What is the treatment for abnormal ferritin levels?

Treatment for Abnormal Ferritin Levels

Treatment for abnormal ferritin levels must be tailored to the underlying cause, with iron supplementation for low ferritin and phlebotomy for high ferritin being the primary interventions.

Low Ferritin (Iron Deficiency)

Diagnosis

• Iron deficiency is diagnosed by low serum ferritin (typically <30 ng/mL) in individuals without inflammatory conditions or by transferrin saturation less than 20% 1
• Common causes include bleeding (menstrual, gastrointestinal), impaired iron absorption (atrophic gastritis, celiac disease, bariatric surgery), inadequate dietary iron intake, and pregnancy 1

Oral Iron Therapy

• Oral iron is the first-line therapy for iron deficiency anemia 2
• Ferrous sulfate 200 mg three times daily (or equivalent ferrous gluconate or ferrous fumarate) is the standard treatment 2
• Each tablet of ferrous sulfate contains 324mg, equivalent to 65mg of elemental iron 3
• Treatment should be continued for three months after correction of anemia to replenish iron stores 2
• Alternative dosing of ferrous sulfate 325 mg once daily may be as effective as three times daily dosing with fewer side effects 4
• Ascorbic acid enhances iron absorption and should be considered when response to iron therapy is poor 2

Intravenous Iron Therapy

• Parenteral iron should only be used when there is intolerance to at least two oral preparations or non-compliance 2
• IV iron is indicated for patients with:
  • Oral iron intolerance
  • Poor absorption (celiac disease, post-bariatric surgery)
  • Chronic inflammatory conditions (CKD, heart failure, IBD, cancer)
  • Ongoing blood loss
  • During second and third trimesters of pregnancy 1
• Ferric carboxymaltose can be administered as a single high dose (1000 mg) and is more effective than oral iron in certain populations 5

Monitoring

• Hemoglobin concentration should rise by 2 g/dL after 3-4 weeks of treatment 2
• Failure to respond is usually due to poor compliance, misdiagnosis, continued blood loss, or malabsorption 2
• Once normal, hemoglobin concentration and red cell indices should be monitored every three months for one year and then after a further year 2

High Ferritin (Iron Overload)

Diagnosis

• High ferritin can be caused by iron overload syndromes (hemochromatosis), inflammatory conditions, malignancy, and liver disease 6
• Transferrin saturation should be checked to distinguish between iron overload and other causes of hyperferritinemia 2

Phlebotomy Treatment

• Phlebotomy is the mainstay of therapy for iron overload conditions like hemochromatosis 2
• During induction phase: 400-500 ml weekly or every 2 weeks until target ferritin is reached 2
• During maintenance phase: phlebotomy every 1-4 months to maintain target ferritin 2
• Target ferritin levels:
  • Induction phase: <50 μg/L 2
  • Maintenance phase: 50-100 μg/L 2, though some experts suggest <200 μg/L for women and <300 μg/L for men may be tolerated in elderly patients 2

Monitoring During Phlebotomy

• Serum hemoglobin should be monitored at each phlebotomy session 2
• If hemoglobin <12 g/dL, decrease frequency of phlebotomy 2
• If hemoglobin <11 g/dL, discontinue phlebotomy and reassess 2
• Serum ferritin should be measured monthly during induction phase (or after every 4th phlebotomy) 2
• When ferritin decreases below 200 μg/L, check ferritin every 1-2 sessions 2
• During maintenance phase, monitor ferritin every 6 months 2
• Periodically check plasma folate and cobalamin levels, especially in patients requiring numerous venesections 2

Dietary Recommendations for Iron Overload

• Dietary modifications should not substitute for iron removal therapy 2
• Iron supplementation should be avoided 2
• Iron-fortified food should be avoided where possible 2
• Supplemental vitamin C should be avoided, especially before iron depletion 2
• Red meat consumption should be limited 2
• Alcohol intake should be restricted, particularly during the iron depletion phase 2
• Patients with cirrhosis should abstain from alcohol consumption 2

Special Considerations

• Pre-menopausal women with iron deficiency >45 years of age should be investigated according to guidelines for potential underlying causes 2
• Patients with severe co-morbidity should have individualized treatment decisions, with careful consideration of whether investigation would influence management 2
• In patients with chronic kidney disease, IV iron may be preferred over oral iron due to better efficacy and fewer side effects 2, 5