What is the treatment for hyperferremia (elevated iron levels)?

Treatment for Hyperferremia (Elevated Iron Levels)

The primary treatment for elevated iron levels (hyperferremia) is therapeutic phlebotomy, which should be performed weekly until ferritin levels reach 50-100 μg/L to prevent organ damage and reduce mortality. 1, 2

Diagnosis and Assessment

• Before initiating treatment, confirm the cause of iron overload through evaluation of serum ferritin and transferrin saturation, as this will guide treatment approach 3
• Evaluate for hereditary hemochromatosis (HH) in patients with persistently elevated iron levels, especially with transferrin saturation >45% 1
• Assess for secondary causes of iron overload including transfusion-dependent anemias, chronic liver disease, and metabolic disorders 1
• Consider organ damage assessment if ferritin is significantly elevated (>1000 μg/L), particularly focusing on liver, heart, and endocrine organs 1

Treatment Algorithm

Primary Treatment: Therapeutic Phlebotomy

• For hereditary hemochromatosis and most cases of iron overload:
  • Initiate weekly phlebotomy (removal of 450-500 mL of blood) as tolerated 1, 2
  • Monitor hemoglobin and hematocrit at each phlebotomy session 1, 2
  • Postpone phlebotomy if anemia develops (hemoglobin <12 g/dL) 1
  • Check serum ferritin every 10-12 phlebotomies to track progress 2
  • Continue until target ferritin level of 50-100 μg/L is achieved 1, 3

Maintenance Phase

• After achieving target ferritin levels, transition to maintenance phlebotomy:
  • Typically performed every 3-6 months 2, 3
  • Monitor ferritin levels every 6 months 3
  • Adjust frequency based on rate of iron reaccumulation 1
  • Resume more frequent phlebotomy if ferritin exceeds upper limit of normal 1

Alternative Treatment: Iron Chelation Therapy

• For patients who cannot tolerate phlebotomy or have transfusion-dependent anemias:
  • Deferoxamine: Administered subcutaneously via infusion pump at 40 mg/kg/day for 8-12 hours, 5-7 nights weekly 1
  • Deferasirox: Oral iron chelator, dosing based on body weight and degree of iron overload 4
  • Monitor for potential side effects including renal dysfunction, gastrointestinal disturbances, and skin reactions 4

Special Considerations

• Avoid vitamin C supplements during treatment as they enhance iron absorption and may worsen iron overload 1, 2
• Avoid iron supplements and iron-fortified foods 3
• Limit alcohol consumption, which can increase iron absorption and worsen liver damage 2, 3
• Raw shellfish should be avoided in patients with hemochromatosis due to risk of Vibrio vulnificus infection 1
• For patients with end-organ damage, more aggressive iron removal may be required, but the same target ferritin levels apply 1

Monitoring During Treatment

• Monitor hemoglobin and hematocrit at each phlebotomy session 1, 2
• Check serum ferritin periodically to assess iron stores 1, 3
• For patients with organ damage, monitor specific organ function (cardiac, hepatic, endocrine) 1
• In patients receiving chelation therapy, monitor for specific drug-related toxicities including renal function, hearing, and vision 4

Expected Outcomes

• Early treatment before development of cirrhosis or diabetes results in normal survival rates 1
• Organ damage may not be fully reversible, particularly arthropathy 1
• Endocrine and cardiac abnormalities may show variable improvement depending on the degree of damage before treatment initiation 1
• Advanced cirrhosis is not reversed with iron removal and may require liver transplantation consideration 1

Treatment Pitfalls to Avoid

• Delaying treatment can lead to irreversible organ damage and increased mortality 1
• Excessive phlebotomy can cause anemia and worsen fatigue 2
• Overlooking secondary causes of hyperferritinemia (inflammation, infection) can lead to inappropriate treatment 3
• Failing to maintain long-term therapy can result in reaccumulation of iron and recurrence of complications 1