Phlebotomy Frequency in Hemochromatosis
For patients with hemochromatosis, perform phlebotomy weekly or biweekly (removing 500 mL per session) during the induction phase until ferritin reaches 50 μg/L, then switch to maintenance phlebotomy every 2-6 times per year to keep ferritin between 50-100 μg/L. 1, 2
Induction Phase Protocol
Initial iron depletion requires aggressive treatment:
- Remove 500 mL of blood weekly or biweekly as tolerated 1, 2, 3
- Each unit removes approximately 200-250 mg of iron 4
- Continue until serum ferritin reaches 50 μg/L (target for induction) 1, 2
- This phase typically requires 6 months to 3 years depending on initial iron burden 4, 5
Critical monitoring during induction:
- Check hemoglobin before every single phlebotomy session 1, 2, 3
- If hemoglobin drops below 12 g/dL, reduce phlebotomy frequency 1, 2
- If hemoglobin falls below 11 g/dL, pause treatment entirely 1
- Monitor ferritin every 4 phlebotomies until it reaches 200 μg/L, then check every 1-2 sessions 1
The European Association for the Study of the Liver guidelines provide the most recent (2022) and comprehensive framework, establishing clear hemoglobin cutoffs that prevent the complication of iatrogenic iron deficiency, which can persist for over 2 years if not caught early 6.
Maintenance Phase Protocol
Once target ferritin is achieved, shift to individualized maintenance:
- Frequency typically ranges from 2-6 phlebotomies per year 1
- Target ferritin: maintain between 50-100 μg/L 1, 2, 3
- The specific interval varies significantly between patients due to different rates of iron reaccumulation 4
- Average iron reaccumulation is approximately 100 μg/L per year without treatment 4
Maintenance monitoring schedule:
- Check hemoglobin before each phlebotomy 1, 4
- Monitor ferritin and transferrin saturation every 6 months 1, 4
- Adjust phlebotomy frequency based on ferritin trends to maintain target range 3, 4
Research shows that most patients require phlebotomy intervals of 6-16 weeks during maintenance, with evidence of iron reaccumulation occurring at intervals of 8 weeks or longer 7. Compliance with maintenance therapy decreases by approximately 6.8% annually, highlighting the importance of clear scheduling 8.
Alternative Treatment Option
Erythrocytapheresis can be considered as first-line in selected cases:
- Removes up to twice the red blood cells per session compared to phlebotomy 1, 9
- Reduces total number of procedures by approximately 70% during induction 9
- Causes fewer hemodynamic changes and returns valuable blood components 1
- Mild citrate reactions are more common but manageable 1
- Use depends on local availability and expertise 1
- Same target ferritin goals apply: 50 μg/L for induction, 50-100 μg/L for maintenance 1
Critical Pitfalls to Avoid
Common errors that worsen outcomes:
- Over-phlebotomy leading to iron deficiency can cause persistent symptoms for 2+ years 6
- Failing to check hemoglobin before each session risks severe anemia 1, 6
- Using transferrin saturation alone is unreliable as it fluctuates considerably during treatment 7
- Relying solely on ferritin without hemoglobin monitoring misses iron deficiency 6
Essential patient counseling:
- Avoid iron supplements, vitamin C supplements, and daily red meat consumption 1, 2
- Avoid raw or undercooked seafood and contact of wounds with seawater (Vibrio vulnificus risk) 1, 5
- Patients with advanced liver disease must abstain from alcohol completely 1
- Dietary iron restriction is unnecessary as it only affects 2-4 mg/day versus 200-250 mg removed per phlebotomy 4
Special Population Considerations
Elderly patients may tolerate more relaxed targets:
- Consider maintenance ferritin targets up to 200 μg/L for women and 300 μg/L for men 2, 3
- This reduces treatment burden while maintaining safety 3
Patients with cardiac involvement require caution: