What is the treatment for iron deficiency with a ferritin level of 22?

Treatment for Ferritin 22

Start oral ferrous sulfate 325 mg (65 mg elemental iron) once or twice daily immediately, as this ferritin level indicates iron deficiency requiring treatment. 1, 2

Understanding Your Iron Status

A ferritin of 22 ng/mL indicates true iron deficiency that requires treatment, even if you don't yet have anemia. 1, 3, 4

• The most recent AGA guideline (2024) uses a ferritin cutoff of 45 ng/mL to diagnose iron deficiency, and your level is well below this threshold. 1
• Multiple guidelines recognize that ferritin levels below 30-35 ng/mL represent depleted iron stores requiring intervention. 1, 3, 4
• Recent evidence suggests the body's physiologic ferritin "cutoff" is actually 50 ng/mL, meaning your stores are significantly depleted. 5

First-Line Treatment: Oral Iron

Take ferrous sulfate 325 mg (providing 65 mg elemental iron) once or twice daily. 2, 6

• This is the most cost-effective first-line treatment recommended by the AGA. 2
• Each 325 mg tablet of ferrous sulfate contains 65 mg of elemental iron. 6
• Alternative preparations include ferrous fumarate or ferrous gluconate, which are equally effective if you experience side effects. 1, 2

How to Take Oral Iron for Best Results

• Take on an empty stomach for optimal absorption, but if you experience nausea or stomach upset, taking it with food is acceptable. 1, 2
• Add vitamin C (250-500 mg) with each iron dose to enhance absorption. 2
• Avoid tea, coffee, and calcium supplements around the time you take iron, as these impair absorption. 1
• If gastrointestinal side effects occur (constipation, nausea, abdominal pain), switch to alternate-day dosing rather than stopping treatment entirely. 1, 2

Duration of Treatment

Continue oral iron for 3 months after your ferritin normalizes to fully replenish iron stores. 2, 3

• Don't stop treatment too early—this is a common pitfall that leads to recurrent deficiency. 2
• Your body needs time to rebuild stores even after blood tests improve. 2, 3

Monitoring Your Response

Recheck blood work at 2 weeks to confirm you're responding to treatment. 2

• You should see hemoglobin rise by at least 10 g/L (1 g/dL) if you have anemia. 2
• Repeat testing at 8-10 weeks to assess overall treatment success. 1, 2, 3
• Failure to respond indicates either non-compliance, malabsorption, continued bleeding, or another underlying problem. 2

When to Consider IV Iron

Switch to intravenous iron if: 1, 2

• You cannot tolerate at least two different oral iron preparations due to side effects. 2
• You fail to respond after 2 weeks of daily oral therapy (no hemoglobin rise). 2
• You have a malabsorption condition like celiac disease or inflammatory bowel disease. 1, 2
• You need rapid iron correction for severe symptoms. 1, 2

The recommended IV formulation is 1 gram of iron as ferric carboxymaltose given as a single dose over 15 minutes, which allows rapid store replenishment. 1

Investigate the Underlying Cause

You must identify why your ferritin is low—iron deficiency in adults is rarely due to diet alone. 2, 3, 4

If You Are a Menstruating Woman:

• Heavy menstrual bleeding is the most common cause. 4
• However, if you're over 45 years or have persistent symptoms, gastrointestinal evaluation is still needed. 2

If You Are Male or Postmenopausal Female:

• Age >45 years: You need both upper endoscopy with small bowel biopsy AND colonoscopy to exclude gastrointestinal bleeding or malignancy. 2
• Age <45 years: Consider celiac disease screening first; proceed to endoscopy only if you have upper GI symptoms. 2

Other Causes to Consider:

• Chronic use of NSAIDs or aspirin causing occult GI bleeding. 4
• Atrophic gastritis or H. pylori infection impairing iron absorption. 4, 7
• Vegetarian/vegan diet with inadequate iron intake. 1, 3
• Inflammatory bowel disease, chronic kidney disease, or heart failure. 4

Critical Pitfalls to Avoid

• Don't assume dietary deficiency alone—always investigate for pathological blood loss, especially in adults. 2
• Don't stop oral iron when you feel better—continue for 3 months after normalization to replenish stores. 2, 3
• Don't use modified-release iron preparations—these have reduced absorption and are less effective. 2
• Don't supplement iron if ferritin becomes normal or high—this is potentially harmful. 1, 3