From the Guidelines
Elevated ferritin levels require treatment only when associated with iron overload conditions, and the primary treatment is phlebotomy to achieve a target ferritin level of 50-100 lg/L. The approach to managing elevated ferritin levels depends on the underlying cause, and treatment is necessary when hyperferritinemia is associated with iron overload conditions like hereditary hemochromatosis 1. According to the 2011 practice guideline by the American Association for the Study of Liver Diseases, patients with hemochromatosis and iron overload should undergo therapeutic phlebotomy weekly to achieve a target ferritin level of 50-100 lg/L 1.
Key Considerations
- The decision to treat elevated ferritin levels depends on the presence of iron overload and the underlying cause of hyperferritinemia.
- Phlebotomy is the primary treatment for hereditary hemochromatosis, with a target ferritin level of 50-100 lg/L 1.
- In the absence of indicators suggestive of significant liver disease, C282Y homozygotes with elevated ferritin levels (<1000 lg/L) can proceed to phlebotomy without a liver biopsy 1.
- Patients with end-organ damage due to iron overload should undergo regular phlebotomy to the same endpoints as indicated above 1.
Treatment Approach
- Phlebotomy is the primary treatment for iron overload conditions, with a target ferritin level of 50-100 lg/L 1.
- Dietary adjustments are unnecessary during treatment, and vitamin C supplements and iron supplements should be avoided 1.
- Patients with hemochromatosis and iron overload should be monitored for reaccumulation of iron and undergo maintenance phlebotomy 1.
From the FDA Drug Label
Deferasirox tablets therapy should only be considered when a patient has evidence of chronic transfusional iron overload. The evidence should include the transfusion of at least 100 mL/kg of packed red blood cells (e.g., at least 20 units of packed red blood cells for a 40 kg person or more in individuals weighing more than 40 kg), and a serum ferritin consistently greater than 1000 mcg/L If the serum ferritin falls below 1000 mcg/L at 2 consecutive visits, consider dose reduction, especially if the deferasirox tablets dose is greater than 17.5 mg/kg/day If the serum ferritin falls below 500 mcg/L, interrupt deferasirox tablets therapy and continue monthly monitoring.
Elevated ferritin levels require treatment when they are consistently greater than 1000 mcg/L in patients with chronic transfusional iron overload. The treatment goal is to reduce serum ferritin levels to a target range, and the minimum effective dose of deferasirox should be used to achieve this goal 2.
- Key points to consider:
- Serum ferritin levels should be monitored monthly to assess the need for treatment and to adjust the dose of deferasirox.
- Treatment should be interrupted if serum ferritin levels fall below 500 mcg/L.
- The dose of deferasirox should be reduced or interrupted if serum ferritin levels fall below 1000 mcg/L at two consecutive visits 2.
From the Research
Elevated Ferritin Levels and Treatment
Elevated ferritin levels can be caused by various conditions, including iron overload, inflammation, and malignancy 3, 4, 5, 6, 7. The need for treatment depends on the underlying cause of the elevated ferritin level.
Conditions Requiring Treatment
- Iron overload syndromes, such as hereditary hemochromatosis, may require treatment with venesection or chelation therapy 4, 5.
- Dysmetabolic iron overload syndrome (DIOS) or alcohol-related hemosiderosis can be treated with venesection in selected cases if there is a significant deposition of iron in the liver on MRI 4.
- Hemophagocytic lymphohistiocytosis/macrophage activation syndrome (HLH/MAS) is a medical emergency that requires prompt diagnosis and treatment 7.
Diagnostic Approach
- A full clinical examination, measurement of waist circumference, and simple biological tests, including transferrin saturation, can help determine the underlying cause of hyperferritinemia 4, 5.
- Magnetic resonance imaging (MRI) can be used to assess iron content in the liver and guide treatment decisions 4, 5.
- An algorithm for the investigation of hyperferritinemia can facilitate diagnosis and management in both primary and inpatient care 4, 6.
Treatment Principles
- Treatment of iron overload typically involves reducing iron stores through venesection or chelation therapy 5.
- Chelators, such as deferasirox, may be used in iron overload associated with anemia 5.
- Deferoxamine (parenteral route) is the treatment of choice for severe iron overload or emergency conditions 5.