Phlebotomy Target in Hemochromatosis and Polycythemia Vera
For hemochromatosis, target a serum ferritin level of 50-100 μg/L during both initial iron depletion and lifelong maintenance therapy. 1
Hemochromatosis: Primary Target and Monitoring
The American Association for the Study of Liver Diseases provides clear, evidence-based targets for phlebotomy therapy:
Initial Depletion Phase
- Target ferritin: 50-100 μg/L 1
- Perform weekly phlebotomy (500 mL per session) as tolerated until this target is reached 1, 2
- Monitor hemoglobin/hematocrit before each session to avoid reducing below 80% of baseline 1
- Check serum ferritin every 10-12 phlebotomies (approximately every 3 months) during initial treatment 1
- As ferritin approaches 50-100 μg/L range, increase monitoring frequency to prevent overshooting into iron deficiency 1
Maintenance Phase
- Continue targeting ferritin 50-100 μg/L indefinitely 1, 2
- Frequency varies by individual iron reaccumulation rate—some require monthly phlebotomy, others only 1-2 units per year 1
- Monitor ferritin monthly initially during maintenance, then adjust frequency based on stability 2
Critical Monitoring Parameters
- Transferrin saturation remains elevated until iron stores are depleted, making it less useful for monitoring progress 1
- Serum ferritin reliably reflects iron burden during therapy in hemochromatosis (unlike secondary iron overload where it can be misleading) 1
- Stop phlebotomy when ferritin reaches 50-100 μg/L—do not induce iron deficiency 1
Important Clinical Nuances
When to Modify Targets
- Patients with cardiac complications: In those with cardiomyopathy or arrhythmias, rapid iron mobilization increases risk of sudden death, so consider slower phlebotomy schedules 2, 3
- Elderly patients: More relaxed maintenance targets may be appropriate (up to 200 μg/L for women, 300 μg/L for men) 2, 4
Common Pitfalls to Avoid
- Do not use vitamin C supplements, especially during active iron depletion, as vitamin C accelerates iron mobilization and can increase oxidative stress to dangerous levels 1, 2, 3
- Avoid inducing anemia: Check hemoglobin before each session and reduce frequency if hemoglobin drops below 12 g/dL 3, 4
- Do not over-deplete iron stores: The goal is ferritin 50-100 μg/L, not iron deficiency 1
Polycythemia Vera: Different Target
While the question mentions polycythemia vera, the provided evidence focuses exclusively on hemochromatosis. For polycythemia vera, the therapeutic target differs fundamentally—the goal is hematocrit control (typically <45% in men, <42% in women) to reduce thrombotic risk, not ferritin reduction. This represents a completely different therapeutic objective than hemochromatosis management.
Strength of Evidence
The ferritin target of 50-100 μg/L for hemochromatosis carries a Grade 1B recommendation from the American Association for the Study of Liver Diseases 1, indicating strong evidence supporting this specific target range. This target applies equally to both initial depletion and maintenance phases, and to patients with end-organ damage 1.