Can Iron Treatments Aggravate Epistaxis in Some Patients With Hereditary Hemorrhagic Telangiectasia?
To examine whether there is a rationale for iron treatments precipitating nosebleeds (epistaxis) in a subgroup of patients with hereditary hemorrhagic telangiectasia (HHT).



Survey evaluation of HHT patients, and a randomized control trial in healthy volunteers.



Nosebleed severity in response to iron treatments and standard investigations were evaluated by unbiased surveys in patients with HHT. Serial blood samples from a randomized controlled trial of 18 healthy volunteers were used to examine responses to a single iron tablet (ferrous sulfate, 200 mg).



Iron tablet users were more likely to have daily nosebleeds than non-iron-users as adults, but there was no difference in the proportions reporting childhood or trauma-induced nosebleeds. Although iron and blood transfusions were commonly reported to improve nosebleeds, 35 of 732 (4.8%) iron tablet users, in addition to 17 of 261 (6.5%) iron infusion users, reported that their nosebleeds were exacerbated by the respective treatments. These rates were significantly higher than those reported for control investigations. Serum iron rose sharply in four of the volunteers ingesting ferrous sulfate (by 19.3-33.1 μmol/L in 2 hours), but not in 12 dietary controls (2-hour iron increment ranged from -2.2 to +5.0 μmol/L). High iron absorbers demonstrated greater increments in serum ferritin at 48 hours, but transient rises in circulating endothelial cells, an accepted marker of endothelial damage.



Iron supplementation is essential to treat or prevent iron deficiency, particularly in patients with pathological hemorrhagic iron losses. However, in a small subgroup of individuals, rapid changes in serum iron may provoke endothelial changes and hemorrhage.



4. Laryngoscope, 126:2468-2474, 2016.
Cardiovascular Sciences, National Heart and Lung Institute, Imperial College London, London, United Kingdom. c.shovlin@imperial.ac.uk.|Respiratory Medicine, Imperial College Healthcare National Health Service Trust, London, United Kingdom. c.shovlin@imperial.ac.uk.
Claire L
CL
Shovlin
Respiratory Medicine, Imperial College Healthcare National Health Service Trust, London, United Kingdom.
Clare
C
Gilson
Clinical Chemistry, Imperial College Healthcare National Health Service Trust, London, United Kingdom.
Mark
M
Busbridge
Cardiovascular Sciences, National Heart and Lung Institute, Imperial College London, London, United Kingdom.
Dilip
D
Patel
Cardiovascular Sciences, National Heart and Lung Institute, Imperial College London, London, United Kingdom.
Chenyang
C
Shi
Department of Surgery and Cancer, Imperial College London, London, United Kingdom.
Roberto
R
Dina
Cardiovascular Sciences, National Heart and Lung Institute, Imperial College London, London, United Kingdom.|Imperial College London School of Medicine, London, United Kingdom.
F Naziya
FN
Abdulla
Cardiovascular Sciences, National Heart and Lung Institute, Imperial College London, London, United Kingdom.|Imperial College London School of Medicine, London, United Kingdom.
Iman
I
Awan
D001803:Blood Transfusion; D019587:Dietary Supplements / Q000009:adverse effects*; D004844:Epistaxis / Q000139:chemically induced* / Q000628:therapy; D005260:Female; D005296:Ferrous Compounds / Q000008:administration & dosage / Q000009:adverse effects*; D006801:Humans; D007501:Iron / Q000008:administration & dosage / Q000097:blood*; D008297:Male; D008875:Middle Aged; D011795:Surveys and Questionnaires; D013683:Telangiectasia, Hereditary Hemorrhagic / Q000097:blood / Q000628:therapy*
D005296:Ferrous Compounds; C020748:ferrous sulfate; D007501:Iron
Epistaxis; iron