How to manage hyperferritinemia with iron overload?

Management of Hyperferritinemia with Iron Overload

Therapeutic phlebotomy is the first-line treatment for hyperferritinemia with iron overload, with a target ferritin level of 50-100 μg/L to prevent organ damage and improve survival. 1

Assessment of Iron Status

Your laboratory values show:

• Iron: 57 μg/dL
• TIBC: 210 μg/dL
• Iron saturation: 27%
• Ferritin: 477 μg/L

These results indicate hyperferritinemia with normal iron saturation. This pattern requires careful evaluation as it could represent:

1. Early hemochromatosis
2. Secondary iron overload
3. Inflammatory hyperferritinemia
4. Metabolic syndrome-associated hyperferritinemia

Treatment Algorithm

Step 1: Confirm Iron Overload

• Transferrin saturation (27%) is not elevated (normal range typically 20-45%)
• Ferritin is elevated at 477 μg/L
• Consider additional testing:
  • HFE gene testing for C282Y and H63D mutations
  • Liver function tests to assess for liver damage
  • Inflammatory markers (CRP) to rule out inflammatory causes

Step 2: Initiate Phlebotomy

• For confirmed iron overload, begin therapeutic phlebotomy:
  • Remove 450-500 mL of blood (containing 200-250 mg of iron) weekly 2
  • Monitor hemoglobin and hematocrit at each session
  • Continue until ferritin reaches target level of 50-100 μg/L 1

Step 3: Maintenance Therapy

• Once target ferritin is achieved, implement maintenance phlebotomy:
  • Typically 3-4 phlebotomies per year for men, 1-2 for women 2
  • Monitor ferritin every 3-4 months 1
  • Adjust frequency based on ferritin trends

Dietary Modifications

• Avoid iron supplements and iron-fortified foods
• Limit red meat consumption
• Restrict alcohol intake (increases iron absorption) 2
• Avoid vitamin C supplements, especially before meals (enhances iron absorption) 1
• Avoid multivitamin tablets containing iron 2

Monitoring Parameters

• Ferritin: Every 3-4 months during maintenance phase
• Hemoglobin: At each phlebotomy session
• Liver function tests: Regularly to assess improvement
• Transferrin saturation: Periodically to assess iron status

Special Considerations

For Patients Who Cannot Undergo Phlebotomy

If phlebotomy is contraindicated (severe anemia, hemodynamic instability, malignancy):

• Consider iron chelation therapy with:
  • Deferasirox (oral): Starting dose 14 mg/kg/day for transfusional iron overload 3
  • Deferoxamine: For severe iron overload, administered subcutaneously or intravenously 2

Organ-Specific Monitoring

• For patients with ferritin >1000 μg/L: Consider liver biopsy or non-invasive methods (transient elastography) to assess for fibrosis 2
• For patients with cirrhosis: Regular screening for hepatocellular carcinoma 2
• Consider cardiac MRI for patients with severe iron overload to assess cardiac iron deposition 2

Common Pitfalls

1. Misinterpreting elevated ferritin: Not all hyperferritinemia indicates iron overload. Inflammation, liver disease, and metabolic syndrome can elevate ferritin without true iron excess 1

2. Overtreating: Reducing ferritin below 50 μg/L can lead to symptomatic iron deficiency 1

3. Undertreating: Inadequate phlebotomy can allow continued organ damage 1

4. Missing underlying conditions: Hyperferritinemia may be secondary to other conditions requiring specific treatment 4

By following this structured approach, hyperferritinemia with iron overload can be effectively managed to prevent complications and improve long-term outcomes.