What is the target ferritin level for treating iron deficiency anemia in adults and adolescents?

Goal Ferritin for Iron Deficiency Anemia

For adults and adolescents with iron deficiency anemia, target a ferritin level of 30-100 ng/mL during treatment, with the specific goal depending on clinical context: aim for ≥50 ng/mL in general populations, ≥100 ng/mL in inflammatory bowel disease patients, and maintain 50-100 ng/mL in chronic kidney disease patients on dialysis. 1

Diagnostic Thresholds vs. Treatment Goals

The ferritin level that diagnoses iron deficiency differs from the target during treatment:

• Diagnosis: Ferritin <45 ng/mL confirms iron deficiency anemia in patients without inflammation 1, 2
• Treatment goal: Higher targets are needed to replete iron stores and prevent recurrence

Target Ferritin by Clinical Context

General Adult Population (No Chronic Disease)

Target ferritin: 30-50 ng/mL minimum

• A ferritin <30 ng/mL indicates depleted iron stores even after hemoglobin correction 1, 3
• Emerging evidence suggests 50 ng/mL represents the body's physiologic threshold for adequate iron stores 4
• Many women with ferritin 30-50 ng/mL have no bone marrow iron stores, indicating this range is insufficient 4

Inflammatory Bowel Disease

Target ferritin: ≥100 ng/mL

• After successful IV iron treatment, re-treatment should begin when ferritin drops below 100 ng/mL 1
• In the presence of inflammation, ferritin up to 100 ng/mL may still reflect iron deficiency 1
• This higher target accounts for ferritin elevation from chronic inflammation 1

Chronic Kidney Disease on Hemodialysis

Target ferritin: 100-500 ng/mL (maintenance range 50-100 ng/mL)

• Minimum threshold: Maintain ferritin ≥100 ng/mL to prevent functional iron deficiency during erythropoietin therapy 1
• Optimal maintenance range: 50-100 ng/mL balances efficacy with safety 1
• Upper safety limit: Avoid chronically maintaining ferritin >800 ng/mL due to iron overload risk 1
• Note: More recent guidelines suggest targets of 250-500 ng/mL, though this represents aggressive iron repletion strategies 1

Heart Failure

Target ferritin: >100 ng/mL

• Iron deficiency in heart failure is defined as ferritin <100 ng/mL or ferritin 100-299 ng/mL with transferrin saturation <20% 3
• IV iron improves exercise capacity in this population regardless of anemia presence 2, 3

Monitoring During Treatment

Oral Iron Therapy

• Assess response at 2-4 weeks by checking hemoglobin 2
• Continue treatment for 3-6 months after hemoglobin normalization to replete iron stores 2
• Target ferritin of 30-50 ng/mL is appropriate for most patients on oral therapy 5

Intravenous Iron Therapy

• Check ferritin every 3 months in hemodialysis patients to optimize dosing 1
• In IBD, re-initiate IV iron when ferritin drops below 100 ng/mL or hemoglobin falls below 120-130 g/L 1

Critical Caveats

Ferritin interpretation requires clinical context:

• Ferritin is an acute-phase reactant; inflammation, infection, liver disease, and malignancy artificially elevate levels 1
• In inflammatory conditions, ferritin <100 ng/mL suggests iron deficiency despite appearing "normal" 1
• A ferritin >150 ng/mL makes absolute iron deficiency unlikely even with inflammation 1
• Transferrin saturation <20% helps confirm functional iron deficiency when ferritin is equivocal 1, 3

Avoid over-treatment:

• Ferritin >500 ng/mL in non-dialysis patients suggests adequate or excessive iron stores 1
• Iron overload risk increases substantially with ferritin >800 ng/mL 1
• In dialysis patients, ferritin >800 ng/mL warrants temporary cessation of IV iron 1

Population-specific considerations:

• Premenopausal women with heavy menstrual bleeding may require ongoing maintenance therapy to keep ferritin >30 ng/mL 1, 2
• Pregnant women in second/third trimester should receive IV iron to achieve adequate stores (ferritin >30 ng/mL) 2, 3
• Elderly patients may tolerate more relaxed ferritin targets during maintenance therapy 1