Should I start iron supplements and aspirin (acetylsalicylic acid) therapy in a patient with elevated ferritin level of 901?

Do Not Start Iron Supplementation with a Ferritin of 901

Iron supplementation is not recommended and is potentially harmful when ferritin is 901 ng/mL in the absence of confirmed iron deficiency anemia or functional iron deficiency. 1

Why Iron Supplementation is Contraindicated

Your ferritin level of 901 ng/mL is substantially elevated and indicates adequate to excessive iron stores. The evidence is clear on this point:

• Iron supplementation in the presence of normal or high ferritin values is not recommended and is potentially harmful. 1
• Guidelines specifically recommend avoiding chronic maintenance of ferritin at or above 800 ng/mL through iron administration. 1
• At ferritin levels between 300-800 ng/mL in dialysis patients, there has been no evidence of benefit, and your level exceeds even this range. 1

Critical Assessment Needed Before Any Decision

Before considering any intervention, you must determine why your ferritin is elevated:

• Ferritin is an acute-phase reactant that becomes elevated during inflammation, infection, liver disease, malignancy, or metabolic syndrome—not just iron overload. 1, 2
• Check C-reactive protein (CRP) to identify if inflammation is falsely elevating your ferritin while masking true iron status. 3
• Measure transferrin saturation (TSAT) and hemoglobin to assess functional iron availability. 1, 3

When Iron Might Be Considered (Rare Exception)

Iron therapy could only be justified in the highly specific scenario of functional iron deficiency despite elevated ferritin:

• This requires TSAT <20% with evidence of anemia or inadequate erythropoiesis. 1, 3
• Even in this scenario, the DRIVE study showed that patients with ferritin 500-1200 ng/mL and TSAT <25% could respond to IV iron, but this study was not powered to assess safety. 1
• This decision should only be made in the context of chronic kidney disease, dialysis, or erythropoietin therapy—not in otherwise healthy individuals. 1

Regarding Aspirin

The question about aspirin appears unrelated to your ferritin level, but there is an important interaction to understand:

• Chronic low-dose aspirin (75-100 mg/day) can actually cause iron deficiency anemia in approximately 20% of elderly individuals through iron chelation by aspirin metabolites, independent of gastrointestinal bleeding. 4
• With your elevated ferritin, aspirin is not causing iron deficiency in your case. 4
• Whether to start aspirin depends entirely on cardiovascular risk factors, bleeding risk, and other clinical indications—not your ferritin level.

Common Pitfalls to Avoid

• Do not assume elevated ferritin always means iron overload—it may reflect inflammation, and treating with iron could be dangerous. 1, 2
• Do not supplement iron based on ferritin alone—you need TSAT, hemoglobin, and inflammatory markers to make an informed decision. 1, 3
• Do not continue iron if there is no erythropoietic response—this leads to true iron overload with potential organ damage. 1

Recommended Next Steps

1. Measure TSAT, hemoglobin, and CRP immediately to understand your true iron status and whether inflammation is present. 3, 2
2. Investigate the cause of elevated ferritin (inflammatory conditions, liver disease, metabolic syndrome, hemochromatosis). 1, 2
3. Withhold all iron supplementation until you have confirmed iron deficiency with appropriate testing. 1
4. Consider aspirin only based on cardiovascular indications, not ferritin levels—discuss with your physician based on your specific risk profile.