What is the significance of elevated ferritin levels in an 88-year-old female with hyperferritinemia, taking ferrous sulfate (iron supplement) 325mg daily?

From the Guidelines

I strongly recommend discontinuing the ferrous sulfate 325 mg daily as this patient's iron studies indicate iron overload rather than deficiency. The elevated ferritin level of 359.6 ng/mL suggests excess iron stores, while the low transferrin (179 mg/dL) and low-normal TIBC (240 μg/dL) further support this assessment 1. In elderly patients, continued iron supplementation when not needed can lead to iron accumulation in organs, potentially causing damage to the liver, heart, and other tissues.

Instead, the patient should have further evaluation to determine the cause of the elevated ferritin, which could include inflammation, liver disease, or hemochromatosis. A complete blood count should be checked to assess for anemia, and liver function tests would be appropriate. If iron supplementation is truly needed in the future based on new findings, it should be restarted at that time. The patient should follow up with her physician within 1-2 months after stopping the supplement to reassess her iron status.

According to the most recent guidelines, the target ferritin level for patients with hemochromatosis is between 50-100 lg/L 1. In this case, the patient's ferritin level is significantly elevated, suggesting iron overload. The American Association for the Study of Liver Diseases recommends that serum ferritin levels be used to monitor iron stores and adjust treatment accordingly 1.

It is also important to note that iron parameters should not be evaluated within 4 weeks of a transferrin saturation (TSAT) measurement, as the circulating iron can interfere with the assay leading to specious results 1. Therefore, it is recommended to wait at least 4 weeks after stopping the iron supplement before rechecking the patient's iron parameters.

In terms of monitoring, serum haemoglobin should always be monitored during both induction and maintenance phases, at the time of each bloodletting session, and serum ferritin should be monitored every 6 months to adapt the treatment schedule and ensure that ferritin remains within the target range 1.

Overall, the patient's iron studies suggest iron overload, and discontinuing the ferrous sulfate supplement is the most appropriate course of action to prevent potential organ damage and other complications.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Patient's Iron Status

• The patient is an 88-year-old female with a ferritin level of 359.6, transferrin level of 179, and TIBC of 240.
• She is currently taking ferrous sulfate 325 mg daily.

Interpretation of Biochemical and Haematological Findings

• According to 2, ferritin measurement is the most important analysis in the study of iron deficiency, but there is no consensus on the diagnostic cut-off.
• The study suggests that a ferritin level of < 30 μg/L can be used as a diagnostic cut-off for detecting iron deficiency, but this may not be applicable in cases of inflammation.
• Transferrin receptor level in plasma increases with iron deficiency without being influenced by inflammation and is therefore a good supplement to ferritin measurement.

Iron Management and Supplementation

• 3 recommends prophylactic supplementation with ferrous sulfate (325 mg up to three times daily) in patients with iron deficiency, especially during the acute phase of therapy.
• The study also suggests that intravenous iron dextran may be required when oral supplements are insufficient to meet the extraordinary needs resulting from erythropoiesis.

Hyperferritinemia

• 4 states that elevated serum ferritin, or hyperferritinemia, is a common finding on routine bloodwork and often prompts referral for further evaluation.
• The study suggests that hyperferritinemia does not always represent true iron overload and that the decision to treat such patients should be individualized.

Diagnosis of Iron Deficiency Anemia in the Elderly

• 5 found that in elderly subjects, iron deficiency anemia may develop with higher levels of serum ferritin, and the conventional cutoff of serum ferritin for the diagnosis of iron deficiency anemia in young adults is not appropriate for the elderly population.
• The study suggests that a serum ferritin cutoff level of 100 ng/mL can differentiate patients with and without iron deficiency anemia with a sensitivity of 60% and specificity of 59%.

Iron Absorption from Supplements

• 6 found that iron absorption from supplements is greater with alternate day than with consecutive day dosing in iron-deficient anemic women.
• The study suggests that alternate day dosing of oral iron supplements may be preferable because it sharply increases fractional iron absorption.