Management of Normal Ferritin with Elevated Iron in a Woman with Prior Iron Deficiency
Stop iron supplementation immediately and investigate for alternative causes of the elevated iron, as continued supplementation with normal or elevated ferritin is not recommended and potentially harmful. 1, 2
Immediate Assessment
Discontinue all iron therapy - both oral and intravenous iron supplementation should be stopped when ferritin values are normal or high, as this is potentially harmful and provides no benefit. 1, 2
Verify True Iron Status
Measure inflammatory markers (CRP) to exclude false-normal ferritin levels, since ferritin is an acute phase reactant that can be falsely elevated during inflammation, masking true iron deficiency. 1, 2
Check transferrin saturation (TSAT) - this provides additional information about functional iron availability. Normal TSAT is 20-50%; elevated iron with normal ferritin may show elevated TSAT. 1
Assess complete blood count including hemoglobin, MCV, and MCH to determine if anemia has resolved and red cell indices have normalized. 1, 3
Interpretation Framework
If CRP is Elevated (Inflammation Present)
Ferritin 30-100 μg/L with inflammation suggests combined iron deficiency and anemia of chronic disease. 1
Ferritin >100 μg/L with TSAT <20% and inflammation indicates anemia of chronic disease without true iron deficiency. 1
In this scenario, the "normal" ferritin may be masking ongoing iron deficiency, and hepcidin measurement provides more reliable assessment than ferritin or transferrin saturation in inflammatory states. 1
If CRP is Normal (No Inflammation)
Normal ferritin (>30 μg/L in women >15 years) with elevated serum iron indicates adequate iron stores have been restored. 2
This represents successful treatment of the prior iron deficiency. 4
No further iron supplementation is indicated at this time. 1, 2
Investigate Elevated Iron Levels
Rule Out Secondary Causes
Hemochromatosis or iron overload disorders - particularly if ferritin is substantially elevated (>200-300 μg/L) or if there is family history. 1
Recent iron infusion - ferritin levels are falsely high immediately after IV iron and should not be measured until 8-10 weeks post-infusion. 1, 2
Liver disease - can cause elevated ferritin and altered iron metabolism. 1
Hemolysis - check reticulocyte count and peripheral smear if elevated iron persists. 1
Ongoing Monitoring Strategy
Repeat laboratory assessment in 8-10 weeks (not earlier) including hemoglobin, ferritin, and TSAT to confirm stable iron stores. 1, 2
Long-Term Follow-Up for Women with History of Iron Deficiency
Monitor every 6-12 months with basic iron studies (hemoglobin, ferritin) to detect recurrent deficiency, especially in premenopausal women with heavy menstrual bleeding. 2
Resume iron supplementation only if ferritin drops below 30 μg/L or if anemia recurs. 2
Address underlying cause - ensure the original etiology of iron deficiency (menstrual blood loss, GI bleeding, malabsorption) has been adequately treated. 1, 3
Critical Pitfall to Avoid
Do not continue iron supplementation based solely on history of prior deficiency - long-term daily oral or IV iron supplementation in the presence of normal or high ferritin values is harmful and can lead to iron overload. 1, 2 The goal is restoration of iron stores (ferritin >100 μg/L after treatment), not indefinite supplementation. 1