What is the treatment for elevated iron levels (hyperferritinemia)?

Treatment of Hyperferritinemia (Elevated Iron Levels)

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

Diagnostic Approach Before Treatment

Before initiating treatment, it's essential to determine the cause of hyperferritinemia:

1. Distinguish between primary and secondary iron overload:

   • Check transferrin saturation:
     • High (>45%): Suggests hereditary hemochromatosis 2, 1
     • Normal/low: Consider other causes (inflammatory conditions, chronic liver disease, metabolic syndrome) 3

2. Additional testing to consider:

   • HFE gene testing for C282Y and H63D mutations
   • Liver function tests
   • Inflammatory markers (CRP)
   • Fasting glucose (screen for diabetes)
   • Cardiac evaluation if symptoms suggest cardiomyopathy 1

Treatment Algorithm

1. Hereditary Hemochromatosis or Confirmed Iron Overload

• Initial Phlebotomy Phase:

  • Remove 450-500 mL of blood weekly 2, 1
  • Check hematocrit before each phlebotomy; allow no more than 20% drop from prior level 2
  • Monitor serum ferritin every 10-12 phlebotomies 2
  • Continue until serum ferritin falls below 50 μg/L 2, 1

• Maintenance Phase:

  • Continue phlebotomy at intervals to maintain serum ferritin between 25-50 μg/L 2
  • Monitor ferritin levels every 3-4 months 1

2. Secondary Iron Overload Due to Dyserythropoiesis

• Iron Chelation Therapy:
  • Deferoxamine at 20-40 mg/kg body weight per day 2
  • Consider deferasirox for oral administration
  • Caution: Monitor for bone marrow suppression, renal/hepatic dysfunction, and hypersensitivity reactions with chelation therapy 4

3. Hyperferritinemia Without Significant Iron Overload

• Treat underlying cause:

  • Address inflammatory conditions
  • Manage chronic liver disease
  • Treat metabolic syndrome components

• Consider lactoferrin supplementation:

  • 200 mg once or twice daily before meals has shown efficacy in reducing serum ferritin levels in non-hemochromatosis hyperferritinemia 5

Monitoring During Treatment

• Regular laboratory assessment:

  • Hemoglobin/hematocrit at each phlebotomy session
  • Serum ferritin levels
  • Liver function tests
  • Blood glucose levels

• Specialized monitoring:

  • Consider liver biopsy or transient elastography to assess fibrosis in patients with ferritin >1000 μg/L 1
  • Regular screening for hepatocellular carcinoma in patients with cirrhosis 2, 1
  • Cardiac MRI in severe iron overload cases 1

Important Precautions

• Avoid vitamin C supplements during phlebotomy or chelation therapy as they accelerate iron mobilization and may increase free-radical activity 2
• Watch for overchelation: If serum ferritin falls below 500 μg/L, interrupt therapy and monitor monthly 4
• Monitor elderly patients more frequently for toxicity with chelation therapy 4
• Be alert for severe cutaneous adverse reactions with chelation therapy, including Stevens-Johnson syndrome 4

Alternative Treatment Options

• Therapeutic erythrocytapheresis:
  • Can remove up to 1000 mL erythrocytes per session (vs. 250 mL with phlebotomy)
  • Reduces total number and duration of treatments by approximately 70%
  • Consider for patients with severe iron overload requiring intensive treatment 6

Dietary and Lifestyle Modifications

• Avoid iron supplements and iron-fortified foods
• Limit red meat consumption
• Restrict alcohol intake
• Avoid raw seafood (especially in patients with liver disease) 7

By following this treatment approach, most patients with hyperferritinemia will achieve a negative iron balance and experience improvement in symptoms and laboratory parameters, including liver function tests 8.