What is the treatment for low ferritin levels?

Treatment for Low Ferritin Levels

Oral iron supplementation with ferrous sulfate 325 mg daily (65 mg elemental iron) is the first-line treatment for low ferritin levels in most patients. 1, 2

Diagnosis and Assessment

• Low serum ferritin (<30 ng/mL) is the most specific indicator of depleted iron stores, especially when used with other tests to assess iron status 3
• In patients with inflammation, chronic infection, or tissue damage, serum ferritin may be falsely elevated despite iron deficiency 3
• Transferrin saturation <20% is an additional marker for iron deficiency, particularly useful when inflammation is present 3, 2

Treatment Approach

Oral Iron Therapy

• Ferrous sulfate 325 mg daily (providing 65 mg of elemental iron) is typically the first-line therapy 1, 2
• Alternative dosing schedule of every other day may improve absorption and reduce gastrointestinal side effects 3
• Treatment should continue until ferritin levels normalize and iron stores are replenished 2
• Common side effects include constipation, diarrhea, and nausea 3, 4

Intravenous Iron Therapy

• Indicated for patients with:
  • Oral iron intolerance 2
  • Poor absorption (celiac disease, post-bariatric surgery) 2
  • Chronic inflammatory conditions (CKD, heart failure, IBD, cancer) 2
  • Ongoing blood loss 2
  • Second and third trimesters of pregnancy 2
• IV iron formulations include iron sucrose, ferric gluconate, ferric carboxymaltose, and others 3
• Total intravenous iron doses should be calculated based on formulas of body iron deficit 3

Monitoring Treatment

• Serum ferritin levels should be monitored during treatment 3
• For oral iron therapy, repeat basic blood tests after 8-10 weeks of treatment 3
• For IV iron therapy, wait at least 8-10 weeks before checking ferritin levels as they may be falsely elevated immediately after infusion 3
• During maintenance therapy, serum ferritin should be monitored every 6 months 3

Special Considerations

Iron Deficiency in Hemochromatosis Patients

• In patients with hemochromatosis undergoing therapeutic phlebotomy, monitor hemoglobin and ferritin levels to prevent iron deficiency 5
• If iron deficiency develops, consider extending the phlebotomy interval 3
• Brief courses of ferrous sulfate may be used to treat symptomatic iron deficiency in these patients 5

Dietary Recommendations

• Avoid iron supplementation when ferritin values are normal or high 3
• Limit red meat consumption and alcohol intake 3
• Avoid supplemental vitamin C, especially before iron depletion in patients with iron overload 3
• Avoid iron-fortified foods in patients with iron overload 3

Pediatric Considerations

• Children with low ferritin may be treated with ferrous sulfate at 3 mg/kg/day 4
• Serum ferritin levels should be monitored and preferably should not exceed 500 μg/L to avoid toxicity of iron overload, especially in children and adolescents 3
• A new ferrous sulfate oral solution (20 mg/mL) at 2 mg/kg daily has shown high efficacy and tolerability in young children with iron deficiency anemia 4

Pitfalls and Caveats

• Do not treat based on low ferritin alone without considering other markers of iron status and underlying causes 3
• Investigate unexpected changes in serum ferritin or transferrin saturation levels 3
• Consider that inflammation can mask iron deficiency by falsely elevating ferritin levels 3
• Avoid iron supplementation in patients with normal or high ferritin levels as it can be potentially harmful 3