Management of Iron Overload

Assessment and Treatment

The American College of Cardiology recommends therapeutic phlebotomy as the first-line treatment for patients with elevated ferritin and polycythemia to reduce iron stores and improve symptoms of chronic fatigue 1, 2
The patient's ferritin level indicates mild iron overload, and the elevated hemoglobin, hematocrit, and RBC count indicate polycythemia, which can contribute to hyperviscosity and associated complications 1, 2

Initiate therapeutic phlebotomy with removal of 450-500 mL of blood weekly or biweekly until ferritin levels decrease to 50 ng/mL or less, as recommended by the American College of Cardiology and Hepatology 1, 3
Monitor hematocrit prior to each phlebotomy session, and avoid allowing hematocrit to fall by more than 20% of prior level during any single session, according to Hepatology guidelines 3
Check serum ferritin level every 10-12 phlebotomies to track progress, as suggested by Hepatology 3
Once target ferritin level is achieved, transition to maintenance phlebotomy, typically 3-4 times per year for men and 1-2 times for women, as recommended by the American College of Cardiology 1

Monitor serum ferritin, hemoglobin, and hematocrit regularly during treatment, as recommended by the American College of Cardiology and Hepatology 1, 3
Avoid vitamin C supplements, which can enhance iron absorption and potentially worsen iron overload, according to the American College of Cardiology and Hepatology 1, 3
Minimize alcohol consumption, which increases iron absorption, as recommended by the American College of Cardiology 1

Avoid excessive phlebotomy, which could lead to anemia and worsen fatigue symptoms, as warned by Hepatology 3
Consider genetic testing for hereditary hemochromatosis if ferritin levels remain elevated despite therapy or if there is a family history of iron overload, as suggested by Hepatology 3
Be aware that ferritin is an acute phase reactant, and inflammatory conditions may falsely elevate levels, so interpret in context of clinical picture, according to Clinical Nutrition 2