Should a patient with thalassemia (a genetic disorder affecting hemoglobin production) take iron tablets?

Iron Supplementation in Thalassemia: Contraindicated

Iron tablets are contraindicated in thalassemia patients and should never be given, as the anemia is due to defective hemoglobin production and ineffective erythropoiesis, not iron deficiency—iron supplementation will worsen iron overload and cause life-threatening organ damage. 1

Critical Distinction: Thalassemia vs. Iron Deficiency Anemia

The fundamental error in thalassemia management is treating the anemia with iron supplementation. The pathophysiology is completely different from iron deficiency anemia:

• Thalassemia patients already have increased gastrointestinal iron absorption due to hepcidin suppression from ineffective erythropoiesis, making any additional iron supplementation dangerous 1
• The anemia results from defective hemoglobin synthesis, not lack of iron—adding more iron cannot fix the underlying genetic defect and only accelerates toxic iron accumulation 1, 2
• Transfusion-dependent thalassemia major patients accumulate 0.3-0.6 mg/kg/day of iron from each unit of blood, leading to fatal cardiac iron deposition by the second decade of life without chelation therapy 2, 3

Why Iron Is Harmful in Thalassemia

Iron overload is the primary cause of morbidity and mortality in thalassemia:

• Cardiac iron deposition causes restrictive cardiomyopathy and arrhythmias, with 47% risk of heart failure within one year if cardiac T2* MRI shows <6 ms 3
• Hepatic iron accumulation leads to cirrhosis and hepatocellular carcinoma 3
• Endocrine dysfunction including diabetes, hypogonadism, and growth failure results from pancreatic and pituitary iron deposition 2
• Non-transferrin-bound iron generates free radicals causing oxidative damage to organs when transferrin saturation exceeds capacity 2

The Correct Management Approach

Instead of iron supplementation, thalassemia patients require the opposite intervention:

For Thalassemia Major (Transfusion-Dependent):

• Iron chelation therapy is mandatory starting after ≥20 red blood cell transfusions or when serum ferritin reaches ≥1000 ng/mL 4
• Deferoxamine, deferasirox, or deferiprone are the available chelators to remove excess iron and prevent organ damage 3, 4
• Cardiac T2 MRI monitoring* is essential, with intensive chelation required when T2* <10 ms to prevent heart failure 3, 4

For Thalassemia Minor (Carriers):

• Standard multivitamins WITHOUT iron should be used 1
• Vitamin C must be limited to ≤500 mg daily as it enhances iron absorption and can mobilize iron from stores, potentially causing cardiac deterioration 3, 1
• Red meat consumption should be limited to reduce heme iron intake 3, 1

Common Clinical Pitfall

The most dangerous error is assuming anemia in thalassemia requires iron supplementation. 3, 1 This mistake occurs when:

• Providers see low hemoglobin and reflexively prescribe iron without checking the underlying diagnosis
• Mild anemia in thalassemia minor is mistaken for iron deficiency anemia
• In pregnant women of African, Mediterranean, or Southeast Asian ancestry, mild anemia unresponsive to iron therapy should prompt evaluation for thalassemia minor or hemoglobinopathy 3

Diagnostic Confirmation Before Any Iron

Before considering iron in any patient with microcytic anemia:

• Check hemoglobin electrophoresis to rule out thalassemia trait or other hemoglobinopathies 3
• Measure serum ferritin and transferrin saturation to assess actual iron stores 1
• Review ethnic background (Mediterranean, Southeast Asian, African ancestry increases thalassemia risk) 3
• Evaluate family history of anemia or transfusion dependence 3

Iron supplementation in thalassemia transforms a manageable genetic condition into a life-threatening iron overload crisis—the treatment is chelation to remove iron, never supplementation to add more. 1, 2