Community Oncologist

I have a myeloma patient off treatment due to severe recurrent UTI's, AKI, poor PS who is now ready to resume therapy with Dara/Pom. Her Hb is 7.7, GFR 29, iron sat 12%, ferritin 1400 (likely had UTI at the time). She has risk factors for bleeding on eliquis and diverticular disease. She has been on intermittent retacrit missed several doses recently but does take oral iron bid. I believe by insurance guidelines and my review of some sources like uptodate iron sat must be over 20% before retacrit should continue. Would you proceed with IV iron even with such an elevated ferritin? I have had this question before in other cases of anemia of chronic disease. What ferritin is to high to hold of on treating as absolute iron deficiency if iron sat is low? Should it be iron sat <20% AND ferritin <100 or iron sat <20% OR ferritin <100 (in which case she should get IV iron)?

Classical Hematology Specialist

I wouldn’t consider it iron deficiency if ferritin that high, so typically I would say both TSAT <20 AND ferritin <100-150. I would imagine the patient does not have features of iron deficiency on smear or MCV? Also PO iron should not be given BID, can have a counterproductive effect. Should be every other day or daily. Consider expanding anemi work up to look for other causes.