What is the treatment for high ferritin levels?

From the Guidelines

Therapeutic phlebotomy is the primary treatment for high ferritin levels, aiming to reduce serum ferritin to a target range of 50-100 lg/L, as recommended by the most recent guidelines 1. The treatment for high ferritin levels depends on the underlying cause, with therapeutic phlebotomy being the primary treatment for conditions like hemochromatosis.

• This procedure involves removing about 400-500 mL of blood every 1-2 weeks until ferritin levels normalize, followed by maintenance phlebotomies every 1-4 months, depending on the patient’s iron status 1.
• The target for iron depletion during induction is a serum ferritin of 50 lg/L, but not lower to avoid iron deficiency, and in the maintenance phase, serum ferritin can be maintained with some flexibility in the range of 50-100 lg/L 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 and in specific cases a reduction in volume should be considered 1.
• Serum ferritin should always be monitored to ensure that the target value is achieved and maintained and to avoid overtreatment, and during the induction phase, serum ferritin should be measured every month (or after every 4th phlebotomy) 1.
• It is also advisable to periodically check plasma folate and plasma cobalamin, especially in patients who require numerous venesections; if necessary, vitamin supplements should be administered 1.
• For secondary iron overload, chelation therapy may be used, with medications like deferasirox (Exjade, 20-40 mg/kg/day orally), deferoxamine (Desferal, 20-60 mg/kg/day subcutaneously), or deferiprone (Ferriprox, 75-100 mg/kg/day orally in three divided doses) 1.
• If inflammation is causing elevated ferritin, treating the underlying inflammatory condition is essential, and dietary modifications can help, including limiting iron-rich foods, vitamin C (which enhances iron absorption), and alcohol 1.
• Regular monitoring of ferritin levels, complete blood counts, and liver function is important during treatment, and patients should stay hydrated before phlebotomy sessions and report any side effects from chleation therapy, which can include gastrointestinal issues, rash, or kidney/liver problems 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

Initiating Therapy: 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.

During Therapy: Monitor serum ferritin monthly and adjust the dose of deferasirox tablets, if necessary, every 3 to 6 months based on serum ferritin trends

The treatment for high ferritin levels due to transfusional iron overload is deferasirox. The recommended initial dose is 14 mg per kg body weight orally, once daily. The dose should be adjusted based on serum ferritin levels, with the goal of achieving a trend of decreasing ferritin. 2

• Key points:
  • Deferasirox is used to treat transfusional iron overload.
  • The initial dose is 14 mg per kg body weight orally, once daily.
  • The dose should be adjusted based on serum ferritin levels.
  • Monitor serum ferritin monthly and adjust the dose every 3 to 6 months as needed.

From the Research

Treatment for High Ferritin Levels

The treatment for high ferritin levels depends on the underlying cause of the condition.

• In cases of hemochromatosis, the first-line therapy involves regular and life-long phlebotomy to remove iron from the blood, which improves the prognosis and may prevent the development of end-stage liver disease such as cirrhosis and hepatocellular carcinoma 3.
• For patients with chronic anemia that prevents initiation of phlebotomy, iron chelation with deferasirox has been shown to be a safe and effective means of substantially lowering ferritin levels 4.
• In cases where hyperferritinemia is caused by inflammation or other conditions, treatment of the underlying condition is necessary to reduce ferritin levels.

Diagnosis of High Ferritin Levels

Diagnosis of high ferritin levels is facilitated by combining ferritin with elevated fasting transferrin saturation, genetic testing, and family screening 3.

• A low fecal iron content during therapeutic iron depletion reduces colonic inflammation and oxidative stress 3.
• Serum ferritin is a commonly used clinical biochemical parameter and hyperferritinemia is used as a surrogate marker for iron overload, acute or chronic inflammation, malignancy or cell death 5.

Causes of High Ferritin Levels

High ferritin levels can be caused by a variety of conditions, including:

• Hemochromatosis, a genetic disorder that leads to iron overload 3, 6
• Inflammatory conditions such as adult-onset Still's disease, systemic juvenile idiopathic arthritis, and hemophagocytic lymphohistiocytosis/macrophage activation syndrome 7
• Malignancy 7
• Iron-overload syndromes 7
• Anemia of chronic inflammation 7