No Iron Supplementation Needed
This elderly male patient does not require iron supplementation because his hemoglobin is normal (13 g/dL) and his iron studies are normal. 1
Why Iron Is Not Indicated
Normal Hemoglobin Status
- The patient's hemoglobin of 13 g/dL meets the WHO definition for normal hemoglobin in men (≥13 g/dL), so he is not anemic 1
- Iron supplementation is only indicated when hemoglobin is below the lower limit of normal for the population 1
- The British Society of Gastroenterology guidelines explicitly state that investigation and treatment should be considered when there is anemia in the presence of iron deficiency 1
Normal Iron Studies
- With normal iron studies (ferritin and transferrin saturation within normal range), there is no evidence of iron deficiency 2
- Serum ferritin is the single most useful marker of iron deficiency, and when normal, it indicates adequate iron stores 1
- Transferrin saturation <20% would suggest iron deficiency even with normal ferritin, but this patient's iron studies are normal 1, 2
Risks of Unnecessary Iron
- Preventative iron administration in the presence of normal iron stores is inefficient, has side effects, and appears to be harmful 3
- Long-term iron supplementation with normal or high ferritin values is not recommended and is potentially harmful 3
What to Do Instead
Investigate the Elevated RBC Count
- The RBC count of 6.6 million/μL is elevated and warrants investigation, as this is the abnormal finding 4
- Consider secondary polycythemia causes: chronic hypoxemia (COPD, sleep apnea), smoking history, renal pathology, or other causes of elevated erythropoietin 4
- Consider primary polycythemia (polycythemia vera) if other causes excluded 4
Monitor Appropriately
- Repeat complete blood count in 3 months to assess stability of the elevated RBC count 1
- Only recheck iron studies if hemoglobin drops below 13 g/dL or if microcytosis/hypochromia develops 2, 4
Key Clinical Pitfall
Starting iron without confirming deficiency can mask underlying conditions requiring treatment and cause harm from iron overload. 2, 3 The focus should be on explaining the elevated RBC count (possible polycythemia), not treating non-existent iron deficiency.