What is the target ferritin level and phlebotomy protocol for a patient with hemochromatosis (iron overload disorder)?

Target Ferritin Levels and Phlebotomy Protocol for Hemochromatosis

For patients with hemochromatosis, target a serum ferritin of 50 μg/L during the induction phase through weekly or biweekly phlebotomy of 400-500 mL, then maintain ferritin between 50-100 μg/L during the maintenance phase with phlebotomy every 1-4 months. 1

Induction Phase Protocol

Target Ferritin Level

• Aim for serum ferritin of 50 μg/L, but do not go lower to avoid iron deficiency 1
• The European Association for the Study of the Liver emphasizes this specific target to balance effective iron removal while preventing iatrogenic iron deficiency 1, 2

Phlebotomy Frequency and Volume

• Remove 400-500 mL of blood weekly or every 2 weeks, depending on body weight and patient tolerance 1, 3
• Each unit removes approximately 200-250 mg of iron 3
• The induction phase may take 2-3 years for patients with significant iron overload (>30g total body iron) 3

Monitoring During Induction

• Check hemoglobin before every phlebotomy session 1, 3
• Measure serum ferritin monthly or after every 4th phlebotomy 1
• When ferritin decreases below 200 μg/L, measure ferritin every 1-2 sessions until target is reached 1
• If hemoglobin falls below 12 g/dL, decrease phlebotomy frequency 1, 2
• If hemoglobin falls below 11 g/dL, discontinue phlebotomy and reassess 1, 2

Maintenance Phase Protocol

Target Ferritin Range

• Maintain serum ferritin between 50-100 μg/L with some flexibility 1, 2, 3
• This range represents consensus among major guidelines including the American Association for the Study of Liver Diseases and European Association for the Study of the Liver 1

Phlebotomy Frequency

• Perform phlebotomy every 1-4 months depending on individual iron reaccumulation rates 1, 3
• On average, serum ferritin rises approximately 100 μg/L per year without treatment, but this varies widely among patients 1, 3

Monitoring During Maintenance

• Monitor serum ferritin every 6 months to adjust treatment schedule 1, 3
• Continue checking hemoglobin before each phlebotomy session 3, 4

Special Populations and Considerations

Elderly Patients

• Consider more relaxed ferritin targets during maintenance: <200 μg/L for women and <300 μg/L for men 2, 4
• Aiming for ferritin of 50 μg/L is poorly tolerated by elderly patients 1

Patients with Cardiac Disease

• Patients with cardiomyopathy or arrhythmias face increased risk of sudden death with rapid iron mobilization 3, 4
• Consider slower phlebotomy schedule or iron chelation therapy in these high-risk patients 4

Anemic Patients

• Phlebotomy is not appropriate for patients with anemia or secondary iron overload 5
• Iron chelation therapy (deferoxamine 20-40 mg/kg/day subcutaneously) is the alternative for patients who cannot tolerate phlebotomy 4

Critical Pitfalls to Avoid

Overtreatment Leading to Iron Deficiency

• Symptomatic iron deficiency can develop in hemochromatosis patients from excessive phlebotomy 1, 6
• Iron deficiency may persist for extended periods (average 25 months in one study) if monitoring is inadequate 6
• Do not target ferritin below 50 μg/L during induction to prevent this complication 1

Inadequate Monitoring

• Infrequent or incorrect use of iron status parameters is a common cause of treatment complications 6
• Always monitor hemoglobin before each session and ferritin at appropriate intervals 1, 3

Dietary Considerations

• Avoid vitamin C supplements entirely, especially during active iron depletion, as vitamin C accelerates iron mobilization 3, 4
• Avoid medicinal iron and mineral supplements 7
• Dietary iron restriction is generally unnecessary since phlebotomy removes far more iron (200-250 mg/unit) than dietary modification can affect (2-4 mg/day) 3