Iron Supplementation in Thalassemia: Contraindicated
Iron supplementation is contraindicated in patients with thalassemia due to the inherent risk of iron overload from chronic transfusions and increased gastrointestinal iron absorption. The primary therapeutic goal in thalassemia is iron removal through chelation therapy, not iron supplementation 1.
Why Iron Supplementation is Harmful
Mechanisms of Iron Overload in Thalassemia
Transfusion-dependent thalassemia major (TDT) patients accumulate approximately 200 mg of iron per unit of transfused blood, combined with mildly increased gastrointestinal iron uptake related to hepcidin suppression 1.
Non-transfusion-dependent thalassemia (NTDT) patients develop iron overload through enhanced intestinal absorption secondary to ineffective erythropoiesis and hepcidin suppression, even without regular transfusions 2.
Without adequate iron chelation therapy, almost all patients with beta-thalassemia will accumulate potentially fatal iron levels 3.
Organ Toxicity from Iron Overload
Cardiac complications from myocardial siderosis are among the leading causes of death in thalassemia patients, with iron-induced cardiomyopathy historically causing death in the second decade of life before effective chelation became available 1, 3.
Hepatic, endocrine, and other organ damage occurs from prolonged exposure to iron toxicity, including endocrinopathy, osteoporosis, cirrhosis, renal failure, and malignant transformation 4.
Iron that is not saturated by transferrin becomes a toxic agent that generates hydroxyl and oxygen radicals, causing lipid peroxidation and damage to cell membranes, proteins, and DNA 1.
The Role of Iron Chelation Therapy
Standard Management Approach
Iron chelation is the cornerstone of therapy in thalassemia, not iron supplementation 1.
Available iron chelators include deferoxamine (subcutaneous), deferiprone (oral), and deferasirox (oral), which are used to prevent and treat complications of iron overload 5, 2.
The primary goal of chelation therapy is to avoid 24-hour exposure to toxic iron and maintain body iron levels within the normal range 4.
Monitoring Iron Burden
Serum ferritin levels should be monitored, with goals of maintaining levels less than 1000-2500 mcg/L depending on clinical context 1.
Cardiac MRI T2* and liver iron concentration (LIC) by MRI are the gold standards for assessing organ-specific iron burden 1, 2.
Recent real-world data shows that oral chelators have led to persistent improvements in iron burden, with mean increases in cardiac T2* by 1.68 ms per year and decreases in LIC by 0.24 mg/g dry weight per year 6.
Critical Pitfall to Avoid
Never supplement iron in thalassemia patients based on low hemoglobin alone. The anemia in thalassemia is due to ineffective erythropoiesis and hemoglobin production defects, not iron deficiency 1. Adding iron supplementation will only worsen the already present iron overload and accelerate organ damage.
Special Consideration: Vitamin C
Avoid vitamin C supplementation in iron-overloaded thalassemia patients, as it can mobilize iron from reticuloendothelial stores, increase iron availability, and accelerate cardiac deterioration 1.
If vitamin C supplementation is deemed necessary, limit dosage to 500 mg daily and only after discussing with a physician 1.