Is intravenous (IV) iron therapy indicated for a patient with low ferritin, normal hemoglobin, and normal iron levels?

IV Iron for Ferritin 31 ng/mL with Normal Hemoglobin and Iron

Oral iron supplementation should be the first-line treatment for this patient with low ferritin (31 ng/mL) and normal hemoglobin, reserving intravenous iron only for those who fail oral therapy, cannot tolerate it, or have specific conditions requiring rapid repletion. 1

Initial Assessment Required

Before making any treatment decision, you must measure transferrin saturation (TSAT) to complete the iron status assessment, as ferritin alone is insufficient to guide therapy 1. Additionally, check C-reactive protein to exclude inflammatory conditions that could falsely elevate ferritin while masking true iron deficiency 1.

Treatment Algorithm

Start with Oral Iron First

• Oral iron is the appropriate first-line therapy for patients with low ferritin and normal hemoglobin 1
• Recommend heme iron sources (meat, seafood) for better bioavailability, and co-administer vitamin C with non-heme iron sources to enhance absorption 1
• Advise patients to avoid tea and coffee around meal times as they impair iron absorption 1

When to Consider IV Iron

IV iron should be reserved for specific circumstances only 1:

• Documented intolerance to oral iron due to gastrointestinal side effects 1
• Failure to meet iron status targets despite maximally tolerated oral iron doses 1
• Documented malabsorption disorders such as celiac disease 1
• Rapid correction required per European drug label indications 2

Why IV Iron Is NOT Recommended as First-Line Here

• IV iron carries a 4.3% risk of infusion-related adverse events including allergic and anaphylactic reactions 1
• Considerably more expensive than oral preparations 1
• May jeopardize future vascular access options 1
• Lacks evidence for clinical benefit when hemoglobin is already normal or elevated, and carries risk of iron overload 1

Critical Pitfalls to Avoid

• Do not initiate IV iron based on low ferritin alone when hemoglobin is normal—this approach lacks evidence for improving morbidity, mortality, or quality of life 1
• Excessive iron supplementation can lead to iron overload with potential organ damage 1
• Relying solely on ferritin without considering TSAT and clinical context can lead to misdiagnosis, as ferritin is an acute phase reactant that can be elevated in inflammatory conditions 3, 4

Monitoring Plan

• Recheck hemoglobin, ferritin, and TSAT after 3 months of oral iron therapy 1
• If no improvement occurs despite adequate oral iron trial, then reconsider IV iron 1
• Target ferritin levels should reach at least 100-200 ng/mL for adequate iron stores 5