From the Guidelines
Phlebotomy is the recommended treatment for individuals with elevated ferritin levels, particularly those with hereditary hemochromatosis or iron overload conditions, with a target ferritin level of 50-100 μg/L. Treatment typically involves removing 500ml of blood (approximately one unit) every 1-2 weeks until ferritin levels decrease to the target range, as stated in the 2022 EASL clinical practice guidelines on haemochromatosis 1. For maintenance, phlebotomy may continue at less frequent intervals, typically every 2-4 months, based on regular ferritin monitoring.
Key Considerations
- The procedure effectively reduces iron stores because each unit of blood removed contains approximately 200-250mg of iron.
- Patients should stay well-hydrated before and after procedures, consume adequate protein to support hemoglobin regeneration, and maintain regular follow-up appointments to monitor ferritin, hemoglobin, and transferrin saturation levels.
- Phlebotomy works because the body uses stored iron (measured as ferritin) to produce new red blood cells after blood removal, effectively depleting excess iron stores.
- This treatment is particularly important because untreated iron overload can damage multiple organs including the liver, heart, and pancreas, potentially leading to cirrhosis, heart failure, diabetes, and other complications.
Monitoring and Maintenance
- Serum haemoglobin should always be monitored during both induction and maintenance phases, at the time of each bloodletting session, as recommended in the 2022 EASL guidelines 1.
- Serum ferritin should always be monitored to ensure that the target value is achieved and maintained and to avoid overtreatment.
- The frequency of phlebotomy may vary among individuals, depending on the rate of iron accumulation, and should be adjusted based on regular ferritin monitoring, as stated in the 2022 EASL guidelines 1.
Alternative Treatment Options
- Erythrocytapheresis may be considered as an alternative to phlebotomy in selected cases, particularly in patients with severe cardiac iron overload or those who cannot tolerate phlebotomy, as mentioned in the 2022 EASL guidelines 1.
- Iron-chelating drugs, such as deferasirox, may be used as a second-line treatment option in patients who cannot undergo phlebotomy or erythrocytapheresis, but their use should be carefully considered due to potential side effects and limited evidence, as stated in the 2022 EASL guidelines 1.
From the Research
Ferritin and Phlebotomy
- Ferritin is a protein that stores iron in the body, and elevated levels can indicate iron overload [(2,3,4,5,6)].
- Phlebotomy, or the removal of blood from the body, is a common treatment for iron overload disorders, including hereditary hemochromatosis [(2,3,4)].
- The goal of phlebotomy is to reduce the amount of iron in the body by removing iron-rich blood 3.
Diagnosis and Treatment
- Diagnosis of iron overload disorders typically involves laboratory tests, including serum ferritin and transferrin saturation [(2,3,4,5,6)].
- Genetic testing for the HFE mutation can also be performed to confirm a diagnosis of hereditary hemochromatosis [(2,4,6)].
- Treatment with phlebotomy is usually effective in reducing iron stores and improving symptoms 3.
Indications for Phlebotomy
- Phlebotomy is typically indicated for patients with hereditary hemochromatosis or other iron overload disorders [(2,3,4)].
- It may also be used to treat patients with secondary iron overload, such as those with thalassemia or myelodysplastic syndrome 6.
- However, phlebotomy is not always the treatment of choice for elevated serum ferritin, and other causes of hyperferritinemia should be ruled out before initiating treatment 5.