Therapeutic Phlebotomy Parameters for Hereditary Hemochromatosis and Iron Overload

Volume and Frequency

The American Association for the Study of Liver Diseases recommends performing weekly or biweekly phlebotomy removing 500 mL of blood per session until serum ferritin reaches 50-100 μg/L, then transitioning to maintenance therapy 1
Remove 500 mL of blood per session during the initial iron depletion phase, as recommended by the American Association for the Study of Liver Diseases 1, 3
Perform phlebotomy weekly or twice weekly as tolerated by the patient, according to the American Association for the Study of Liver Diseases 1, 3
Each 500 mL unit removes approximately 200-250 mg of iron, as stated by the American Association for the Study of Liver Diseases 1

Check hemoglobin or hematocrit before every phlebotomy session, as recommended by the American Association for the Study of Liver Diseases 1
Do not allow hematocrit/hemoglobin to fall more than 20% from baseline, according to the American Association for the Study of Liver Diseases 1

Continue maintenance phlebotomy at individualized intervals to prevent iron reaccumulation, as recommended by the American Association for the Study of Liver Diseases 1, 3
Maintenance frequency varies widely, with some patients requiring monthly phlebotomy and others needing only 1-2 units removed per year, according to the American Association for the Study of Liver Diseases 1

Stop phlebotomy when ferritin reaches 50-100 μg/L to prevent overt iron deficiency, as recommended by the American Association for the Study of Liver Diseases 1, 3
Use extreme caution in patients with cardiac arrhythmias or cardiomyopathy due to increased risk of sudden death with rapid iron mobilization, according to the American Association for the Study of Liver Diseases 1

Avoid vitamin C supplements as they accelerate iron mobilization to potentially dangerous levels, as recommended by the American Association for the Study of Liver Diseases 1, 3, 6
Avoid iron supplements, according to the American Association for the Study of Liver Diseases 3, 7

Reserve iron chelation as second-line therapy only when phlebotomy is not feasible, as recommended by the American Association for the Study of Liver Diseases 4
Deferoxamine: 20-40 mg/kg/day for secondary iron overload due to dyserythropoiesis, according to the American Association for the Study of Liver Diseases 1, 6