From the Guidelines
Low ferritin, copper, and B12 levels in a patient with complex autoimmune disease, despite normal hematocrit, likely stem from multiple factors related to their autoimmune condition, and I recommend a comprehensive approach including supplementation and dietary changes to address these deficiencies. These deficiencies may result from malabsorption issues (particularly if the patient has autoimmune gastritis, celiac disease, or inflammatory bowel disease), chronic inflammation that sequesters iron, reduced dietary intake, or medication interactions 1.
Causes of Deficiencies
- Malabsorption issues due to autoimmune gastritis, celiac disease, or inflammatory bowel disease
- Chronic inflammation that sequesters iron
- Reduced dietary intake
- Medication interactions
Treatment Approach
For treatment, I recommend:
- Supplementation: ferrous sulfate 325mg daily (or every other day if GI side effects occur), copper gluconate 2mg daily, and vitamin B12 1000mcg daily orally or 1000mcg monthly injections if absorption is severely compromised
- Dietary changes: increase dietary sources of these nutrients - red meat, legumes, and leafy greens for iron; shellfish, nuts, and whole grains for copper; and animal products for B12
- Laboratory monitoring: repeat testing in 2-3 months to assess improvement
- Optimal management of the underlying autoimmune condition to prevent perpetuation of these deficiencies
- Evaluation of proton pump inhibitors or H2 blockers, as they can reduce absorption of these nutrients 1
Importance of Inflammation Status
The evaluation of anaemia in any given patient is always incomplete if the inflammatory status is not clearly defined, and measurements of inflammatory parameters that are independent of iron metabolism (ESR, CRP) should be carried out to aid diagnosis 1.
Diagnosis of Iron Deficiency
Diagnostic criteria for iron deficiency depend on the level of colonic inflammation, and in patients without any evidence of inflammation, a serum ferritin level < 30 mcg/L or transferrin saturation < 16% define iron deficiency 1.
Monitoring and Adjustment
Regular monitoring of the patient's response to treatment and adjustment of the treatment plan as needed is crucial to ensure optimal management of these deficiencies and prevention of potential complications 1.
From the Research
Low Ferritin, Copper, and B12 Levels
- Low ferritin levels can be an indicator of iron deficiency, which can occur in patients with complex autoimmune diseases 2.
- Copper deficiency can also be present in patients with autoimmune diseases, although the provided studies do not specifically address this topic.
- Low B12 levels can be caused by various factors, including autoimmune disorders, but the provided studies do not discuss this topic in detail.
Relationship between Autoimmune Diseases and Ferritin Levels
- Ferritin levels can be elevated in patients with autoimmune diseases, such as autoimmune hepatitis, due to inflammation and acute phase reactions 3, 4.
- However, low ferritin levels can also occur in patients with complex autoimmune diseases, which may be related to iron deficiency or other factors 5, 2.
- The provided studies suggest that ferritin levels can be influenced by various factors, including inflammation, iron stores, and immune response regulation 5, 2, 6.
Diagnostic Considerations
- Elevated ferritin levels can be a non-specific finding and may require further evaluation to determine the underlying cause 2.
- In patients with complex autoimmune diseases, a comprehensive diagnostic workup may be necessary to determine the cause of low ferritin, copper, and B12 levels 3, 4.
- A normal hematocrit level may not necessarily rule out iron deficiency or other underlying conditions, and further testing may be required to determine the cause of low ferritin and other nutrient levels 2.