What does a ferritin level of 622 ng/mL indicate in a patient with ulcerative colitis?

Interpretation of Ferritin 622 ng/mL in Ulcerative Colitis

A ferritin level of 622 ng/mL in a patient with ulcerative colitis indicates anemia of chronic disease (ACD), reflecting active inflammation rather than iron overload, and requires assessment of disease activity and inflammatory markers to guide treatment. 1

Understanding Ferritin in the Context of Inflammation

Ferritin is an acute phase reactant that becomes elevated during inflammation, making interpretation fundamentally different in ulcerative colitis compared to healthy individuals. 1

Diagnostic Criteria Based on Inflammation Status

The European Crohn's and Colitis Organisation provides clear thresholds for ferritin interpretation in IBD:

• Without inflammation: Ferritin <30 μg/L indicates iron deficiency 1
• With inflammation: Ferritin up to 100 μg/L may still be consistent with iron deficiency 1
• Anemia of chronic disease: Ferritin >100 μg/L combined with transferrin saturation <20% is diagnostic 1

Your patient's ferritin of 622 μg/L far exceeds the 100 μg/L threshold, placing them firmly in the anemia of chronic disease category if anemia is present. 1

What This Level Tells You Clinically

Active Inflammation is Present

A ferritin of 622 μg/L signals significant ongoing inflammatory activity in the ulcerative colitis, regardless of clinical symptoms. 1

• This elevation reflects cytokine-mediated upregulation of ferritin synthesis during inflammation 2
• The level is too high to represent simple iron repletion or mild inflammation 1

Iron Status Assessment Requires Additional Testing

You cannot determine true iron status from ferritin alone at this level—transferrin saturation is essential. 1

Required additional tests include:

• Transferrin saturation (TSAT): If <20%, confirms ACD; if <16%, suggests possible coexisting iron deficiency 1
• C-reactive protein (CRP): Quantifies inflammatory burden 1
• Complete blood count with MCV and RDW: Characterizes anemia type 1
• Soluble transferrin receptor (sTfR): Most reliable test when inflammation is present—elevated in iron deficiency, normal/low in pure ACD 2, 3

Critical Diagnostic Pitfall

Between ferritin 30-100 μg/L, a combination of true iron deficiency and ACD is likely, but at 622 μg/L, pure ACD predominates unless transferrin saturation is severely depressed. 1

• In ulcerative colitis with CRP >10 mg/L, optimal ferritin threshold for iron deficiency diagnosis is 80 μg/L 3
• Your patient's level of 622 μg/L is nearly 8-fold higher than this threshold 3

Therapeutic Implications

Primary Treatment Target

The underlying ulcerative colitis inflammation must be treated first—this is the root cause of the elevated ferritin and any associated anemia. 1, 2

• Optimize IBD therapy to achieve disease remission 1
• Reassess ferritin after inflammation is controlled 1

Iron Supplementation Decision

Do not initiate iron supplementation based on ferritin alone at this level. 1

The algorithm for iron supplementation:

1. Obtain transferrin saturation immediately 1
2. If TSAT <20%: Iron supplementation is recommended in all UC patients with confirmed iron deficiency anemia 1
3. If TSAT ≥20%: Iron stores are adequate; focus solely on treating inflammation 1

Monitoring Strategy

Ferritin levels should decrease as UC inflammation is controlled—failure to decrease suggests inadequate disease control or an alternative diagnosis. 1

• Recheck ferritin, CRP, and hemoglobin after 4-8 weeks of optimized UC therapy 1, 4
• Persistent elevation warrants investigation for other inflammatory conditions or complications 1

Rare but Important Consideration

While extremely unlikely, hereditary hemochromatosis can coexist with ulcerative colitis and present with markedly elevated ferritin. 5

• If transferrin saturation is >50% (especially >90%), consider genetic testing for hemochromatosis 5
• This scenario is rare but critical not to miss, as management differs completely 5