Removal of iron from a patient with hemochromatosis is typically done by repeat phlebotomy. The decisions are when to initiate therapy and when to taper the frequency of treatments. The Hemochromatosis Management Working Group has given recommendations for initiating therapeutic phlebotomy in these patients.


Each unit of blood from a nonanemic patient contains approximately 250 mg of iron. A patient with anemia can still be phlebotomized but the procedure will be less efficient.


The guidelines apply to a person:

(1) homozygous for hemochromatosis genes

(2) heterozygous for hemochromatosis genes

(3) with a hemochromatosis phenotype (iron overload and appropriate clinical features) irregardless of genotype for hemochromatosis genes


Age and Factors

Serum Ferritin Threshold for Starting Phlebotomy


< 18 years

>= 200 µg/L


>= 18 years

>= 300 µg/L


< 18 years, nonpregnant

>= 200 µg/L


< 18 years, pregnant

>= 500 µg/L


>= 18 to menopause, nonpregnant

>= 200 µg/L


>= 18 to menopause, pregnant

>= 500 µg/L



>= 300 µg/L



• Post-menopausal includes post-hysterectomy or states without menstruation.

• The original table was a little unclear for handling a female < 18 years and pregnant.

• A pregnant woman will lose 1 gram of iron if the pregnancy is taken to term.

• The notes to the table says that therapeutic phlebotomy is usually deferred in a pregnant woman unless there is significant cardiac or hepatic dysfunction. But then the patient would be become nonpregnant and a lower threshold would seem to apply. It would appear that the organ dysfunction becomes the key determinant.

• The patient with iron overload associated with chronic transfusion therapy for anemia is usually managed differently (with iron chelators) since they would probably not tolerate the loss of blood.


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