Absolute Contraindications for Iron Supplementation
Iron supplementation is absolutely contraindicated in patients with hemochromatosis and other iron overload disorders, as it exacerbates tissue damage to the liver, heart, and pancreas. 1
Primary Absolute Contraindications
Hemochromatosis and iron overload states: Iron supplementation must be avoided in hereditary hemochromatosis (HFE-related C282Y homozygosity, C282Y/H63D compound heterozygosity), juvenile hemochromatosis, and secondary iron overload conditions including thalassemia major, sideroblastic anemia, and chronic hemolytic anemias. 2
Normal or elevated ferritin levels: Iron supplementation is contraindicated when ferritin is normal or elevated, as it can be potentially harmful and unnecessary. 1
Pregnancy (for iron chelators only): All iron chelation drugs are absolutely contraindicated in pregnancy, though this applies to chelators, not iron supplementation itself. 1
Critical Relative Contraindications
Active infection: Iron supplementation should not be given during active bacterial infections, as iron promotes bacterial growth and may be utilized by microorganisms. 1, 3
Neutropenia: IV iron must be avoided during periods of neutropenia due to increased infection risk from infused iron being used by pathogens. 1, 3
Same-day anthracycline administration: IV iron should never be administered on the same day as anthracyclines due to theoretical risk of potentiating cardiotoxicity; instead, give it before chemotherapy, after chemotherapy, or at the end of a treatment cycle. 1, 3
Important Clinical Nuances
Vitamin C supplementation: Supplemental vitamin C should be avoided, especially before iron depletion in hemochromatosis patients, as pharmacologic doses accelerate iron mobilization to levels that may saturate transferrin, increasing pro-oxidant and free-radical activity. 2 Patients receiving iron chelators should not exceed 200 mg of vitamin C daily. 2
Iron-fortified foods: These should be avoided where possible in patients with hemochromatosis or iron overload. 2
Shellfish and seawater exposure: In patients with hemochromatosis and iron overload, direct handling of raw or undercooked shellfish and wound exposure to seawater has been associated with rare but serious systemic bacterial infection by Vibrio vulnificus and other siderophilic pathogens in certain geographical regions. 2
Common Pitfall to Avoid
The most critical error is failing to check ferritin and transferrin saturation before initiating iron therapy. Iron parameters can be misleading in the presence of inflammation, requiring careful assessment before supplementation. 1 In hemochromatosis patients on maintenance phlebotomy, iron deficiency can paradoxically develop if monitoring is inadequate, but even in this scenario, iron supplementation should only be given as a brief course (2-6 weeks) if symptomatic, and is generally unnecessary for mild self-limited anemia after initial iron depletion. 4