How to decrease elevated ferritin levels?

Management of Elevated Ferritin Levels

The most effective approach to decrease elevated ferritin levels is therapeutic phlebotomy, with a target ferritin level of 50-100 μg/L. 1, 2

Primary Treatment: Therapeutic Phlebotomy

Induction Phase

• Initial protocol: Weekly phlebotomy of 400-500 ml of blood until target ferritin is reached 1
• Monitoring during induction:
  • Check hemoglobin at each phlebotomy session
  • Measure ferritin monthly or after every 4th phlebotomy
  • When ferritin drops below 200 μg/L, check levels every 1-2 sessions 1, 2
• Safety parameters:
  • If hemoglobin <12 g/dL: Decrease frequency of phlebotomy
  • If hemoglobin <11 g/dL: Temporarily discontinue phlebotomy 1

Maintenance Phase

• Frequency: Every 1-4 months based on individual iron reaccumulation rate 1, 2
• Target: Maintain ferritin between 50-100 μg/L 1
• Monitoring: Check ferritin every 6 months during maintenance 2

Dietary and Lifestyle Modifications

While phlebotomy is the cornerstone of treatment, dietary modifications can help reduce iron reaccumulation:

• Avoid:

  • Iron supplements and iron-fortified foods 1
  • Vitamin C supplements (>500 mg/day) as they enhance iron absorption 1
  • Raw shellfish (risk of Vibrio vulnificus infection in iron overload) 1

• Limit:

  • Red meat consumption 1
  • Alcohol intake (suppresses hepcidin expression, increasing iron absorption) 1

Alternative Approaches

For patients who cannot tolerate phlebotomy, alternative options include:

1. Erythrocytapheresis: Selectively removes red blood cells, requiring fewer procedures than phlebotomy (1.9 vs 3.3 procedures per year) 3

2. Iron chelation therapy: Only for patients with contraindications to phlebotomy

   • Deferoxamine (subcutaneous or IV) can be used, but is not indicated for primary hemochromatosis 4

Special Considerations

• Elderly patients: May tolerate more relaxed ferritin targets (200-300 μg/L) 1
• Monitoring for complications: Regular assessment for end-organ damage is essential 2
• Nutritional monitoring: Check folate and vitamin B12 levels in patients requiring numerous phlebotomies 1

Common Pitfalls

1. Overtreatment: Excessive phlebotomy can lead to symptomatic iron deficiency 1
2. Inadequate monitoring: Failure to check hemoglobin before each phlebotomy can lead to anemia 1
3. Relying solely on diet: Dietary modifications alone are insufficient to reduce significantly elevated ferritin 1, 2
4. Ignoring unexpected changes: Fluctuations in ferritin levels should be investigated as they may indicate other conditions 1

Therapeutic phlebotomy remains the gold standard for reducing ferritin levels, with strong evidence showing its efficacy in preventing complications of iron overload when initiated early and maintained consistently 2, 5.