What is the treatment for low ferritin (iron deficiency) in an adolescent male?

Treatment of Low Ferritin in Adolescent Males

Initiate oral iron supplementation with 60-120 mg of elemental iron daily (typically ferrous sulfate 324 mg tablets containing 65 mg elemental iron, taken once daily between meals) for at least 3 months to replenish iron stores. 1, 2, 3, 4

Diagnostic Confirmation and Baseline Assessment

Before starting treatment, confirm iron deficiency with:

• Serum ferritin <30 μg/L indicates depleted iron stores in adolescent males (ferritin <15 μg/L confirms absolute deficiency) 5, 6
• Check complete blood count to assess for anemia (hemoglobin, MCV, MCH, RDW) 5
• Measure transferrin saturation (TSAT) to evaluate circulating iron availability—TSAT <20% confirms functional iron deficiency even if ferritin appears adequate 2
• Exclude inflammation by checking C-reactive protein, as ferritin is an acute-phase reactant and can be falsely elevated during infection or inflammation 5, 6

Critical pitfall: Adolescent males have higher average ferritin levels (135 μg/L) than females, so a "low-normal" ferritin may still represent significant depletion requiring treatment. 5

Oral Iron Therapy Protocol

Dosing Strategy

• Prescribe 60-120 mg elemental iron once daily (ferrous sulfate 324 mg tablet = 65 mg elemental iron) 1, 3, 4
• For symptomatic patients or confirmed anemia, use 3-6 mg/kg/day of elemental iron 7, 8
• Administer in the morning on an empty stomach or between meals to maximize absorption 1, 4
• Add vitamin C (250-500 mg) with iron to enhance absorption 1, 7

Optimizing Tolerance

• If gastrointestinal side effects occur, take iron with meals (though this reduces absorption by ~50%) 1
• Switch to alternative formulations (ferrous gluconate or ferrous fumarate) if ferrous sulfate is not tolerated 1
• Use preparations with 28-50 mg elemental iron to minimize side effects while maintaining efficacy 6
• Consider liquid preparations if tablets are poorly tolerated 1

Important caveat: Once-daily dosing is superior to multiple daily doses for absorption and compliance. 4

Monitoring and Treatment Duration

Initial Response Assessment

• Recheck hemoglobin at 4 weeks—expect ≥1 g/dL rise if compliant and no ongoing losses 1, 7, 8
• If no response after 4 weeks despite documented compliance, obtain additional testing: MCV, RDW, serum ferritin, and consider soluble transferrin receptor (sTfR) 1

Treatment Continuation

• Continue iron supplementation for 2-3 months after hemoglobin normalizes to replenish iron stores 1, 7, 4
• Target ferritin >30 μg/L (ideally >50 μg/L) before discontinuing therapy 2, 6
• Total treatment duration typically 3-6 months depending on severity 4, 8

Long-term Follow-up

• Recheck hemoglobin and ferritin approximately 6 months after completing treatment 1
• For adolescents with recurrent deficiency, consider intermittent oral supplementation and monitor ferritin every 6-12 months 6

Identifying and Addressing Underlying Causes

Investigate potential sources of iron loss or inadequate intake:

• Dietary assessment: Adolescent males require ~0.2 mg/kg/day of iron, with increased demands during rapid growth spurts 2
• Screen for gastrointestinal blood loss if no clear dietary cause (consider celiac disease, inflammatory bowel disease, H. pylori) 7
• Evaluate for malabsorption syndromes if poor response to oral therapy 1
• Assess athletic participation—competitive athletes have higher rates of iron deficiency (10.9% in males) due to increased losses and demands 9

Dietary counseling: Emphasize heme iron sources (red meat, seafood), vitamin C co-ingestion with plant-based iron, and avoidance of calcium, tea, and coffee within 2 hours of iron-rich meals. 7, 4

When to Consider Intravenous Iron

Parenteral iron is not first-line therapy but should be considered for: 1

• Intolerance to at least two different oral iron preparations 1
• Documented non-compliance with oral therapy 1
• Malabsorption conditions (inflammatory bowel disease with active inflammation, celiac disease) 1, 4
• Severe symptomatic anemia requiring urgent correction 4

Warning: IV iron carries risks of anaphylaxis, is more expensive, and provides no faster hemoglobin rise than oral iron in most cases. 1

Special Considerations for Adolescent Males

• Puberty increases iron demands dramatically: Blood volume expands by ~1900 mL, requiring ~1000 mg iron for erythropoiesis alone 2
• Adolescent athletes, vegetarians/vegans, and those with eating disorders are at highest risk 6, 4, 9
• Males aged 16-18 with frequent blood donation show 1.9% rate of absent iron stores and 12.4% rate of iron-deficient erythropoiesis 10
• Do not provide preventive iron supplementation if stores are normal—this is inefficient, causes side effects, and may be harmful 6