Should ferrous sulfate (iron supplement) be discontinued with elevated ferritin levels (iron overload)?

Should Ferrous Sulfate Be Discontinued with a Ferritin Level of 545.9 ng/mL?

Yes, ferrous sulfate should be discontinued immediately with a ferritin level of 545.9 ng/mL, as this indicates iron overload and continuing supplementation risks organ toxicity.

Rationale for Discontinuation

A ferritin level of 545.9 ng/mL significantly exceeds the recommended safety threshold for iron supplementation. Guidelines recommend not exceeding a ferritin concentration of 500 ng/mL to avoid the risk of iron toxicity, especially in children and adolescents 1. The American Association for the Study of Liver Diseases establishes that therapeutic phlebotomy should target ferritin levels of 50-100 µg/L, and maintenance therapy should keep ferritin between 50-100 µg/L 1. Your current level is approximately 5-10 times higher than these target ranges.

Critical Next Steps

Immediate Actions

• Stop all oral iron supplementation immediately 1
• Avoid vitamin C supplements, as these enhance iron absorption and can worsen overload 1
• Measure transferrin saturation to distinguish between true iron overload versus ferritin elevation from inflammation 2, 3

Diagnostic Workup Required

The combination of elevated ferritin requires assessment of whether this represents:

• True iron overload (high transferrin saturation >45-50%): Consider hereditary hemochromatosis or secondary iron overload 1, 3
• Inflammatory conditions (low-normal transferrin saturation): Ferritin is an acute phase reactant elevated by inflammation, infection, liver disease, or malignancy independent of iron stores 4, 2

Check complete blood count, liver function tests, and C-reactive protein to evaluate for anemia, liver disease, or inflammatory conditions that could elevate ferritin 3.

Management Based on Transferrin Saturation

If Transferrin Saturation is High (>45-50%)

• Consider therapeutic phlebotomy if hereditary hemochromatosis is confirmed 1
• Refer for genetic testing for HFE mutations (C282Y, H63D) 3
• Target ferritin reduction to 50-100 µg/L through regular phlebotomy 1
• Monitor for end-organ damage: Check for diabetes, cardiac dysfunction, and liver disease 1

If Transferrin Saturation is Low (<20%)

• This suggests anemia of chronic disease or inflammation rather than true iron overload 2
• Investigate underlying inflammatory or chronic disease processes 3
• Iron supplementation remains contraindicated until ferritin normalizes and underlying cause is addressed 2

Common Pitfalls to Avoid

Do not assume elevated ferritin always indicates iron overload - it can be elevated by inflammation, making transferrin saturation measurement essential 4, 2. However, at a level of 545.9 ng/mL, the risk of actual iron accumulation is significant enough to warrant immediate cessation of supplementation regardless of the underlying cause.

Do not restart iron supplementation without reassessing iron parameters after 3 months, as ferritin needs time to reflect true body iron stores 4.

Avoid measuring ferritin within 4 weeks of any IV iron administration if that was given, as levels will be artificially elevated 4.

Monitoring Plan

• Recheck ferritin and transferrin saturation in 2-3 months after stopping supplementation 3
• Do not resume iron therapy unless ferritin falls below 50 ng/mL AND there is documented iron deficiency with low transferrin saturation 1
• If ferritin remains elevated, investigate for hemochromatosis, chronic liver disease, or ongoing inflammatory conditions 1, 3

The evidence is clear that continuing iron supplementation at your current ferritin level places you at risk for iron-mediated organ toxicity, particularly affecting the liver, heart, and endocrine organs 1.