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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 (Gut1997;41:14–18) found that gastric cancer cells are more susceptible to photodynamic therapy when iron is removed. Boucheret al (Gut 1997;41:115–20) found that treatment of hepatitis C with interferon leads to a decrease in liver iron content. Bacon (Gut1997;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 α.
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.