What is the management for a patient with normal iron saturation, low ferritin, and normal hemoglobin?

Management of Low Ferritin (7 ng/mL) with Normal Iron Saturation and Normal Hemoglobin

You should initiate oral iron supplementation immediately to replenish depleted iron stores, even though the hemoglobin is currently normal. A ferritin of 7 ng/mL represents true iron deficiency that warrants treatment regardless of anemia status 1.

Why Treatment is Necessary

• Ferritin <15 μg/L is diagnostic of iron deficiency and indicates depleted iron stores, even without anemia 1.
• Iron deficiency impairs multiple physiological functions beyond oxygen transport, including cognitive function, physical performance, nail growth, skin integrity, and mucosal regeneration 1.
• All patients with iron deficiency should receive iron supplementation to correct the deficiency and replenish body stores, regardless of hemoglobin level 2, 1.

First-Line Treatment Approach

Start oral iron supplementation as the initial therapy:

• Ferrous sulfate 200 mg three times daily (or equivalent ferrous gluconate or ferrous fumarate) 2, 1.
• For patients who cannot tolerate this regimen, consider:
  • Liquid iron preparations 2
  • Lower-dose formulations (28-50 mg elemental iron) to reduce gastrointestinal side effects 3
  • Alternate-day dosing 1

Add ascorbic acid (vitamin C) to enhance iron absorption 2, 1.

Duration of Treatment

• Continue iron supplementation for three months after correction of iron deficiency to fully replenish iron stores 2, 1.
• This extended duration is critical because simply normalizing ferritin is insufficient—stores must be adequately repleted 2.

Monitoring Response

Repeat basic blood tests (hemoglobin, ferritin) after 8-10 weeks of treatment to assess response 1, 3.

Long-term follow-up schedule:

• Monitor every three months for the first year 2, 1
• Then annually thereafter 2
• Additional oral iron should be given if ferritin falls below normal again 2

When to Consider Parenteral Iron

Reserve intravenous iron only for specific circumstances:

• Intolerance to at least two different oral iron preparations 1
• Documented malabsorption 1
• Non-compliance with oral therapy 1
• Need for urgent iron repletion (rare in asymptomatic patients) 3

Critical Pitfalls to Avoid

Do not delay treatment while investigating the underlying cause—start iron supplementation immediately 1. The normal iron saturation in your patient suggests this is likely nutritional deficiency or chronic blood loss rather than acute bleeding.

Do not assume normal hemoglobin means no treatment is needed. The guideline evidence is clear that iron deficiency at all levels should be treated, not just iron deficiency anemia 1, 3.

Avoid excessive supplementation once stores are repleted. Long-term daily iron supplementation with normal or high ferritin levels is potentially harmful 1, 3.

Special Consideration for Your Patient

The combination of very low ferritin (7 ng/mL) with normal iron saturation is somewhat unusual but does not change management. This pattern can occur with:

• Dietary insufficiency
• Chronic occult blood loss that has depleted stores but not yet caused anemia
• Increased iron demands (menstruation, pregnancy, athletic activity)

Consider investigating the underlying cause (dietary history, menstrual history, gastrointestinal evaluation if indicated), but this should not delay initiation of iron therapy 2, 1.