Iron reduction therapy in hepatitis C
EDITOR,—Three papers in the July issue
report on the possible association between
iron and tissue damage in conditions other
than haemochromatosis. Tan et al (Gut
1997;41:14–18) found that gastric cancer
cells are more susceptible to photodynamic
therapy when iron is removed. Boucher et al
(Gut 1997;41:115–20) found that treatment
of hepatitis C with interferon leads to a
decrease in liver iron content. Bacon (Gut
1997;41:127–8) briefly commented on the
association between iron and hepatitis C,
including some evidence that iron depletion
may be beneficial in patients who fail to
respond to interferon á.
Shortly after Bacon et al’s pioneering
report in 1993 on iron reduction therapy in
hepatitis C,1 and mainly because of a lack of
any other option at the time, we started
applying this form of therapy in our growing
population of patients who had failed to
respond to interferon and who had the unfavourable
1b genotype.
The simplest and cheapest way to reduce
body iron stores is repeated drawing of one
unit of whole blood (as for haemochromatosis).
However, we encountered several unexpected
difficulties in our attempts to implement
a phlebotomy programme for patients
with chronic hepatitis C. A small group of
patients are reluctant to undergo repeated
phlebotomy because of ethnic or psychological
reasons (there is a belief that blood equals
life and therefore that blood loss depletes the
body of life giving power). A second group
cannot tolerate blood loss because of recurrent
episodes of faintness and presyncope.
These patients need several hours’ observation,
a chaperone, and sometimes intravenous
fluid before they can be discharged home. In
a third group venous access is a problem. The
large bore needles of standard phlebotomy
bags can be inserted into large straight veins
only. Most female and some male patients do
not have suitable veins and this problem
becomes more serious with age. This obstacle
can be overcome by improvisation with
smaller bore needles but this has the
disadvantage of slower flow, increased stasis
and coagulation within the tubing, sometimes
necessitating reinsertion of the iv line. A
fourth impediment in a busy gastroenterology/
hepatology department is lack of
enthusiasm among nursing staff and a shortage
of beds and space in the recovery room. It
also seems unwise to place patients with
chronic hepatitis C undergoing phlebotomy
and large quantities of potentially hazardous
blood alongside uninfected patients recovering
from endoscopy. This also limits the time
available for phlebotomy.
We devised a simple way to circumvent all
of these difficulties: all new patients with
chronic hepatitis C (unless they have an iron
deficiency) are shown a 50 ml syringe as early
as possible in their workup. They are told that
from now on they should ask for all blood
tests to be taken only with such syringes and
that any surplus blood should be discarded
with the syringe in the biohazard containers.
This also applies when vacutainer tubes are
used. As iron overload in these patients is not
as great as in those with haemochromatosis,
iron depletion can be accomplished in 20–40
phlebotomy sessions (a 50 ml syringe can
contain ~70 ml blood). Thus iron reduction
therapy is achieved more slowly than with
conventional phlebotomy but is integrated
into the routine workup and is accepted by
both patients and staff alike.
We hope that our method may be useful to
other clinicians in the field.
Y LURIE
M BEER GABEL
I LAMBORT
T SOUMATZKY
S D H MALNICK
D D BASS
Kaplan Medical Center,Affiliated to the
Hebrew University Medical School and Hadassah,
PO Box 1, Rehovot 76100, Israel

Who loves ya.
Tom

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