Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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Decompensated iron overload or a septic hot joint
Syncope, chest pain, arrhythmia, heart failure, decompensated cirrhosis, acute liver deterioration or severe hyperglycaemia requires urgent medical care; a feverish acutely swollen joint still requires septic-arthritis assessment despite chondrocalcinosis.
Action: Admit through the appropriate acute pathway, stabilise cardiac, hepatic, endocrine or infectious complications, obtain cultures and joint fluid before antibiotics when safe, and involve hepatology, haematology, cardiology, endocrinology or rheumatology without delaying treatment for a genetic result.
Synopsis
Recognise the characteristic hand and crystal-associated joint pattern as a clue to systemic iron overload, confirm hereditary haemochromatosis correctly, and treat organ risk and persistent joint disease as related but distinct problems.
Think haemochromatosis when osteoarthritis-like pain involves the second and third MCP joints, especially with hook osteophytes, wrist or knee chondrocalcinosis, ankle disease or early hip replacement.
The first biochemical pair is fasting or repeat transferrin saturation and ferritin: transferrin saturation detects inappropriate circulating iron availability, whereas ferritin is an acute-phase and liver-injury marker as well as an iron-store marker.
In an HFE C282Y homozygote, raised transferrin saturation plus ferritin above sex-appropriate thresholds can establish provisional iron overload; other genotypes generally need specialist evidence of hepatic iron on MRI or biopsy.
Key red flags
Exertional syncope, sustained palpitations, chest pain, breathlessness, oedema or heart failure can reflect iron-related cardiomyopathy or arrhythmia and requires urgent cardiac assessment.
Investigation priorities
01
First-line transferrin saturation and ferritinFirst stepFirst line
Identify biochemical iron loading while distinguishing circulating iron excess from nonspecific hyperferritinaemia.
Management branches
First diagnostic priorityConfirm iron loading, not ferritin alone
Characteristic MCP or CPPD-pattern arthropathy, systemic features or a family history raises suspicion.
Request transferrin saturation and ferritin together, with FBC, liver profile and CRP or clinical inflammation context; repeat discordant borderline results.
If biochemical loading is present, arrange HFE testing with consent and ancestry-aware interpretation and review alcohol, metabolic liver disease, transfusions and haematological causes.
Systemic stagingDefine organ harm before routine joint care
Hereditary haemochromatosis or convincing iron overload is confirmed.
Key medicines
Therapeutic venesectionIn induction, remove about 400 to 500 mL of blood weekly or every two weeks, individualised to size and tolerance, until ferritin is about 50 micrograms/L but not lower. In maintenance, repeat often every 1 to 4 months to keep ferritin around 50 to 100 micrograms/L.
Diclofenac 1.16% gelApply 2 to 4 g over the painful hand or other superficial joint three or four times daily for the shortest useful period; wash the hands afterwards unless they are the treatment site.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.