How to manage anemia with elevated ferritin in an elderly patient?

Management of Anemia with Elevated Ferritin in an 81-Year-Old Female

This patient likely has anemia of chronic disease/inflammation rather than iron deficiency anemia and should undergo further diagnostic evaluation before initiating treatment.

Diagnostic Assessment

The patient presents with:

• Hemoglobin of 88 g/L (anemia)
• Ferritin of 298 μg/L (elevated)
• No blood in stool
• Asymptomatic ("feels fine")

Interpretation of Laboratory Findings

• The elevated ferritin (298 μg/L) with anemia suggests anemia of chronic disease/inflammation rather than classic iron deficiency anemia 1.
• In elderly patients, anemia is often multifactorial, with multiple potential contributing causes 2.
• Additional testing needed:
  • Transferrin saturation (TSAT) - critical to distinguish between true iron deficiency and functional iron deficiency
  • Complete blood count with red cell indices (MCV, MCH, MCHC, RDW)
  • Inflammatory markers (ESR, CRP)
  • Renal function tests (creatinine, GFR)
  • Vitamin B12 and folate levels

Diagnostic Algorithm

1. If TSAT <20% with ferritin 100-299 μg/L: This indicates functional iron deficiency despite normal iron stores 1.

2. If TSAT >20% with elevated ferritin: This suggests anemia of chronic disease/inflammation 1.

3. If RDW >14% with low MCHC: This pattern would suggest iron deficiency despite elevated ferritin 1.

Management Approach

Initial Treatment

• If functional iron deficiency is confirmed (TSAT <20%):

  • Oral iron supplementation with ferrous sulfate 200 mg twice daily 2.
  • Treatment should continue for three months after hemoglobin normalizes to replenish iron stores 2.

• If anemia of chronic disease is more likely:

  • Investigate underlying causes (chronic kidney disease, inflammatory conditions, occult malignancy)
  • Consider intravenous iron if oral iron is ineffective or poorly tolerated 2.

Special Considerations for Elderly Patients

• Iron deficiency in the elderly has many potential causes including poor diet, reduced iron absorption, occult blood loss, medication effects (e.g., aspirin), and chronic disease 2.
• The risks and benefits of invasive endoscopic investigations should be carefully weighed in this 81-year-old patient 2.
• Despite normal stool testing, gastrointestinal evaluation may still be warranted if no other cause of anemia is identified, as occult GI malignancy remains a concern in this age group 2.

Monitoring

• Monitor hemoglobin, ferritin, and transferrin saturation at regular intervals (initially at 4-6 weeks) 2.
• If hemoglobin fails to rise by 1-2 g/dL within 4-6 weeks of treatment, reassess diagnosis and treatment approach 1.
• Follow-up should continue at three-monthly intervals for one year after normalization of hemoglobin 2.

Potential Pitfalls to Avoid

1. Misinterpreting ferritin levels: Ferritin is an acute-phase reactant and can be elevated in inflammatory states despite iron deficiency 1.

2. Overlooking functional iron deficiency: Patients may have functional iron deficiency despite normal or elevated ferritin levels, especially with chronic inflammatory conditions 2.

3. Inadequate investigation: Accepting anemia without thorough investigation in elderly patients can miss serious underlying pathology 2.

4. Deferring treatment while awaiting investigations: Iron replacement should not be delayed if iron deficiency is confirmed 1.

5. Failing to evaluate for other nutrient deficiencies: B12 and folate deficiencies are common comorbid conditions in elderly patients with anemia 1.

The patient's age, mild anemia, elevated ferritin, and absence of symptoms suggest a chronic process that requires careful evaluation before definitive treatment. The most important next step is to complete the diagnostic workup to determine the specific type of anemia before initiating targeted therapy.