Stop Iron Supplementation Immediately
This patient does not have iron deficiency and should discontinue iron supplementation. The laboratory values reveal a paradoxical picture: normal hemoglobin (14.2 g/dL), markedly elevated ferritin (585 µg/L), low serum iron (38 µg/dL), and low transferrin saturation (12.9%)—a pattern consistent with functional iron deficiency or anemia of inflammation, not absolute iron deficiency requiring supplementation 1.
Why Iron Supplementation Should Be Stopped
Ferritin >150 µg/L excludes absolute iron deficiency, even in the presence of inflammation 1. This patient's ferritin of 585 µg/L is nearly four times this threshold, indicating adequate or excessive iron stores 1.
The low transferrin saturation with high ferritin suggests functional iron deficiency (iron sequestration due to inflammation) or iron overload with impaired utilization, not true iron depletion 1.
Continuing oral iron in this setting is futile and potentially harmful, as the body already has sufficient stored iron that is simply not being mobilized effectively 1.
Immediate Management Steps
1. Discontinue Iron Supplementation
Stop all oral iron immediately to prevent further iron accumulation 1.
2. Investigate the Underlying Cause
Screen for inflammatory conditions:
- Check C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR) to identify occult inflammation that could explain the elevated ferritin and functional iron deficiency 1.
- Consider chronic infections, autoimmune diseases, or malignancy as potential causes of elevated ferritin 1.
Evaluate for iron overload syndromes:
- If inflammation markers are normal, consider hereditary hemochromatosis or secondary iron overload 2.
- Genetic testing for HFE mutations may be warranted if clinical suspicion exists 2.
Assess for chronic disease:
- Review for chronic kidney disease, liver disease, or malignancy that could cause anemia of chronic disease with functional iron deficiency 1.
3. Additional Confirmatory Testing
If the diagnosis remains unclear:
- Measure soluble transferrin receptor (sTfR) or reticulocyte hemoglobin content to differentiate true iron deficiency from functional iron deficiency 1.
- The sTfR/log ferritin ratio provides superior discrimination in chronic disease states 1.
4. Monitor Hemoglobin Status
- Recheck complete blood count in 4 weeks after stopping iron to ensure hemoglobin remains stable 1.
- If hemoglobin drops significantly, this suggests ongoing blood loss or another cause of anemia requiring investigation 1.
Common Pitfalls to Avoid
Do not reflexively treat low iron saturation with oral iron when ferritin is elevated—this represents iron dysregulation, not deficiency 1.
Do not assume normal hemoglobin excludes the need for investigation—the elevated ferritin with low iron parameters warrants evaluation for underlying pathology 1.
Ferritin is an acute-phase reactant—elevated levels may indicate inflammation, infection, or malignancy rather than iron overload 1, 2.
Follow-Up Strategy
- Repeat iron studies in 3 months after addressing any identified inflammatory condition to reassess true iron status 1.
- If ferritin remains >300 µg/L persistently, consider hepatology referral for evaluation of iron overload and potential need for phlebotomy or chelation therapy 2.
- Monitor for development of anemia every 3 months for the first year, then every 6 months for 2-3 years to detect any evolving pathology 1.
The key principle here is that iron supplementation treats absolute iron deficiency, not functional iron deficiency or iron dysregulation 1. This patient's iron stores are replete or excessive; the therapeutic focus must shift to identifying and treating the underlying cause of the abnormal iron metabolism 1.