What is the treatment for abnormal ferritin (iron) levels?

Treatment for Abnormal Ferritin (Iron) Levels

The treatment for abnormal ferritin levels depends on whether the patient has iron deficiency or iron overload, with specific approaches tailored to the underlying cause and severity of the condition. Treatment should prioritize reducing morbidity and mortality while improving quality of life.

Iron Deficiency (Low Ferritin)

Diagnosis Confirmation

• Serum ferritin is the preferred initial diagnostic test for iron deficiency, with levels below 30 μg/L being highly specific (98%) for iron deficiency in non-healthy adults 1
• Additional tests may include total iron-binding capacity, transferrin saturation, serum iron, and serum transferrin receptor levels if ferritin is between 46-99 ng/mL 1

Treatment Approach

• Oral iron supplementation is the first-line treatment for iron deficiency anemia 2
  • Ferrous sulfate 200 mg three times daily is recommended (ferrous gluconate and ferrous fumarate are equally effective) 2
  • Treatment should continue for three months after correction of anemia to replenish iron stores 2
• Ascorbic acid supplementation can enhance iron absorption when taken with oral iron 2
• For patients who cannot tolerate tablets, liquid preparations may be used 2

Follow-up Monitoring

• Monitor hemoglobin concentration and red cell indices at regular intervals 2
• Recommended follow-up: every three months for one year and then after a further year 2
• Additional oral iron should be given if hemoglobin or MCV falls below normal 2

Iron Overload (High Ferritin)

Diagnosis Confirmation

• Serum ferritin >1,000 ng/mL may indicate iron overload, particularly in transfusion-dependent patients 2
• Liver MRI is the non-invasive standard method to diagnose and monitor hepatic iron overload 3
• T2 and T2* relaxometry are considered the standard of care for MRI assessment of liver iron content 3

Treatment Based on Etiology

Transfusional Iron Overload

• Iron chelation therapy is indicated when 2:

  • Serum ferritin levels reach 1,000 ng/mL
  • Patient requires ≥2 units of blood/month for >1 year
  • Patient has low-risk myelodysplastic syndrome with life expectancy ≥1 year

• Deferasirox administration 4:

  • Starting dose: 14 mg/kg/day orally for patients with eGFR >60 ml/min/1.73 m²
  • Monitor serum ferritin monthly and adjust dose every 3-6 months based on trends
  • Dose adjustments in steps of 3.5 or 7 mg/kg (maximum 28 mg/kg/day)
  • Reduce dose if ferritin falls below 1,000 mcg/L at two consecutive visits
  • Interrupt therapy if ferritin falls below 500 mcg/L

Monitoring During Chelation Therapy

• Monitor serum ferritin levels at least every 3 months 2
• Monitor blood counts, liver function, and renal function monthly 4
• Perform auditory and ophthalmic testing before starting treatment and at regular intervals (every 12 months) 4
• Continue chelation as long as transfusion therapy continues and iron overload remains clinically relevant 2

Special Considerations for Iron Overload

Genetic Disorders with Iron Overload

• For patients with IRIDA (Iron-Refractory Iron Deficiency Anemia) 2:
  • Intravenous iron supplementation is recommended when oral iron is ineffective
  • Monitor serum ferritin to avoid exceeding 500 μg/L to prevent iron toxicity
  • Consider combination therapy with erythropoietin in selected cases

Pediatric Patients

• Interrupt deferasirox for pediatric patients with acute illnesses causing volume depletion 4
• Monitor more frequently during these periods and resume therapy when oral intake and volume status normalize 4
• Use minimum effective dose to maintain iron burden in the target range 4

Important Caveats and Pitfalls

• Hyperferritinemia is often not related to iron overload: Only about 10% of cases are related to true iron overload; the rest are due to acute phase reactions and other underlying conditions 5
• Ferritin is an acute phase reactant: Elevated levels can occur during inflammation without true iron overload 6
• Risk of overchelation: Monitor ferritin levels closely during chelation therapy to avoid excessive iron removal, especially in pediatric patients 4
• Potential serious adverse effects of chelation: Monitor for renal dysfunction, hepatic impairment, auditory/ocular abnormalities, and severe skin reactions during deferasirox treatment 4
• Age-related risks: Elderly and pediatric patients may be at higher risk for toxicity from chelation therapy and require more frequent monitoring 4