What is the treatment for elevated ferritin levels?

Treatment for Elevated Ferritin Levels

The primary treatment for elevated ferritin due to iron overload is therapeutic phlebotomy (removal of 500 mL blood weekly), with a target ferritin level of 50-100 μg/L. 1

Diagnostic Approach Before Treatment

Before initiating treatment, it's crucial to determine whether elevated ferritin represents:

1. True iron overload: Characterized by TSAT >45% and ferritin consistently >1000 ng/mL
2. Inflammatory response: Characterized by TSAT <20% and elevated inflammatory markers

Essential laboratory workup includes:

• Complete iron studies (ferritin, TSAT)
• Liver function tests
• Complete blood count
• Inflammatory markers (CRP, ESR) 1

Treatment Algorithm Based on Etiology

For True Iron Overload (TSAT >45%, ferritin >1000 ng/mL)

1. Therapeutic phlebotomy:

   • Weekly removal of 500 mL blood
   • Target ferritin level: 50-100 μg/L
   • Only initiate when hemoglobin >11 g/dL 1
   • Contraindicated in patients with anemia (Hb <11 g/dL)

2. Iron chelation therapy (for patients who cannot tolerate phlebotomy):

   • Deferasirox: Monitor for bone marrow suppression, renal toxicity, and hypersensitivity reactions 2
   • Deferoxamine: Less commonly used; monitor for auditory/ocular toxicity and renal dysfunction 3

3. Lifestyle modifications:

   • Avoid iron supplementation and iron-fortified foods
   • Limit red meat consumption
   • Avoid vitamin C supplements >200 mg/day with meals (enhances iron absorption)
   • Restrict alcohol intake during iron depletion phase 1

For Secondary Hyperferritinemia (TSAT <20%, elevated inflammatory markers)

1. Treat underlying condition:

   • Infections
   • Inflammatory disorders
   • Malignancies
   • Liver disease 4, 5

2. Avoid iron depletion therapy unless iron overload is confirmed 1

Monitoring During Treatment

1. Initial phase:

   • Check ferritin and TSAT every 3 months
   • Monitor hemoglobin and hematocrit before each phlebotomy
   • Regular CBC monitoring (every 1-2 months initially)
   • Liver function tests every 3 months 1

2. Maintenance phase (when approaching target ferritin):

   • More frequent monitoring of ferritin and hemoglobin
   • Adjust phlebotomy frequency based on response
   • Avoid overchelation (serum ferritin <500 μg/L) 1

Special Considerations

1. Risk of overchelation: If serum ferritin falls below 500 μg/L, interrupt therapy and monitor monthly 1, 2

2. Anemia management during treatment:

   • If anemia develops, extend phlebotomy interval
   • Consider adjunctive erythropoietin therapy
   • Target hemoglobin: 11.0-12.0 g/dL 1

3. Cardiac iron assessment:

   • Consider cardiac MRI T2* for patients with severe iron overload
   • Particularly important in transfusion-dependent disorders 4

Pitfalls and Caveats

1. Misdiagnosis of iron overload: Many conditions cause hyperferritinemia without true iron overload (infections, inflammation, malignancy, liver disease) 5, 6

2. Inappropriate phlebotomy: Initiating phlebotomy in patients with secondary hyperferritinemia can worsen anemia without addressing the underlying cause 1

3. Overlooking multiple etiologies: 41-70% of patients with hyperferritinemia have multiple underlying causes 6

4. Gastric glandular siderosis: Finding ≥5% gastric glandular siderosis on biopsy should trigger workup for systemic iron overload 7

5. Medication risks: Iron chelators carry significant risks including renal toxicity, bone marrow suppression, and hypersensitivity reactions; close monitoring is essential 2, 3

By following this structured approach to diagnosis and treatment, clinicians can effectively manage elevated ferritin levels while minimizing risks associated with inappropriate therapy.