Do you stop iron supplements if you have a high red blood cell (RBC) count?

Management of Iron Supplements in Patients with High RBC Count

Yes, you should stop iron supplements if you have a high red blood cell count to prevent complications related to iron overload.

Rationale for Discontinuing Iron Supplements

• Iron supplementation should be discontinued in patients with elevated red blood cell counts as this may indicate iron overload, which can lead to significant morbidity and mortality through organ damage 1
• The European Society for Parenteral and Enteral Nutrition (ESPEN) recommends reducing iron stores through venesection in conditions of iron overload to prevent complications 1
• Excess iron can cause oxidative stress through generation of reactive oxygen species, leading to cellular damage in vital organs 2

Assessment of Iron Status

• Before making decisions about iron supplementation, a comprehensive iron status evaluation should include:

  • Serum ferritin (primary marker of iron stores)
  • Transferrin saturation
  • Complete blood count with RBC indices
  • C-reactive protein (to assess for inflammation that may falsely elevate ferritin) 3

• High RBC count with elevated ferritin (>1000 ng/mL) strongly suggests iron overload requiring intervention 1

Management Algorithm

1. For confirmed iron overload with high RBC:

   • Immediately discontinue all iron supplements 1, 3
   • Avoid vitamin C supplements which can increase iron absorption and mobilization 1
   • Consider therapeutic phlebotomy if ferritin >1000 ng/mL 4

2. For high RBC without confirmed iron overload:

   • Temporarily suspend iron supplements while investigating cause 3
   • Evaluate for other causes of elevated RBC (polycythemia vera, chronic hypoxemia, etc.) 1

Monitoring After Discontinuation

• Monitor hemoglobin and hematocrit regularly after stopping iron supplements 4
• Check serum ferritin levels every 3 months until stabilized 1
• Target ferritin level should be between 50-100 μg/L to prevent both iron overload and deficiency 1

Risks of Continued Iron Supplementation with High RBC

• Continued iron supplementation with elevated RBC can lead to:
  • Cardiac dysrhythmias and cardiomyopathy 1
  • Liver damage and potential cirrhosis 1
  • Increased risk of infections, particularly from Vibrio vulnificus 1
  • Hyperviscosity syndrome with headaches and poor concentration 1

Special Considerations

• Patients with hereditary hemochromatosis require more aggressive management with regular therapeutic phlebotomy 1
• Patients with secondary iron overload due to multiple transfusions may require iron chelation therapy rather than simply stopping supplements 5
• Avoid excessive phlebotomy which can lead to iron deficiency with its own complications 6

Resuming Iron Supplementation

• Iron supplementation should only be resumed when:
  • RBC count has normalized
  • Ferritin levels have decreased to <50 μg/L
  • Clinical evidence of iron deficiency is present 3
• When restarting, use lower doses and monitor ferritin and RBC parameters monthly 4

Remember that both iron overload and iron deficiency carry significant health risks, so proper monitoring and adjustment of iron status is essential for optimal patient outcomes 2.