Therapeutic Phlebotomy Frequency Guidelines
Therapeutic phlebotomy should be performed weekly or biweekly (once or twice per week) during the initial iron depletion phase, followed by individualized maintenance phlebotomy every 1-4 months based on the patient's rate of iron reaccumulation. 1
Initial Iron Depletion Phase
- One unit of blood (approximately 400-500 mL) should be removed weekly or biweekly as tolerated during the initial phase of treatment 1
- Hemoglobin or hematocrit must be checked before each phlebotomy to ensure it does not fall below 80% of the starting value 1
- If hemoglobin falls below 12 g/dL, reduce the frequency of phlebotomy 1
- If hemoglobin falls below 11 g/dL, temporarily discontinue phlebotomy and reassess later 1
- Monitor serum ferritin after every 10-12 phlebotomies (approximately every 3 months) during initial treatment 1
- When ferritin decreases below 200 μg/L, check levels more frequently (every 1-2 sessions) 1
- The initial depletion phase may take up to 2-3 years for patients with significant iron overload (>30g total body iron) 1
Maintenance Phase
- Once the target ferritin level of 50-100 μg/L is reached, transition to maintenance phlebotomy 1, 2
- The frequency of maintenance phlebotomy varies significantly among individuals due to variable rates of iron reaccumulation 1, 3
- Some patients require monthly maintenance phlebotomy, while others may need only 1-2 units removed per year 1
- On average, serum ferritin rises by approximately 100 μg/L per year without treatment 1
- During maintenance, monitor serum ferritin every 6 months to adjust the treatment schedule 1, 2
Monitoring Parameters
- Check hemoglobin/hematocrit before each phlebotomy session 1
- Monitor serum ferritin to ensure the target range is maintained and to avoid iron deficiency 1, 2
- Unexpected changes in serum ferritin or transferrin saturation should always be investigated 1
- Consider periodic monitoring of plasma folate and cobalamin, especially in patients requiring numerous phlebotomies 1
Special Considerations
- For patients with cardiac arrhythmias or cardiomyopathy, there is increased risk with rapid iron mobilization, requiring more cautious phlebotomy scheduling 1
- Avoid vitamin C supplements during treatment as they can accelerate iron mobilization to potentially dangerous levels 1, 2
- Erythrocytapheresis can be considered as an alternative to standard phlebotomy in selected cases, potentially reducing the total number of procedures needed 4, 5
- In polycythemia vera, therapeutic phlebotomy is targeted to maintain hematocrit levels <45% to prevent thrombotic events 6
Practical Implementation
- Each phlebotomy removes approximately 200-250 mg of iron 1, 3
- The target ferritin level for the initial depletion phase is 50-100 μg/L 1
- Avoid iron supplementation and iron-fortified foods during treatment 2, 7
- Dietary modifications alone are insufficient to treat iron overload but limiting red meat consumption is recommended 1, 2