What to do for a 67-year-old female with elevated ferritin (iron storage protein) levels?

Management of Elevated Ferritin Level of 183.6 μg/L in a 67-Year-Old Female

For a 67-year-old female with a ferritin level of 183.6 μg/L, no immediate intervention is necessary as this value is only mildly elevated and does not indicate significant iron overload. 1, 2

Initial Assessment

• A ferritin level of 183.6 μg/L is only mildly elevated and significantly below the threshold of 1000 μg/L that would suggest potential organ damage or significant iron overload 2
• Ferritin is a highly sensitive test for iron overload but suffers from low specificity as elevated values can result from inflammatory, metabolic, and neoplastic conditions 1
• Common non-iron overload causes of mild hyperferritinemia include:
  • Inflammatory conditions
  • Diabetes mellitus
  • Alcohol consumption
  • Liver disease
  • Malignancy 1, 3

Recommended Diagnostic Approach

• Measure transferrin saturation to better assess iron status - this is crucial to differentiate true iron overload from other causes of hyperferritinemia 2
• If transferrin saturation is normal (<45%), the elevated ferritin is likely due to inflammation or other non-iron overload conditions 2, 4
• If transferrin saturation is elevated (>45%), further evaluation for hemochromatosis is warranted 2

Further Testing (if transferrin saturation is elevated)

• HFE gene testing for C282Y and H63D mutations should be performed to evaluate for hereditary hemochromatosis 2, 1
• At this ferritin level (183.6 μg/L), MRI for iron quantification is not required as it is well below concerning thresholds 1
• Liver biopsy is not indicated at this ferritin level, as it is typically reserved for patients with ferritin >1000 μg/L or with elevated liver enzymes 1, 2

Management Based on Findings

• If transferrin saturation is normal and no other concerning features are present:

  • Evaluate and address potential causes of mild hyperferritinemia (inflammation, metabolic syndrome, alcohol consumption) 1
  • Consider repeating ferritin measurement in 3-6 months to monitor trends 1

• If transferrin saturation is elevated and genetic testing confirms hemochromatosis:

  • Therapeutic phlebotomy is indicated only if ferritin continues to rise or reaches concerning levels 1, 2
  • At the current ferritin level, immediate phlebotomy is not necessary 1

Important Considerations

• The post-test likelihood of C282Y homozygosity (hereditary hemochromatosis) in a female with ferritin between 200-300 μg/L is only about 0.3-3.6% 4
• Iron overload is rarely the cause of mild hyperferritinemia in the range seen in this patient 4
• Avoid unnecessary dietary iron restrictions unless true iron overload is confirmed 1
• Avoid vitamin C supplements exceeding 500 mg/day if iron overload is confirmed 1

Monitoring

• If no evidence of iron overload is found, consider monitoring ferritin annually along with other routine health screenings 1
• If early hemochromatosis is diagnosed but phlebotomy not yet indicated, monitor ferritin every 3-6 months 1, 2