From the Guidelines
Iron overload treatment should primarily involve phlebotomy, with chelation therapy considered for patients who cannot tolerate phlebotomy or have severe iron overload, as recommended by the most recent guidelines 1.
Treatment Options
- Phlebotomy is the first-line treatment for hereditary hemochromatosis, removing one unit of blood (approximately 500 mL) weekly until ferritin levels reach 50-100 ng/mL, followed by maintenance phlebotomies every 2-4 months.
- For patients who cannot tolerate phlebotomy, iron chelation therapy with deferoxamine (Desferal) or oral alternatives like deferasirox (Exjade/Jadenu) or deferiprone (Ferriprox) may be considered.
Chelation Therapy
- Deferoxamine is administered subcutaneously or intravenously at 20-40 mg/kg/day over 8-24 hours, 5-7 days per week.
- Oral alternatives include deferasirox at 14-28 mg/kg daily or deferiprone at 75-100 mg/kg daily divided into three doses.
Monitoring and Maintenance
- Treatment efficacy is monitored through regular serum ferritin measurements, transferrin saturation, and organ-specific assessments.
- Chelation therapy should continue until iron levels normalize, which may take months to years.
Special Considerations
- In patients with advanced liver disease, oral deferasirox should be avoided due to the risk of gastrointestinal side effects and impairment in kidney function 1.
- In juvenile haemochromatosis, combination chelation therapy with oral deferiprone and intravenous deferoxamine may be considered for life-threatening cardiac iron overload 1.
From the FDA Drug Label
DESFERAL is an iron-chelating agent indicated: For the treatment of transfusional iron overload in patients with chronic anemia. (1.2)
Chronic Iron Overload: (2. 2) Subcutaneous Infusion: Average daily dose is between 20 and 60 mg/kg. In patients with serum ferritin level below 2,000 ng/mL require about 25 mg/kg/day. Patients with serum ferritin level between 2,000 and 3,000 ng/mL require about 35 mg/kg/day. Patients with higher serum ferritin may require up to 55 mg/kg/day
Iron Overload Treatment: Deferoxamine (Desferal) is indicated for the treatment of transfusional iron overload in patients with chronic anemia.
- The average daily dose for subcutaneous infusion is between 20 and 60 mg/kg.
- The dose required depends on the serum ferritin level, with higher levels requiring higher doses.
- The recommended dose is:
- 25 mg/kg/day for patients with serum ferritin level below 2,000 ng/mL.
- 35 mg/kg/day for patients with serum ferritin level between 2,000 and 3,000 ng/mL.
- Up to 55 mg/kg/day for patients with higher serum ferritin levels. 2
From the Research
Iron Overload Treatment Options
- Iron overload is a serious condition that can result from multiple blood transfusions, and it requires prompt treatment to prevent organ damage 3, 4.
- Treatment options for iron overload include phlebotomy, erythrocytapheresis, and chelation therapy with drugs such as deferoxamine, deferiprone, and deferasirox 4, 5.
- Deferasirox is an oral, once-daily iron chelator that has been shown to be effective in reducing iron burden in patients with beta-thalassemia, sickle cell anemia, and myelodysplastic anemia 3, 6.
- Combination therapy of deferasirox and deferoxamine has also been shown to be effective in patients with severe iron overload who do not respond to monotherapy 7.
Benefits and Risks of Treatment
- The benefits of iron overload treatment include preventing deaths due to cardiac siderosis and hepatic cirrhosis, as well as improving quality of life and survival in patients with iron overload disorders 4.
- The risks of treatment include adverse effects such as gastrointestinal disruptions, skin rash, and increased susceptibility to infectious organisms, particularly with deferoxamine therapy 6, 5.
- Patient compliance can be compromised by the routes of administration and cost of iron chelation therapy, highlighting the need for convenient and effective treatment options like deferasirox 3, 5.
Monitoring and Management
- Serum ferritin concentrations should be measured regularly to monitor the effectiveness of iron overload treatment 5.
- Liver and cardiac magnetic resonance imaging (MRI) can be used to assess iron overload and monitor the response to treatment 7.
- Individualized treatment plans may be necessary to tailor chelation therapy to the specific needs of patients with iron overload, particularly those with severe iron burden or refractory disease 7.