Phlebotomy (Therapeutic Bloodletting) for Iron Overload
The patient is describing phlebotomy (also called therapeutic bloodletting or venesection), a procedure where blood is regularly removed from the body to reduce excess iron stores, most commonly used to treat hereditary hemochromatosis 1.
How It Works
Phlebotomy removes iron-rich red blood cells from circulation, forcing the body to mobilize stored iron to produce new red cells, thereby depleting excess iron stores over time. This is the gold standard treatment for iron overload conditions 1, 2.
Treatment Protocol
The procedure follows a two-phase approach 1:
Induction Phase
- Volume and frequency: 400-500 mL of blood removed weekly or every 2 weeks
- Target: Serum ferritin reduced to 50 μg/L
- Monitoring: Ferritin checked monthly (or every 4th phlebotomy); when ferritin drops below 200 μg/L, check every 1-2 sessions
- Hemoglobin monitoring: Check at each session; reduce frequency if Hb <12 g/dL, discontinue if <11 g/dL
Maintenance Phase
- Frequency: Blood removal every 1-4 months depending on iron reaccumulation rate
- Target: Maintain ferritin 50-100 μg/L (more relaxed targets of <200 μg/L for women, <300 μg/L for men may be tolerated, especially in elderly patients)
- Monitoring: Ferritin every 6 months to maintain target range
Primary Indication: Hemochromatosis
Phlebotomy should be initiated in men with serum ferritin ≥300 μg/L and women with ferritin ≥200 μg/L, regardless of symptoms 2. When started before severe iron overload develops, this prevents:
- Hepatic cirrhosis and liver cancer
- Diabetes mellitus
- Cardiomyopathy
- Joint disease
- Hypogonadism 2
Important Caveats
What Improves with Treatment
Phlebotomy effectively resolves 1, 2:
- Weakness and fatigue
- Elevated liver enzymes
- Right upper quadrant pain
- Skin hyperpigmentation
What May Not Improve
- Established cirrhosis, joint disease, diabetes, and cardiac abnormalities often require additional specific management 2
- In dysmetabolic iron overload syndrome (DIOS), phlebotomy does not improve metabolic parameters and may cause weight gain and fatigue 3
Safety Considerations
- The procedure is generally safe, effective, and low-cost 4
- Avoid iron deficiency: Stop if ferritin drops too low (<20 μg/L can increase iron absorption and cause symptomatic deficiency) 1
- Monitor for fatigue (occurred in 25% of patients in one study) 3
- Check folate and cobalamin periodically in patients requiring numerous venesections 1
Dietary Modifications
Patients should avoid 1:
- Medicinal iron and iron-fortified foods
- Supplemental vitamin C (especially before iron depletion)
- Excess alcohol
- Uncooked seafood (reduces Vibrio infection risk)
- Limit red meat consumption
Dietary modifications do not substitute for phlebotomy but can reduce iron reaccumulation rates 1.