What is the recommended frequency for performing therapeutic phlebotomy?

Therapeutic Phlebotomy Frequency Guidelines

For patients with hemochromatosis, therapeutic phlebotomy should be performed once or twice weekly during the initial iron depletion phase, followed by individualized maintenance phlebotomy ranging from monthly to 1-2 times per year based on the patient's rate of iron reaccumulation. 1, 2

Initial Treatment Phase (Iron Depletion)

• Frequency: One unit of blood (450-500 mL, containing 200-250 mg iron) should be removed once or twice weekly as tolerated 1, 2
• Duration: Continues until target ferritin level of 50-100 μg/L is reached
  • May take months to years depending on severity of iron overload
  • Patients with total body iron stores >30g may require 2-3 years of treatment 1
• Monitoring:
  • Check hemoglobin/hematocrit before each phlebotomy session
  • Avoid reducing hemoglobin/hematocrit to <80% of starting value 1
  • Measure serum ferritin after every 10-12 phlebotomies (approximately every 3 months) 1
  • As target range (50-100 μg/L) is approached, test more frequently to avoid iron deficiency 1, 2

Maintenance Phase

• Frequency: Highly variable between individuals due to differences in iron reaccumulation rates:
  • Some patients require monthly maintenance phlebotomy
  • Others may need only 1-2 units removed per year 1, 2
• Monitoring:
  • Regular ferritin level checks to maintain target of 50-100 μg/L
  • Check hemoglobin before each session
  • Reduce frequency if hemoglobin <12 g/dL
  • Temporarily pause treatment if hemoglobin <11 g/dL 2

Special Considerations

Patients with Advanced Disease

• For patients with cardiac arrhythmias or cardiomyopathy, rapid iron mobilization increases risk of sudden death
• More cautious phlebotomy schedule may be warranted 1

Patients with Cirrhosis

• Continue phlebotomy to target ferritin levels
• Maintain lifelong screening for hepatocellular carcinoma even after iron depletion 1, 2
• Phlebotomy will not reverse established cirrhosis but may reduce portal hypertension 1

Asymptomatic Patients

• Even for C282Y homozygotes with modest ferritin elevation (e.g., 800 μg/L) and normal liver tests, prophylactic phlebotomy is often recommended as it is safe, inexpensive, and may prevent future complications 1

Common Pitfalls to Avoid

1. Overtreatment leading to iron deficiency

   • Never reduce ferritin below 50 μg/L 1, 2
   • Iron deficiency can decrease oxygen-carrying capacity and increase stroke risk 2

2. Inadequate monitoring

   • Failure to check hemoglobin before each session
   • Insufficient ferritin monitoring

3. Premature termination of therapy

   • Stopping before reaching target ferritin levels

4. Vitamin C supplementation

   • Patients should avoid supplemental vitamin C during treatment as it accelerates iron mobilization and may increase toxicity 1, 2

5. Missing hepatocellular carcinoma surveillance

   • Patients with cirrhosis require continued screening even after iron depletion 1, 2

By following these evidence-based guidelines for therapeutic phlebotomy frequency, clinicians can effectively manage iron overload while minimizing complications and optimizing patient outcomes.