What is the treatment for a patient with hypoferritinemia (low ferritin level) of 30?

Treatment of Hypoferritinemia (Ferritin 30 µg/L)

A ferritin level of 30 µg/L indicates iron deficiency and warrants iron supplementation, with oral iron as first-line therapy (ferrous sulfate 100-200 mg elemental iron daily, preferably in divided doses or alternate-day dosing) for otherwise healthy individuals, while intravenous iron should be considered for specific populations including those with chronic kidney disease, inflammatory bowel disease, cancer patients, or those who fail oral therapy. 1, 2

Diagnostic Context and Treatment Thresholds

• Ferritin 30 µg/L meets the diagnostic threshold for iron deficiency in healthy adults (>15 years), where the recommended cut-off is 30 µg/L 1
• In the presence of inflammation or cancer, this ferritin level is even more concerning, as the diagnostic threshold increases to 100 µg/L in inflammatory conditions 2
• Always check C-reactive protein (CRP) to exclude acute phase reaction, as ferritin can be falsely elevated during inflammation, potentially masking true iron deficiency 1, 2

Oral Iron Therapy (First-Line for Most Patients)

Dosing Strategy

• Standard dose: 100-200 mg elemental iron daily in divided doses 2
• Ferrous sulfate 325 mg (65 mg elemental iron) is the most common preparation 3, 2
• Recent evidence supports alternate-day dosing (rather than daily) for better absorption and fewer side effects 2
• Single daily dosing is as effective as three-times-daily dosing for treating iron deficiency 4

Practical Considerations

• Integrate dietary advice: consume heme iron sources (red meat), pair non-heme iron with vitamin C, avoid tea/coffee around meal times 2, 1
• Gastrointestinal side effects (constipation, nausea, diarrhea) occur commonly; using preparations with 28-50 mg elemental iron may improve compliance 1, 2
• Reassess after 8-10 weeks with repeat hemoglobin, ferritin, and transferrin saturation 2, 1

Intravenous Iron Therapy (Specific Indications)

When to Use IV Iron

IV iron is preferred over oral iron in the following populations:

• Chronic kidney disease (CKD): Ferric carboxymaltose 1000 mg over 15 minutes is more effective than oral iron, with better tolerability 5, 2
• Inflammatory bowel disease (IBD): IV iron produces superior hemoglobin response compared to oral iron (73% vs 45% response rate) 2
• Cancer patients receiving chemotherapy: IV iron significantly improves hemoglobin response when combined with erythropoiesis-stimulating agents (ESAs) 2
• Failure of oral therapy: Repeated failure of first-step oral therapy or gastrointestinal intolerance 1
• Need for rapid repletion: Pre-operative patient blood management 2

IV Iron Formulations and Dosing

• Ferric carboxymaltose: Up to 1000 mg over 15 minutes (maximum 20 mg/kg body weight per week) 2, 5
• Iron sucrose: 200-500 mg per infusion, minimum 30-210 minutes 2
• Ferric gluconate: Maximum 125 mg per infusion, minimum 60 minutes 2
• Iron isomaltoside: Up to 1000 mg over 15 minutes 2

Safety Monitoring

• Monitor ferritin levels to avoid toxicity: Target ferritin should not exceed 500 µg/L, especially in children and adolescents 2
• Risk of anaphylactoid reactions is very low (<1:250,000 administrations with modern formulations) but requires risk minimization protocols 2
• Avoid high molecular weight iron dextran due to higher adverse event risk 2

Population-Specific Considerations

Athletes and Menstruating Women

• Ferritin <35 µg/L defines iron deficiency in athletes 2
• Monitor twice yearly in female athletes, once yearly in males 2
• Diet rich in red meat is recommended; supplementation above RDA may be considered after consultation 2

CKD Patients (Not on Dialysis)

• Transferrin saturation ≤30% and ferritin ≤300 ng/mL indicates iron deficiency 5, 2
• Ferric carboxymaltose 1000 mg is superior to oral ferrous sulfate for increasing TSAT (8% greater increase) and ferritin (37 ng/ml greater increase) 5, 6
• Consider ESA therapy cautiously if hemoglobin <10 g/dL after iron repletion 2

IBD Patients

• With inflammation present: Ferritin 30-100 µg/L suggests combined true iron deficiency and anemia of chronic disease 2
• Goal: normalize hemoglobin and iron stores with expected increase of ≥2 g/dL hemoglobin within 4 weeks 2
• Simple dosing regimen for ferric carboxymaltose is more effective than Ganzoni formula-calculated iron sucrose 2

Cancer Patients

• Absolute iron deficiency: TSAT <20% and ferritin <30 ng/mL (or <100 ng/mL with inflammation) 2
• IV iron significantly improves ESA response when used in combination therapy 2
• Oral iron does NOT improve outcomes compared to no iron in cancer patients 2

Critical Pitfalls to Avoid

• Do NOT supplement iron if ferritin is normal or high – this is potentially harmful and not recommended 2, 1
• Do NOT ignore inflammatory markers – ferritin can be falsely normal/elevated in inflammation, masking true deficiency 2, 1
• Do NOT use excessive oral iron doses – this increases side effects without improving efficacy 1
• Do NOT delay IV iron in appropriate populations – oral iron is inferior in CKD, IBD, and cancer patients 5, 2
• Do NOT continue oral iron beyond 8-10 weeks without reassessment 2, 1

Monitoring and Follow-Up

• Repeat iron studies at 8-10 weeks (not earlier after IV iron, as ferritin will be falsely elevated) 2, 1
• Long-term monitoring: Every 6-12 months for patients with recurrent deficiency 1, 2
• Target ferritin for maintenance: 50-100 µg/L during maintenance phase, though more relaxed targets (<200 µg/L women, <300 µg/L men) may be tolerated 2