Referral for Therapeutic Phlebotomy in Hereditary Hemochromatosis
Referral to hematology is generally not necessary for therapeutic phlebotomy in hereditary hemochromatosis—primary care physicians and gastroenterologists/hepatologists can manage this straightforward treatment directly. 1
Who Should Manage Phlebotomy
Phlebotomy is a simple, safe, and inexpensive procedure that can be performed in primary care settings, blood donation centers, or gastroenterology/hepatology clinics without requiring hematology consultation in most cases. 1
When Specialist Referral IS Indicated
Refer to a specialist in iron disorders (hepatology/gastroenterology, not necessarily hematology) when: 1
- Significant unexplained iron overload requiring diagnostic workup 1
- Evidence of advanced liver disease (cirrhosis, portal hypertension) requiring hepatology management 1
- Rare hemochromatosis gene variants in young patients with clinical manifestations 1
- Cardiac complications (arrhythmias, cardiomyopathy) where rapid iron mobilization increases risk of sudden death and requires careful monitoring 2, 3
- Patients unable to tolerate phlebotomy who may require iron chelation therapy (deferoxamine 20-40 mg/kg/day subcutaneously) 3
When Primary Care Can Manage Directly
Most patients with confirmed hereditary hemochromatosis can be managed in primary care when: 1, 4
- Ferritin ≥300 μg/L in men or ≥200 μg/L in women with transferrin saturation >45% 4
- No evidence of cirrhosis or advanced organ damage 1, 4
- Ferritin <1000 μg/L without significant liver enzyme elevation (can proceed directly to phlebotomy without liver biopsy) 4
Practical Management Algorithm
Initial Phase (Primary Care)
- Remove 500 mL blood weekly or biweekly as tolerated 2, 3
- Check hemoglobin/hematocrit before each session—do not allow drop >20% from baseline 2, 4
- Monitor ferritin every 10-12 phlebotomies (approximately every 3 months) 2, 3
- Continue until ferritin reaches 50-100 μg/L (may take 2-3 years for significant iron overload >30g) 2, 3
Maintenance Phase
- Adjust frequency to maintain ferritin 50-100 μg/L (typically every 2-4 months, but highly variable) 2, 3
- Monitor ferritin every 6 months during stable maintenance 2
- If hemoglobin falls below 12 g/dL, decrease phlebotomy frequency 2
Critical Pitfalls to Avoid
- Do not refer routinely to hematology—this delays treatment and is unnecessary for straightforward cases 1
- Avoid vitamin C supplements entirely during treatment as they accelerate iron mobilization to dangerous levels 2, 3
- Do not pursue dietary iron restriction—it removes only 2-4 mg/day versus 200-250 mg per phlebotomy session 2
- In cirrhotic patients, continue hepatocellular carcinoma screening even after successful iron depletion, as cancer risk persists 1, 4
Blood Donation Benefit
In the United States, blood acquired through therapeutic phlebotomy may be used for transfusion (deemed safe by American Red Cross and FDA), providing societal benefit while treating the patient. 1