Is intravenous iron infusion indicated for a patient with β‑thalassemia who receives chronic red‑cell transfusions?

Iron Infusion in Beta Thalassemia: Contraindicated

Iron infusion is absolutely contraindicated in patients with β-thalassemia receiving chronic red cell transfusions, as these patients already suffer from life-threatening iron overload that causes 70% of deaths through cardiac complications—they require iron chelation therapy, not additional iron. 1

Why Iron Infusion is Harmful

Mechanism of Iron Accumulation

• Each unit of transfused packed red blood cells delivers 200-250 mg of elemental iron with no physiological mechanism for excretion 2, 3
• Patients receiving transfusions every 3-4 weeks accumulate massive iron burdens that exceed the body's binding capacity 2
• When transferrin saturation is exceeded, toxic non-transferrin bound iron circulates freely and enters cardiac myocytes through L-type calcium channels, causing direct myocardial damage 3

Fatal Consequences of Iron Overload

• Iron-induced cardiomyopathy is the leading cause of death in transfusion-dependent β-thalassemia, accounting for approximately 70% of mortality 1
• Before chelation therapy became available, transfused but unchelated patients died by age 10 years from cardiac complications 1, 2
• Even with modern chelation, cardiac iron overload remains the primary threat to survival 1

The Correct Management: Iron Chelation

When to Initiate Chelation

Begin iron chelation immediately when regular transfusions are established, after ≥20 red blood cell transfusions, or when serum ferritin reaches ≥1000 ng/mL. 2, 4

First-Line Chelation Options

• Deferasirox (oral): 20-40 mg/kg/day as first-line therapy for most patients ≥2 years of age 4
• Deferoxamine (subcutaneous/IV): 50 mg/kg/day via infusion 5-7 nights per week, reserved for severe cardiac iron overload (T2* <10 ms) or acute cardiac decompensation 2, 4
• Deferiprone (oral): 75 mg/kg/day divided in three doses, particularly effective for cardiac iron removal and used in combination therapy for severe cases 2, 4

Monitoring Requirements

• Cardiac MRI T2 annually* to detect cardiac iron before symptoms develop (T2* <20 ms indicates cardiac iron accumulation; T2* <6 ms carries 47% risk of heart failure within 1 year) 2, 4
• Serum ferritin every 3 months as a trend marker, maintaining levels <1000 ng/mL 2, 4
• Echocardiography annually to assess left ventricular ejection fraction 2

Critical Pitfall to Avoid

Never administer iron supplements, multivitamins containing iron, or intravenous iron to transfusion-dependent β-thalassemia patients. 2 These patients have the opposite problem—they are dying from too much iron, not too little. Adding more iron accelerates organ damage and hastens death from cardiac failure.

Additional Dietary Restrictions

• Limit red meat consumption to reduce heme iron intake, which is highly absorbed 2
• Avoid iron-fortified foods when possible 2

Management of Severe Iron Overload

If acute heart failure develops from iron overload, immediately transfer to a specialized thalassemia center and initiate continuous intravenous deferoxamine 50 mg/kg/day PLUS oral deferiprone 75 mg/kg/day (combined intensive chelation therapy). 2, 4 Cardiac iron removal requires several years of intensive chelation even after resolution of acute cardiac failure. 4