What is the recommended dosage and treatment protocol for Deferoxamine (Deferoxamine) in patients with iron overload?

Deferoxamine Dosage and Treatment Protocol for Iron Overload

For patients with iron overload, deferoxamine should be administered subcutaneously at 20-60 mg/kg/day for standard therapy, or intravenously at higher doses for patients with cardiac iron overload or heart failure. 1

Standard Dosing Regimens

• For long-term subcutaneous administration, deferoxamine is typically given at doses of 20-60 mg/kg/day via slow subcutaneous infusion over 8-12 hours, 5-7 days per week 1
• For patients with significant cardiac iron loading (T2* <10 ms on MRI), higher doses and continuous administration may be required 1
• For acute cardiac decompensation or severe cardiac iron overload (T2* <6 ms), continuous intravenous deferoxamine at higher doses is recommended for rapid removal of cardiac iron 1

Administration Methods

• Subcutaneous administration: The preferred route for long-term maintenance therapy, typically administered via portable infusion pump over 8-12 hours, often overnight 1
• Intravenous administration: Reserved for patients with severe cardiac iron overload or cardiac failure, allowing for continuous 24-hour therapy 1
• Combination therapy: Deferoxamine can be combined with oral deferiprone (75-100 mg/kg/day) for enhanced efficacy, particularly in patients with cardiac iron overload 1, 2

Monitoring Protocol

• Serum ferritin should be monitored every 3 months, with a target of reducing levels to less than 1000 ng/mL 1
• For patients with transfusion-dependent thalassemia, cardiac T2* MRI should be performed annually to assess cardiac iron content 1
• Liver iron concentration should be monitored annually using MRI techniques 1
• Regular cardiac assessments including electrocardiography and echocardiography should be performed annually starting at age 10 in transfusion-dependent patients 1

Special Clinical Scenarios

• For patients with cardiac failure due to iron overload:

  • Continuous intravenous deferoxamine at higher doses (up to 50-60 mg/kg/day) 1
  • Consider combination with deferiprone at 75 mg/kg/day in divided doses 1
  • Clinical stabilization may occur within 14 days but can take months 1

• For patients with mild to moderate cardiac iron loading (T2* 8-20 ms):

  • Combination therapy with subcutaneous deferoxamine plus oral deferiprone has shown superior outcomes compared to deferoxamine alone 1, 2
  • This combination has demonstrated significant improvements in myocardial T2*, left ventricular ejection fraction, and endothelial function 2

Limitations and Challenges

• Deferoxamine has poor oral bioavailability, requiring parenteral administration 1
• The need for frequent administration and use of infusion pumps often leads to poor compliance 1, 3
• High maintenance cost is a significant barrier to optimal therapy 1
• Patient satisfaction and convenience are significantly lower with deferoxamine compared to oral chelators like deferasirox 3

Treatment Duration

• For maintenance therapy in transfusion-dependent patients, lifelong chelation is typically required 1
• After resolution of decompensated heart failure, treatment may need to continue for several years to completely remove cardiac iron 1
• Treatment should be monitored by assessing clinical status, left ventricular ejection fraction, cardiac T2*, and ferritin trends 1

Alternative Chelation Options

• For patients with poor compliance to deferoxamine, consider switching to oral chelators:
  • Deferasirox (oral, once daily) 1, 3
  • Deferiprone (oral, three times daily) 1, 4
  • Both have shown efficacy in reducing iron burden, with potentially better patient adherence 3, 4