How to manage anemia with low hemoglobin, normal iron, and ferritin levels?

Management of Anemia with Low Hemoglobin, Normal Iron, and Ferritin Levels

Further evaluation is needed to determine the cause of anemia since your lab values show low hemoglobin (9.1 g/dL) with normal iron (70) and ferritin (113) levels, suggesting anemia of chronic disease rather than iron deficiency anemia. 1

Laboratory Interpretation

• Your hemoglobin of 9.1 g/dL is significantly below the WHO-defined normal limits (13 g/dL for men, 12 g/dL for non-pregnant women), confirming the presence of anemia 1
• Your RBC count of 2.47 is reduced, consistent with anemia 1
• Your iron level (70) and ferritin level (113) are within normal range, which rules out absolute iron deficiency anemia 1
• This pattern (low hemoglobin with normal ferritin) suggests possible anemia of chronic disease, functional iron deficiency, or another cause of anemia 1

Recommended Diagnostic Workup

• Complete blood count with red cell indices (MCV, MCH, RDW) to further characterize the anemia 1
• Reticulocyte count to assess bone marrow response to anemia 1
• Transferrin saturation (TSAT) calculation to assess functional iron availability (target >20%) 1
• CRP or other inflammatory markers to detect underlying inflammation 1
• Additional testing based on clinical suspicion:
  • Vitamin B12 and folate levels, especially if macrocytic indices are present 1
  • Hemoglobin electrophoresis if microcytosis is present with normal iron studies 1
  • Kidney function tests to rule out chronic kidney disease 1

Management Approach

For Anemia of Chronic Disease (if confirmed):

• Identify and treat the underlying inflammatory condition (inflammatory bowel disease, chronic kidney disease, cancer, etc.) 1, 2
• Consider intravenous iron if transferrin saturation is <20% despite normal ferritin (functional iron deficiency) 1
• For patients with chronic kidney disease and hemoglobin <10 g/dL, consider erythropoiesis-stimulating agents (ESAs) after correcting any iron deficiency 1

For Other Causes of Anemia:

• If vitamin B12 or folate deficiency is identified, provide appropriate supplementation 1
• If hemoglobinopathy is detected, refer to hematology for specialized management 1
• For unexplained anemia with normal iron studies in men or postmenopausal women, consider gastrointestinal evaluation to rule out occult bleeding 1, 3

Monitoring and Follow-up

• Recheck hemoglobin within 4-8 weeks of initiating treatment 1
• Monitor for response to therapy - target hemoglobin increase of 1-2 g/dL per month with treatment 1
• If no improvement with initial therapy, reassess diagnosis and consider hematology consultation 1

Common Pitfalls to Avoid

• Don't assume iron deficiency based solely on anemia without considering ferritin and iron levels 1
• Ferritin can be falsely elevated in inflammatory states, masking iron deficiency; consider this when interpreting results 1
• Don't initiate iron supplementation without confirming iron deficiency, as it may be ineffective or potentially harmful 3
• Avoid missing underlying serious conditions by ensuring appropriate workup of unexplained anemia 1, 4