ArcaMax

DEAR DR. ROACH: I am Greek and have thalassemia minor. In general, my red blood cells are much smaller than typical ones, and my iron content is significantly low. Every time I see a different doctor who prescribes a blood test, they always emphasize that my iron content is low and that I should take iron supplements.

I am not sure this is reasonable advice, as I understand thalassemia isn't an issue with absorbing iron from the diet, but rather an inability to store iron in the red blood cells due to their small size.

Will taking iron supplements increase my iron levels? I am afraid of taking in more iron than my body can store. Will the excess iron ultimately be excreted? I know that high iron levels are bad for overall health. It isn't as if my body will create more red blood cells to store iron as heme just because I have an increased iron intake; my body will remove the excess iron.

If iron supplements aren't truly effective, what are my options to avoid fatigue during exercise due to lack of iron? -- P.L.

ANSWER: There are two different families of thalassemia, which comes from the Greek word for sea. (Thalassemias are very common in the Mediterranean.) Alpha thalassemias have reduced or missing alpha chains, while beta thalassemias have reduced or missing beta chains. There are four alpha genes and two beta genes, which means that there's an immense number of possibilities of different kinds of thalassemias.

You most likely have beta thalassemia minor (one normal gene and one that causes low beta-cell-chain production), which consists of mild anemia and very small cells. This condition can look very much like iron deficiency. Clinicians should make sure of the diagnosis before treating patients with iron.

Unless they also have iron deficiency, iron won't help people with beta thalassemia minor at all. The combination of thalassemia and iron deficiency produces the smallest red blood cells that have been seen in clinical practice. For beta thalassemia minor in particular, iron overload isn't a problem, but other thalassemias can cause iron overload. So, giving iron can be harmful for some.

In your case, I expect that your body will not absorb the extra iron. The body has no way of getting rid of excess iron that's already absorbed, so treatment for people with iron overload either requires bloodletting (phlebotomy) or chelation (giving a medicine to let the body excrete iron).

Someone in your position should have a careful evaluation of their iron stores. Comparing your blood counts with your previous normal readings is helpful. You probably had a hemoglobin electrophoresis test done at some point to make the diagnosis of beta thalassemia minor, so this would be useful to present to new doctors. Making a definitive diagnosis of beta thalassemia minor requires DNA testing, and a hematologist is the expert in diagnosing thalassemias.

Most people with thalassemia minor (alpha or beta) do not develop fatigue due to anemia, as the anemia is quite mild. If you have fatigue with exercise, I'd be concerned that you have more than one problem. Coexisting iron deficiency could be the reason behind it, but there are many causes for fatigue. You need a sharp generalist doctor to help sort out the fatigue.

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Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or send mail to 628 Virginia Dr., Orlando, FL 32803.

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