to Consider IV Iron

• Reserve for patients with:
  • Intolerance to oral iron preparations after trying at least two different formulations
  • Malabsorption conditions
  • Active inflammatory bowel disease
  • Need for rapid iron repletion 1, 2

Common Pitfalls to Avoid

1. Not treating non-anemic iron deficiency - Iron deficiency without anemia still requires treatment to prevent progression to anemia and to address symptoms like fatigue, difficulty concentrating, and restless legs syndrome 2, 4
2. Stopping treatment too early - Continuing treatment for 3 months after normalization is crucial to replenish stores 1
3. Missing the underlying cause - Always investigate the reason for iron deficiency, especially in men and postmenopausal women 1, 3

Follow-up Plan

• Reassess ferritin and transferrin saturation after 1-2 months of treatment
• If no improvement in iron parameters, consider:
  • Poor compliance
  • Continued blood loss
  • Malabsorption
  • Need for alternative iron formulation 1

By treating this patient's iron deficiency now, you can prevent progression to anemia, improve quality of life by addressing potential subclinical symptoms, and identify any underlying pathology that may be causing the iron deficiency.