Treatment of Hemochromatosis-Associated Arthritis

Introduction to Hemochromatosis Arthropathy

Arthropathy affects 45-57% of hemochromatosis patients, commonly presenting as the first manifestation of disease before other systemic symptoms develop 1, 2
Typical distribution involves the 2nd and 3rd metacarpophalangeal joints (46.9%), ankles (69.3%), and hips (56.8%), with earlier age of onset than primary osteoarthritis 1, 2
Radiographic features include joint space narrowing, exuberant osteophytes, subchondral cysts, and chondrocalcinosis in 50% of cases 1, 2
The arthropathy can develop even during maintenance phlebotomy therapy, distinguishing it from other iron-related complications 1, 2

Initiate weekly therapeutic phlebotomy immediately, removing 450-500 mL of blood per session until serum ferritin reaches 50 μg/L 3, 4
Continue lifelong maintenance phlebotomy 2-6 times per year to maintain ferritin between 50-100 μg/L 3, 4
Phlebotomy prevents progression of liver disease, cardiac complications, and diabetes, which account for the majority of hemochromatosis-related mortality 3, 5

Analgesics and NSAIDs are the mainstay of medical management for pain control 1, 2
Joint replacement surgery (hip and knee arthroplasty) is ultimately required for end-stage arthropathy 1, 2
Patients with hemochromatosis have significantly increased risk of requiring hip replacement (HR 2.77) and knee replacement (HR 2.14) compared to controls 1, 2

Avoid iron supplements and iron-fortified foods entirely 3, 4, 6
Avoid supplemental vitamin C, especially during iron depletion phase, as it accelerates iron mobilization and increases oxidative stress 3, 4, 6
Limit red meat consumption and restrict alcohol intake during iron depletion 3, 4, 6

Arthropathy symptoms significantly affect quality of life and often progress despite optimal iron management 1, 2
Monitor for rapid progression to cartilage loss, which is characteristic of hemochromatosis arthropathy 1, 2
Patients with cirrhosis require lifelong HCC screening every 6 months regardless of iron depletion status 3, 7