Recommendations for managing iron chelation in patients with MDS
| Confirm iron overload | • Try to determine the number of RBC units transfused so far. • Measure SF and note possible interference by inflammation. • Measure transferrin saturation (if > 70%-80%, toxic labile plasma iron will be present). • MRI can detect cardiac iron overload not suspected from SF measurements. |
| Consider cardiac comorbidities | Only a minority of MDS patients have cardiac iron overload detectable by MRI. However, iron-related oxidative stress can aggravate cardiac comorbidities. The latter should thus be viewed as a supporting argument for iron chelation. |
| Assess the patient‘s prognosis | Candidates for iron chelation should have a life expectancy of at least 1-2 years because it takes time for iron-related organ damage to become clinically significant. |
| Check the indication for iron chelation | If life expectancy is adequate and continued ineffective erythropoiesis or transfusion need is anticipated, most guidelines recommend starting ICT when SF levels exceed 1000 or 1500 ng/mL. |
| Choose an iron chelator | • The oral iron chelator DFX is most widely used (effective, convenient). • The oral iron chelator DFP is most effective in mobilizing cardiac iron. • Continuous parenteral DFO can be considered in combination with DFP to harness a shuttle effect for enhanced removal of cardiac iron. |
| Monitor for important side effects | • DFX dose must be adjusted to GFR in patients with impaired renal function. • When using DFP, perform regular blood counts to detect agranulocytosis. • During DFO and DFX therapy, monitor for visual disturbances and hearing loss. |
| Confirm iron overload | • Try to determine the number of RBC units transfused so far. • Measure SF and note possible interference by inflammation. • Measure transferrin saturation (if > 70%-80%, toxic labile plasma iron will be present). • MRI can detect cardiac iron overload not suspected from SF measurements. |
| Consider cardiac comorbidities | Only a minority of MDS patients have cardiac iron overload detectable by MRI. However, iron-related oxidative stress can aggravate cardiac comorbidities. The latter should thus be viewed as a supporting argument for iron chelation. |
| Assess the patient‘s prognosis | Candidates for iron chelation should have a life expectancy of at least 1-2 years because it takes time for iron-related organ damage to become clinically significant. |
| Check the indication for iron chelation | If life expectancy is adequate and continued ineffective erythropoiesis or transfusion need is anticipated, most guidelines recommend starting ICT when SF levels exceed 1000 or 1500 ng/mL. |
| Choose an iron chelator | • The oral iron chelator DFX is most widely used (effective, convenient). • The oral iron chelator DFP is most effective in mobilizing cardiac iron. • Continuous parenteral DFO can be considered in combination with DFP to harness a shuttle effect for enhanced removal of cardiac iron. |
| Monitor for important side effects | • DFX dose must be adjusted to GFR in patients with impaired renal function. • When using DFP, perform regular blood counts to detect agranulocytosis. • During DFO and DFX therapy, monitor for visual disturbances and hearing loss. |