What is the best course of treatment for a patient with iron deficiency anemia and mildly elevated liver enzymes?

Management of Microcytic Anemia with Normal Ferritin and Mildly Elevated Liver Enzymes

This patient does NOT have iron deficiency anemia—the ferritin of 120 ng/mL excludes this diagnosis, and the microcytosis with normal iron studies suggests thalassemia trait or anemia of chronic disease. 1

Laboratory Interpretation

Your patient's labs reveal:

• Microcytic anemia (MCV 77, MCH 24.6) with elevated RBC count (6.01), which is the classic pattern for thalassemia trait 2
• Normal iron stores: Ferritin 120 ng/mL is well above the threshold for iron deficiency (<30 ng/mL without inflammation, <100 ng/mL with inflammation) 1
• Borderline iron saturation at 26% (normal >20%), which does not indicate true iron deficiency 3
• Mildly elevated ALT at 60 U/L, which is non-specific but warrants evaluation

Primary Diagnostic Consideration

The most likely diagnosis is thalassemia trait (alpha or beta), not iron deficiency anemia. The combination of:

• Elevated RBC count (6.01)
• Low MCV (77) and MCH (24.6)
• Normal ferritin (120 ng/mL)
• Normal thyroid and kidney function

This pattern is pathognomonic for thalassemia trait rather than iron deficiency 2

Recommended Management Algorithm

Step 1: Confirm Thalassemia Trait

• Order hemoglobin electrophoresis to differentiate beta thalassemia trait (elevated HbA2 >3.5%) from alpha thalassemia trait 2
• If hemoglobin electrophoresis is normal, consider alpha thalassemia trait (requires genetic testing for definitive diagnosis) 2

Step 2: Do NOT Give Iron Supplementation

Iron therapy is contraindicated in this patient because:

• Ferritin of 120 ng/mL confirms adequate iron stores 1
• Iron supplementation in thalassemia trait provides no benefit and risks iron overload 3
• The British Society of Gastroenterology guidelines specify iron therapy only when iron deficiency is confirmed 3

Step 3: Address the Elevated ALT

• Evaluate for common causes of mild transaminitis: fatty liver disease, alcohol use, viral hepatitis, medications 4
• Consider hepatitis panel and abdominal ultrasound if ALT remains elevated on repeat testing 4
• The ALT elevation is unrelated to the microcytic anemia and requires separate workup 4

Common Pitfall to Avoid

The critical error would be prescribing iron supplementation based solely on microcytosis. Many clinicians reflexively treat microcytic anemia with iron without confirming iron deficiency. In this case:

• The ferritin of 120 ng/mL definitively excludes iron deficiency 1
• Giving iron to a patient with thalassemia trait is unnecessary and potentially harmful 2
• Iron supplementation should only occur when ferritin is <30 ng/mL (or <100 ng/mL with inflammation) 1

If Iron Deficiency Were Present (Which It Is Not)

For educational purposes, if this patient had true iron deficiency anemia with ferritin <30 ng/mL, the approach would be:

• Start oral ferrous sulfate 200 mg three times daily for 3-6 months 3, 1
• Recheck hemoglobin at 4 weeks, expecting ≥1 g/dL increase if responsive 1, 5
• Switch to IV iron if hemoglobin fails to rise ≥1 g/dL after 4 weeks of oral therapy 1, 5
• Continue treatment for 2-3 months after hemoglobin normalizes to replenish stores 1

Quality of Life Considerations

Thalassemia trait is typically asymptomatic and requires no treatment. Unlike true iron deficiency anemia, which impairs physical and cognitive function and reduces quality of life 1, thalassemia trait does not cause functional impairment and patients live normal lives without intervention 2. The key is avoiding unnecessary iron supplementation and providing genetic counseling if family planning is relevant 2.