By Alexander K. Glaros, MD, and Ahmar U. Zaidi, MD

If you’re a nerd like

Scratch that…If you’re in Orlando this week, it’s either because you have a favorite blood cell type (gotta be the sea blue histiocyte) or you still haven’t given up on your childhood dream of being a Disney hero/heroine (my Halloween costume was “for the kids,” too…), so let’s not kid ourselves.

Since you’re a nerd like me, chances are, in addition to one of the aforementioned prerequisites for attending the 2019 ASH Annual Meeting, you understand one of two truths. First, the sun set on pre-historic man with the dawn of the iron age, which was marred by centuries of efficiently bloody and barbaric warfare but ultimately led to the cultural and intellectual revolutions of the Classical Greek and Roman Empires. Second, Iron Man is the most important and greatest Avenger who founded it all and ultimately saved the world from certain annihilation at the hands of Thanos by being smart and determined enough to find a happy ending among the ashes of The Snap. If you didn’t know either of those things, you’re too cool for this conference. Orthopedics is meeting in March. If you still think you’re in the right place (nerds come in all shapes and sizes), come to the session IRON: How to Manage When There Is Too Much or Too Little of It, and you will remember that just as the world turns on an axis of iron, so too does the world of hematology. You will come to see time as before iron and after iron, separated by our ability to harness its power for good without destroying the rest of the body in the process.

Michelle Zeller, MD, of McMaster University will chair this case-based Education Program session that will open your eyes to the “earth’s ultimate irony,” but you’ll have to attend to find out what that is. While it may not sound as sexy as the leukemias or lymphomas you’ll hear about at other sessions (according to Dr. Zeller), iron deficiency is much more common than either of them, and its prompt and proper management can have a profound impact on the quality of life of those affected by it. There are only four reasons for developing iron deficiency (problems with absorption, availability, loss, or increased demand), and four ways of replenishing it (via nutrition, oral supplementation, IV supplementation, or blood transfusion), but the management of iron deficiency is anything but a simple four-step problem. Only a multidisciplinary approach and consideration of a very complex system of iron regulation can allow for the rapid identification of problems that can cause the symptom of iron deficiency.

The disconnect between our academic understanding and our clinical understanding of iron metabolism, and the effort to modernize our evaluations of iron status, are the subject of the second portion of this session, presented by Yelena Ginzburg, MD. There are several diagnostic markers and assays available for the evaluation of appropriate or inappropriate iron restriction in complex cases of iron deficiency, but this testing is commonly either not well understood by clinicians or not reimbursable by insurance. The wide availability and rapid clinical effectiveness (though not cost effectiveness) of IV iron infusions especially have made it easy to skirt over a detailed evaluation of disordered iron physiology. Dr. Ginzburg will make you rethink this practice and provide hope for the future of more comprehensive, efficient, and cost-effective management of complex cases of iron deficiency.

Thomas Coates, MD, will complete the portrait of iron as a primary driver of hematologic as well as overall health, by exploring the variability in presentation and necessary management of iron overload, while also painting an optimistic future for this condition in light of recent paradigm shifts in the management strategy. He will discuss the differing toxicity of transferrin-bound and free iron, the variable ability to clear and utilize free iron based on underlying diagnosis, and the newly realized long-term risks of chronic free iron exposure as the massively improved patient survival approaches that of the general population. As is always the case in medicine, the conquering of one problem unmasks another, and the increased risk of cancers and other health problems late in life is the tradeoff for extending the lives of transfusion-dependent patients with anemia beyond the first two decades. Dr. Coates will discuss what has brought us to this point and where we are headed in the future.

Iron management is often considered the low hanging fruit of the hematology world — easy to address and also easy to punt to a general practitioner. However, after this enlightening session, which takes place Sunday at 4:30 p.m. (W331, Level 3, Orange County Convention Center – map it), and again on Monday at 10:30 a.m. (same location), you may look twice at your next “easy RVU” referral and be able to more efficiently bring your patients forward into the happier and healthier longevity of the years after iron.                                                         

Dr. Glaros and Dr. Zaidi indicated no relevant conflicts of interest.

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