What are the alternatives to ICT?

• For MDS patients achieving TI and reasonable Hb levels with MDS therapies such as ESA, lenalidomide or HMA, serial phlebotomy to reduce IOL may be considered. Some data, however, indicate that this treatment alone may not reduce IOL even though RBC transfusion requirements are reduced, possibly a consequence of the erythroferrone/hepcidin pathway¹.
  • Note that phlebotomy will not reduce NTBI quickly.
• When should iron chelation therapy be started?
• In BTM, explicit clinical guidelines have established thresholds of LIC that trigger ICT; thresholds have not been validated in MDS, and the risk/benefit ratio of ICT agents is different in adults. Transfusion rates and iron loading are more heterogeneous in MDS. Without direct measurement of total body iron burden, the decision to start ICT in MDS should be based on determination of actual or predicted physiologically significant IOL, using duration/number of RBC transfusions, SF and transferrin saturation as guidance.
• Future studies should investigate whether intervening earlier & preventing significant IOL may be beneficial vs trying to rescue damaged tissue & being limited by ICT side effects.