From the Guidelines
Elevated ferritin levels should be managed with therapeutic phlebotomy, aiming for a target serum ferritin level of 50-100 lg/L, as recommended by the most recent guidelines 1.
Key Considerations
- Elevated ferritin levels indicate excess iron storage in the body and require medical evaluation to determine the underlying cause, which could be conditions like hemochromatosis, inflammation, liver disease, or certain cancers.
- Initial management involves blood tests, including complete iron studies, liver function tests, and possibly genetic testing for hereditary hemochromatosis.
- Treatment depends on the underlying cause but may include therapeutic phlebotomy for iron overload conditions, with sessions typically removing 400-500ml of blood every 1-2 weeks until ferritin normalizes.
- Dietary modifications to reduce iron intake are also helpful, including limiting red meat, iron-fortified foods, and alcohol, which can worsen liver damage.
- For hereditary hemochromatosis, lifelong maintenance phlebotomy may be needed every 2-4 months to prevent organ damage.
Monitoring and Maintenance
- Serum ferritin should be monitored every month during the induction phase and every 6 months during the maintenance phase to adapt the treatment schedule and ensure that ferritin remains within the target range 1.
- Serum haemoglobin should always be monitored during both induction and maintenance phases, and phlebotomy should be discontinued if haemoglobin concentrations are <11 g/dl.
- Transferrin saturation may remain increased even when serum ferritin levels are within the target range, and its monitoring is still an open issue due to the lack of evidence-based target levels.
Importance of Treatment
- Treating elevated ferritin is crucial to prevent organ damage, as excess iron can deposit in the liver, heart, pancreas, and joints, potentially leading to cirrhosis, heart failure, diabetes, and arthritis if left untreated.
- The goal of treatment is to reduce iron stores to normal levels, improve survival, and enhance the patient's sense of well-being and energy level, as supported by guidelines from reputable sources 1.
From the Research
Causes of Elevated Ferritin Level
- Elevated ferritin levels can be caused by various conditions, including non-human immunodeficiency virus infection, solid tumor, liver dysfunction, renal failure, and hematological malignancy 2
- Hyperferritinemia can also be the result of inflammation, infection, iron overload, or other uncommon pathologies including hemophagocytic lymphohistiocytosis (HLH) 3
- In most cases, hyperferritinemia is not related to an iron overload, but rather to acute phase reactions and reactive increases in ferritin due to underlying conditions 4
Diagnosis and Evaluation
- The level of serum ferritin can be determined by the underlying conditions to a certain extent, but the variation is significant 2
- The H score can be used as a screening tool to rule out the probability of HLH when facing critical clinical situations 3
- An algorithm for the diagnostic workup and management of hyperferritinemia can be proposed, including the evaluation of iron overload and the treatment of underlying conditions 4
Treatment and Management
- Iron chelating therapy can be considered if serum ferritin is above 1000μg/L and if liver iron concentration assessing by MRI exceeds 80μmol/g 5
- The decision to treat hyperferritinemia should be individualized, and may be influenced by the presence of other features of iron overload 6
- Deferoxamine, deferiprone, and deferasirox are iron chelating agents that can be used to treat iron overload, but their use should be carefully evaluated based on the benefit/risk ratio 5