Reasoning GP · Algorithm · 1-page summary
Raised ferritin in adults
For: adults with a raised serum ferritin in primary care. Not for: low ferritin or iron deficiency (use the low ferritin algorithm); known transfusional iron overload is managed by specialist haematology.
Core rule: ferritin is an acute-phase protein. Read it with CRP and transferrin saturation; a high ferritin with a normal saturation is usually inflammation, alcohol or metabolic liver disease, not iron overload. Very high ferritin in an ill patient is HLH until shown otherwise.
0Stop — act today — before anything else
- Haemodynamically unstable, hypoxic, confused, bleeding, organ failure or clinically septic → 999 / ED
- Ferritin >10,000 µg/L + fever, cytopenias, splenomegaly, liver dysfunction, coagulopathy or organ failure → suspect HLH/MAS → Same-day haematology or acute medicine discussion, even if stable. Untreated HLH is rapidly fatal.
- Blood film suggesting acute leukaemia (blast cells) → Same-day haematology
- While arranging: FBC, film, LFTs, U&E, CRP, coagulation/fibrinogen, triglycerides, LDH. Ferritin alone does not diagnose HLH; do not wait for a bone marrow.
1Triage by ferritin level
| Ferritin | Action |
|---|---|
| <1,000 µg/L | Repeat if appropriate; work-up as block 3; manage the cause and repeat. Persistent and unexplained, especially approaching 1,000 → refer. |
| ≥1,000 µg/L | Repeat/confirm if appropriate; if persistent and unexplained → specialist referral whether or not haemochromatosis is confirmed. LFTs, liver imaging per local pathway. |
| >10,000 µg/L | Assess for organ failure, sepsis, HLH/MAS, Still disease, liver injury, malignancy → block 0. |
2Screen — serious causes
- Haemochromatosis with organ damage: ferritin >1,000 + raised ALT/AST, hepatomegaly, bronzing or diabetes; or MCP arthritis, bronzing, diabetes, hypogonadism → Urgent (same-week) hepatology / iron-overload service
- Unexplained lymphadenopathy or splenomegaly → consider suspected cancer pathway (NG12, lymphoma). Hepatosplenomegaly or generalised nodes → very urgent FBC within 48 h.
- Spiking fever, salmon-pink rash, arthritis, neutrophilia, liver dysfunction (possible Still disease, once infection, malignancy and HLH excluded) → Same-day rheumatology / acute medicine
- Many transfusions (thalassaemia, sickle cell, myelodysplasia) → specialist haematology; heart failure or arrhythmia → Urgent specialist / cardiology
3Assess
☐ Ferritin with CRP/ESR ☐ Transferrin saturation, serum iron, transferrin/TIBC (fasting not routinely essential; repeat a borderline result) ☐ FBC, U&E/eGFR, LFTs + GGT, HbA1c ☐ AUDIT-C, BMI, BP; iron supplements, IV iron, transfusions; family history ☐ Hepatitis B/C and liver ultrasound if LFTs abnormal, hepatomegaly or risk factors
TFTs, electrophoresis and malignancy tests only if symptoms or results point there. Never send HFE testing without transferrin saturation.
4Classify — transferrin saturation decides
- Reactive (saturation normal; commonest) — inflammation, infection, liver or renal disease, malignancy → treat the cause; recheck ferritin + CRP once CRP has normalised.
- Alcohol — often missed; ask AUDIT-C, track GGT; repeat LFTs + ferritin after 3 months' abstinence.
- Metabolic (obesity, insulin resistance, fatty liver; saturation normal) → lifestyle (NG49); no venesection.
- Iron overload — saturation persistently >50% men / >40% women with raised ferritin → HFE testing (C282Y/H63D) or specialist advice. Genotype alone does not diagnose.
- C282Y/H63D or H63D/H63D — low penetrance; look for other causes. C282Y carrier — no routine monitoring.
- Uncertain — persistent unexplained rise → hepatology / iron-overload referral.
5Treat today — only these
- Alcohol: AUDIT-C, brief intervention, community alcohol service if needed.
- Metabolic: weight loss, 150 min/week aerobic exercise; optimise diabetes and lipids.
- Stop iron supplements and iron-containing multivitamins unless indicated; avoid high-dose vitamin C.
- Haemochromatosis: balanced diet, no extreme iron restriction; no raw oysters or shellfish if significant overload or liver disease (Vibrio). Venesection is specialist-led.
6Refer routinely
- Hepatology / iron-overload service: persistent unexplained ferritin ≥1,000; raised saturation + raised ferritin; C282Y homozygote with raised ferritin; abnormal LFTs or hepatomegaly.
- Haemochromatosis cirrhosis: liver ultrasound every 6 months (± AFP); new nodule or rising AFP → refer immediately.
- Relatives of a C282Y homozygote: offer adults HFE genotype, ferritin and saturation; no routine testing of children.
- Pregnancy: venesection usually paused; cirrhosis, cardiac iron or severe overload → specialist obstetric / hepatology care.
7Never reassure by
- A ferritin read without a CRP.
- "It's just inflammation" without a recheck once CRP is normal.
- Ancestry — it never rules out testing or referral.
- An HFE genotype on its own, either way.
- Lowering a reactive or metabolic ferritin with venesection.
- Skipping the alcohol history.
8Safety-net — say it, then document it
999 “Call 999 if you become confused, very breathless, collapse or are bleeding.” Same day “Contact us today if you get a fever, unusual bruising or bleeding, yellow skin, or feel very unwell.” Give the raw-shellfish warning in writing at a haemochromatosis diagnosis; book the recheck with a date.
Result received remotely: ferritin >10,000, or very high with fever or abnormal FBC → speak to the patient the same day; do not file it as a routine result.
✓Safe to manage in primary care only if — all five, documented
No block 0–2 row applies; patient well
CRP checked with ferritin
Transferrin saturation done and read
Ferritin <1,000, or referral made
Cause named, recheck dated, safety-net given
Summary of the full Reasoning GP high ferritin algorithm, which holds HFE interpretation, staging, venesection, chelation and evidence. Sources: BSH raised serum ferritin and haemochromatosis guidelines (2018); EASL haemochromatosis 2022; NICE NG50, NG49, NG12 (updated April 2026); BSH 2021 iron overload; EULAR/PReS 2024. Clinical reference — follow local pathways and check doses: NICE/SPC, BNF.