Table 1.

Prevention and therapy of iron overload in MDS: proposed algorithm

Primary considerations:	MDS subtype, IPSS, life expectancy, curative vs. palliative therapy plan, age, comorbidity, mental status
Laboratory investigations:	Haematologic parameters and LDH, serum ferritin, transferrin-saturation, liver enzymes, inflammation parameters, (liver imaging studies, tissue biopsy, preferably bone marrow biopsy)
Prophylactic therapy:	EPO ± G-CSF (Nordic score)
	Lenalidomide (in 5q- syndrome patients)
	ATG + CSA (hypoplastic MDS, HLADR15)
	Demethylating agents (complex karyotype)
	Chemotherapy ± SCT (AML-risk, donor, age)
Established iron overload:	Consider therapy with chelating agents based on the following parameters:
	Serum ferritin > 2000 ng mL−1 (without signs of active inflammation or liver disease)
	Transfusion dependent anaemia
	Life expectancy of more than 2 years
	Organopathy resulting from iron overload*
	Planned chemotherapy or SCT†
Selection of chelating agents:	1. Desferoxamine (Desferal®)‡
	2. Deferasirox, ICL670 (Exjade®)‡
	3. Deferiprone, L1 (Ferriprox®)‡

^*In these cases, chelating agents should be considered even if the life expectancy is less than two years.

^†MDS patients with iron overload who undergo stem cell transplantation have a less favourable outcome (survival) compared to patients without iron overload.

^‡If patients cannot tolerate, or do not respond to Desferal, Exjade should be applied unless kidney function is abnormal. If patients cannot tolerate Exjade, have significant side effects (kidney function) or have no response, Ferriprox or other experimental drugs should be considered (if possible in clinical trials). Abbreviations: MDS, myelodysplastic syndromes; IPSS, international prognostic scoring system; LDH, lactate dehydrogenase; EPO, erythropoietin; G-CSF, granulocyte-macrophage colony-stimulating factor; ATG, antithymocyte globulin; CSA, cyclosporine-A; SCT, stem cell transplantation; AML, acute myeloid leukaemia.