What are the guidelines for therapeutic phlebotomy in a patient with elevated hemoglobin (Hyperhemoglobinemia)?

From the Guidelines

Therapeutic phlebotomy for elevated hemoglobin should be performed to maintain a hematocrit level below 45% in white men and the appropriate corresponding values for females and those of other races, as recommended by the Mayo Clinic Proceedings in 2003 1.

Guidelines for Therapeutic Phlebotomy

The procedure typically involves removing 450-500 mL of blood every 1-2 weeks until the target hemoglobin level is reached, usually below 45-50% hematocrit or hemoglobin below 16-17 g/dL.

• The procedure should be performed in a clinical setting by trained healthcare professionals using standard phlebotomy equipment.
• Before starting, patients should be well-hydrated and have their vital signs checked.
• During each session, patients should be monitored for adverse effects like lightheadedness, dizziness, or syncope.
• The frequency of phlebotomy depends on the underlying condition, with polycythemia vera often requiring more aggressive treatment than secondary erythrocytosis.
• Maintenance phlebotomy may be needed every 2-3 months after target levels are achieved.
• Iron supplementation should be avoided during treatment as it can counteract the therapeutic effect. However, the most recent and highest quality study, published in the Journal of Hepatology in 2022 1, recommends a target ferritin level of 50-100 lg/L during the maintenance phase, and a volume and frequency of phlebotomies of 400-500 ml weekly or every 2 weeks during the induction phase, depending on body weight and patient tolerance.

Key Considerations

• Serum haemoglobin should always be monitored during both induction and maintenance phases, at the time of each bloodletting session.
• If haemoglobin concentrations are <12 g/dl, the frequency of phlebotomy should be decreased and in specific cases a reduction in volume should be considered.
• Serum ferritin should always be monitored to ensure that the target value is achieved and maintained and to avoid overtreatment.
• Patients should maintain adequate hydration between sessions and report any unusual symptoms promptly to their healthcare provider. It's also important to note that the American Association for the Study of Liver Diseases recommends a target ferritin level of 50-100 lg/L for patients with hemochromatosis, and that patients with end-organ damage due to iron overload should undergo regular phlebotomy to the same endpoints as indicated above 1.

From the Research

Therapeutic Phlebotomy Guidelines

The guidelines for therapeutic phlebotomy in patients with elevated hemoglobin levels, particularly those with polycythemia vera (PV), are as follows:

• The primary goal of therapeutic phlebotomy is to reduce the risk of thrombosis by maintaining a hematocrit level below 45% 2, 3.
• Phlebotomy is recommended for all patients with PV, regardless of their risk category 2, 3.
• The frequency of phlebotomy sessions may vary depending on the individual patient's needs, with some patients requiring more frequent sessions to maintain a hematocrit level below 45% 4.
• Patients who require more frequent phlebotomy sessions (3 or more per year) may be at a higher risk of thrombosis and may require closer monitoring and additional treatment 4.
• Therapeutic phlebotomy should be used in conjunction with other treatments, such as aspirin and cytoreductive therapy, to manage PV and reduce the risk of thrombosis 2, 5, 3.

Aspirin Therapy

Aspirin therapy is also an important component of the management of PV and essential thrombocythemia (ET):

• Aspirin is recommended for all patients with PV, unless there are contraindications, to reduce the risk of thrombosis 2, 3, 6.
• The optimal dose of aspirin is not well established, but low-dose aspirin (81 mg daily) is commonly used 3, 6.
• Aspirin therapy may be used in conjunction with phlebotomy and cytoreductive therapy to manage PV and reduce the risk of thrombosis 2, 5, 3.