From the Guidelines
Treatment for elevated ferritin should focus on therapeutic phlebotomy, removing 400-500ml of blood weekly or every 2 weeks during the induction phase, until serum ferritin levels reach 50 lg/L, and then maintaining levels between 50-100 lg/L during the maintenance phase, as recommended by the EASL clinical practice guidelines on haemochromatosis 1.
Key Considerations
- The target for iron depletion during induction is a serum ferritin of 50 lg/L, but not lower to avoid iron deficiency 1.
- In the maintenance phase, serum ferritin can be maintained with some flexibility in the range of 50-100 lg/L 1.
- Phlebotomy should be performed weekly (or fortnightly) until iron stores are depleted, and then maintenance phlebotomies can be done every 1-4 months, depending on the patient’s iron status 1.
- Serum haemoglobin should always be monitored during both induction and maintenance phases, at the time of each bloodletting session, and if haemoglobin concentrations are <12 g/dl, the frequency of phlebotomy should be decreased 1.
Treatment Options
- Therapeutic phlebotomy is the mainstay treatment for primary iron overload (hemochromatosis) 1.
- Iron chelation therapy with medications like deferasirox, deferoxamine, or deferiprone may be used for those who cannot tolerate phlebotomy 1.
- Erythrocytapheresis is a therapeutic option, especially in selected cases, and may reduce fatigue and serum iron parameters more effectively than phlebotomy 1.
Lifestyle Modifications
- Avoiding alcohol, limiting vitamin C supplements, and reducing red meat consumption can help manage ferritin levels 1.
- Regular monitoring of ferritin, transferrin saturation, and hemoglobin is essential during treatment to prevent overtreatment and anemia 1.
From the FDA Drug Label
The recommended initial dose of deferasirox tablets for patients 2 years of age and older with eGFR greater than 60 ml/min/1. 73 m2 is 14 mg per kg body weight orally, once daily. Monitor serum ferritin monthly and adjust the dose of deferasirox tablets, if necessary, every 3 to 6 months based on serum ferritin trends Use the minimum effective dose to achieve a trend of decreasing ferritin Make dose adjustments in steps of 3.5 or 7 mg per kg and tailor adjustments to the individual patient’s response and therapeutic goals.
To treat elevated ferritin, deferasirox can be used. The initial dose is 14 mg per kg body weight orally, once daily. The dose should be adjusted based on serum ferritin trends, with the goal of achieving a decreasing trend. Dose adjustments should be made in steps of 3.5 or 7 mg per kg. It is essential to use the minimum effective dose to maintain iron burden in the target range 2.
- Key considerations:
- Monitor serum ferritin monthly
- Adjust dose every 3 to 6 months as needed
- Use the minimum effective dose to achieve a trend of decreasing ferritin
- Dose adjustments should be made in steps of 3.5 or 7 mg per kg
- Tailor adjustments to the individual patient’s response and therapeutic goals.
From the Research
Treatment Options for Elevated Ferritin
- Iron chelation with deferasirox has been shown to be a safe and effective means of substantially lowering ferritin levels in patients with hyperferritinemia and hemochromatosis-associated HFE genotypes 3.
- Deferasirox has been found to be well tolerated and effective in reducing iron burden in patients with hereditary hemochromatosis, and could be a safe alternative to phlebotomy in selected patients 4.
- In patients with iron overload secondary to hereditary hemochromatosis, deferasirox has been shown to significantly decrease median serum ferritin, mean transferrin saturation, median liver iron concentration, and mean alanine aminotransferase 4.
Causes and Significance of Hyperferritinemia
- Hyperferritinemia can be caused by a variety of conditions, including non-human immunodeficiency virus infection, solid tumor, liver dysfunction, renal failure, and hematological malignancy 5.
- The level of serum ferritin is determined by the underlying conditions to a certain extent, but the variation is significant, and patients with hyperferritinemia frequently have multiple conditions 5.
- Hyperferritinemia is a non-specific finding, and differentiation of the presence or absence of an associated iron overload is essential, although often proves to be complex 6.
Pharmacokinetics and Treatment
- Deferasirox pharmacokinetics can be affected by individual factors, such as genetic background and clinical history, and therapeutic drug monitoring may be necessary to understand reasons for non-response and set individualized treatment 7.
- Good efficacy and normalization of iron markers can be obtained with long-term deferasirox treatment, even in patients with complex conditions 7.