How to manage a 65-year-old female with iron overload, polycythemia, hypertension, hyperlipidemia, and chronic fatigue?

Management of Iron Overload with Polycythemia in a 65-Year-Old Female

Therapeutic phlebotomy is the recommended first-line treatment for this patient with elevated ferritin (243 ng/mL) and polycythemia (Hgb 16.3, Hct 48.5, RBC 5.5) to reduce iron stores and improve symptoms of chronic fatigue.

Assessment of Iron Status and Polycythemia

• The patient's ferritin level of 243 ng/mL indicates mild iron overload, though it is below the threshold that would typically trigger aggressive intervention (>500-1000 ng/mL) 1
• The elevated hemoglobin (16.3), hematocrit (48.5), and RBC count (5.5) indicate polycythemia, which can contribute to hyperviscosity and associated complications 2
• Chronic fatigue in this patient may be related to both iron overload and polycythemia, as both conditions can negatively impact quality of life 3, 4
• The combination of iron overload with polycythemia requires careful management to address both conditions simultaneously 2

Treatment Approach

Phlebotomy Protocol

• Initiate therapeutic phlebotomy with removal of 450-500 mL of blood weekly or biweekly until ferritin levels decrease to 50 ng/mL or less 1
• Monitor hematocrit prior to each phlebotomy session; avoid allowing hematocrit to fall by more than 20% of prior level during any single session 1, 2
• Check serum ferritin level every 10-12 phlebotomies to track progress 1
• Once target ferritin level is achieved, transition to maintenance phlebotomy (typically 3-4 times per year for men, 1-2 times for women) 1
• Adjust frequency of maintenance phlebotomy based on periodic monitoring of ferritin, hemoglobin, and hematocrit 1

Monitoring Protocol

• Monitor serum ferritin, hemoglobin, and hematocrit regularly during treatment 1
• Assess for improvement in symptoms, particularly chronic fatigue 5, 3
• Monitor for potential complications related to both iron overload and polycythemia 3, 4
• Consider periodic assessment of organ function, particularly cardiac and hepatic, if iron overload is significant 1, 3

Dietary and Lifestyle Modifications

• Avoid vitamin C supplements, which can enhance iron absorption and potentially worsen iron overload 1, 5
• Minimize alcohol consumption, which increases iron absorption 1
• Avoid iron-containing multivitamins and supplements 1, 5
• Consider reducing consumption of highly iron-rich foods such as red meat, though dietary restrictions alone have minimal impact on total body iron 1

Management of Comorbidities

• Continue appropriate management of hypertension and hyperlipidemia, as these conditions can worsen cardiovascular risks when combined with iron overload 3
• Address chronic fatigue through both iron reduction therapy and management of underlying conditions 5, 3
• Monitor for development of diabetes, as iron overload increases this risk, especially in patients with other metabolic risk factors 3, 4

Special Considerations and Pitfalls

• Avoid excessive phlebotomy, which could lead to anemia and worsen fatigue symptoms 1, 2
• Do not delay treatment, as early intervention prevents complications of iron overload including organ damage 5, 4
• Consider genetic testing for hereditary hemochromatosis if ferritin levels remain elevated despite therapy or if there is a family history of iron overload 1, 5
• Be aware that ferritin is an acute phase reactant; inflammatory conditions may falsely elevate levels, so interpret in context of clinical picture 1, 6
• Consider additional workup for secondary causes of polycythemia if phlebotomy does not adequately control hematocrit levels 2