What is the treatment for hypoferritinemia (low ferritin levels)?

Treatment of Hypoferritinemia

Oral iron supplementation is the first-line treatment for hypoferritinemia (low ferritin levels), with ferrous sulfate or ferrous fumarate being the most commonly used preparations. 1, 2

Diagnostic Approach

Before initiating treatment, it's important to establish the cause of hypoferritinemia:

• Measure complete blood count, serum ferritin, transferrin saturation (TSAT), and C-reactive protein to differentiate between isolated hypoferritinemia and iron deficiency anemia 3, 4
• Consider genetic causes in cases of severe hypoferritinemia without anemia that don't respond to typical treatment 5
• Rule out ongoing blood loss, particularly from the gastrointestinal tract in males and non-menstruating females 6

Treatment Algorithm

First-Line Treatment: Oral Iron Therapy

• Oral iron preparations:

  • Ferrous sulfate 324mg (65mg elemental iron) daily 1
  • Ferrous fumarate 325mg daily 2
  • Use preparations with reasonable elemental iron content (28-50mg) to minimize gastrointestinal side effects 3

• Duration and monitoring:

  • Continue treatment for 8-10 weeks 3
  • Monitor response with repeat ferritin and hemoglobin measurements after 8-10 weeks 7, 3
  • Target ferritin level: ≥50 μg/L in the absence of inflammation 7, 3

Dietary Modifications

• Integrate heme and free iron regularly into the diet 3
• Avoid iron absorption inhibitors (tea, coffee, calcium) 7
• Limit alcohol intake, especially with elevated liver enzymes 7
• Avoid supplemental vitamin C on an empty stomach (enhances iron absorption but may cause GI upset) 7

Second-Line Treatment: Intravenous Iron

Consider intravenous iron in cases of:

• Failure of oral therapy 3
• Malabsorption disorders 7, 3
• Need for rapid repletion 7

IV iron options include:

• Iron dextran
• Ferric carboxymaltose
• Ferric derisomaltose (can be administered as a single 1000mg dose) 7

Special Considerations

• Hypoferritinemia without anemia (HWA): This condition may cause symptoms like fatigue, weakness, and hair loss despite normal hemoglobin levels 4

• Genetic disorders: Some rare genetic variants of ferritin L-subunit can cause severe hypoferritinemia despite normal or high iron stores 5

• Maintenance therapy: Patients with repeatedly low ferritin may benefit from intermittent oral supplementation to preserve iron stores 3

• Monitoring: Long-term follow-up with basic blood tests every 6-12 months is recommended for patients with recurrent hypoferritinemia 3

Cautions

• Avoid iron supplementation in patients with normal or elevated ferritin levels as it can be harmful 3, 8
• Do not measure iron parameters within 4 weeks of intravenous iron administration as it can interfere with test results 7
• Be cautious with iron supplementation in patients with inflammation, as ferritin is an acute phase reactant and may be falsely elevated 3, 8