European Journal of Haematology 96 (318326)

ORIGINAL ARTICLE

Role of vitamin C as an adjuvant therapy to different iron

chelators in young -thalassemia major patients: efficacy
and safety in relation to tissue iron overload
Mohsen S. Elalfy1, Maha M. Saber2, Amira Abdel Moneam Adly1, Eman A. Ismail3, Mohamed Tarif3,
Fatma Ibrahim2, Omar M. Elalfy2
1

Pediatrics Department, Faculty of Medicine, Ain Shams University, Cairo; 2Child Health in Complementary Medicine, National Research Center,
Cairo; 3Clinical Pathology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt

Abstract
Background: Vitamin C, as antioxidant, increases the efficacy of deferoxamine (DFO). Aim: To investigate
the effects of vitamin C as an adjuvant therapy to the three used iron chelators in moderately ironoverloaded young vitamin C-deficient patients with b-thalassemia major (b-TM) in relation to tissue iron
overload. Methods: This randomized prospective trial that included 180 b-TM vitamin C-deficient patients
were equally divided into three groups (n = 60) and received DFO, deferiprone (DFP), and deferasirox
(DFX). Patients in each group were further randomized either to receive vitamin C supplementation
(100 mg daily) or not (n = 30). All patients received vitamin C (group A) or no vitamin C (group B) were
followed up for 1 yr with assessment of transfusion index, hemoglobin, iron profile, liver iron
concentration (LIC) and cardiac magnetic resonance imaging (MRI) T2*. Results: Baseline vitamin C was
negatively correlated with transfusion index, serum ferritin (SF), and LIC. After vitamin C therapy,
transfusion index, serum iron, SF, transferrin saturation (Tsat), and LIC were significantly decreased in
group A patients, while hemoglobin and cardiac MRI T2* were elevated compared with baseline levels or
those in group B without vitamin C. The same improvement was found among DFO-treated patients postvitamin C compared with baseline data. DFO-treated patients had the highest hemoglobin with the lowest
iron, SF, and Tsat compared with DFP or DFX subgroups. Conclusions: Vitamin C as an adjuvant therapy
possibly potentiates the efficacy of DFO more than DFP and DFX in reducing iron burden in the
moderately iron-overloaded vitamin C-deficient patients with b-TM, with no adverse events.
Key words vitamin C; thalassemia major; iron chelators; tissue iron overload; cardiac MRI T2*
Correspondence Amira Abdel Moneam Adly, 6 A ElSheshini street, Shoubra, Soudia buildings, Cairo, Egypt. Tel: +01005245837;
Fax: +20233375435; e-mail: amiradiabetes@yahoo.com
Accepted for publication 23 May 2015

In the absence of an iron-chelating agent, patients with b-thalassemia major on regular transfusions present complications
of transfusion-related iron overload. Currently, there are three
iron-chelating agents available for continuous use in patients
with thalassemia major on regular transfusions (deferoxamine
[DFO], deferiprone [DFP], and deferasirox [DFX]) providing
good results in reducing cardiac, hepatic, and endocrine toxicity (1). DFO still represents the standard iron-chelating therapy (2, 3). Unfortunately, compliance with the rigorous
requirements of daily subcutaneous DFO infusions is still a
serious limiting factor in treatment success (4). DFP has been

318

doi:10.1111/ejh.12594

in clinical use for over 20 yr and has been shown to be effective in reducing cardiac iron load and improving cardiac function (5). DFX is a once-daily administered chelator that has
gained wide acceptance in transfusionally iron-overloaded
patients (6, 7). Although most patients achieve neutral iron
balance at doses of approximately 25 mg/kg/d, some patients
do not achieve iron balance with doses as high as 40 mg/kg/d
(8). DFX removes iron more consistently from hepatocytes
than from reticuloendothelial macrophages (9, 10).
The principal defense systems against oxygen free radicals
are superoxide dismutases (SOD), reduced glutathione,

2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Vitamin C as adjuvant to iron chelators in b-TM

Elalfy et al.

glutathione peroxidase, and antioxidant nutrients including

vitamins A, E, and C (11, 12). Vitamin C is a strong antioxidant capable of scavenging a wide variety of reactive
oxygen and nitrogen species. It is the most effective antioxidant in human plasma against lipid peroxidation induced by
peroxyl radicals (13). Regular supply of vitamin C or dietary
nutrition is not sufcient to meet the cells requirement for
antioxidant protection in patients with severe transfusiondependent thalassemia (14). Ascorbate deciency is common
in iron-overloaded subjects (15, 16) and may modulate iron
distribution (17). Animal studies showed that ascorbate
replacement in the presence of DFO can markedly improve
urinary iron elimination, consistent with the hypothesis that
redox cycling is necessary for iron mobilization (18, 19).
However, as excessive vitamin C can increase the toxicity of
iron if given to heavily overloaded patients with b-thalassemia major (b-TM), ascorbate repletion must be done
cautiously in any patient having cardiac iron stores because
of the theoretical risk of increased labile myocyte iron (20).
To the best of our knowledge, the inuence of vitamin C
supplementation in iron-overloaded pediatric patients with
b-TM on oral chelation therapy has not been explored in a
prospective study. Therefore, we investigated the efcacy
and safety of oral vitamin C supplementation as an adjuvant
therapy to the three available iron chelators (DFO, DFP, and
DFX) in moderately iron-overloaded children and adolescents with b-TM and assessed its relation to tissue iron
overload over a 1-yr study.
Patients and methods

This randomized prospective study was approved from the

local ethical committee and registered in the ClinicalTrials.gov (NCT02083575). One-hundred and eighty patients
with b-TM (18 yr) who had met the inclusion criteria were
recruited from the regular attendants of the Hematology
Clinic, Pediatric Hospital, Ain Shams University. An
informed consent was obtained from the guardian of each
patient before participation. Reporting of the study conforms
to Consolidated Standards of Reporting Trials (CONSORT)
2010 statement (21).
Inclusion criteria were as follows: moderately iron-overloaded b-TM patients without clinical symptoms of cardiac
dysfunction, had vitamin C deciency, with serum ferritin
(SF) >1000-2500 ng/mL and cardiac T2* > 10 ms calculated as geometric mean, and ejection fraction > 56%.
Exclusion criteria included patients suffered from insulindependent diabetes, left ventricular ejection fraction 56%,
active hepatitis (serum transaminases >5 times above upper
limit of normal [ULN]), or renal impairment (serum creatinine >2 times ULN), sepsis or active infection, participation
in a previous investigational drug study within the 30 d preceding screening, and patients with a known allergy to DFX,
DFP, and DFO.

2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Sample size

The sample size was calculated using power and sample size
calculation program EpiInfo version 6.0 (Centre for Disease
Control and Prevention, Atlanta, GA, USA). Sample size
calculation for three-group repeated-measure experiments
was performed. The sample size was calculated by the
following assumption that the difference in the mean percent
of SF between the baseline value and end study value is
20%, and at alpha level of 0.05 and power of the test of
90%, a sample of at least 30 patients is required to nd a
signicant difference in the mean values of SF between
baseline data and end of treatment.
Randomization process and study groups

Two-hundred and ninety patients with b-TM were screened

for eligibility; 180 were enrolled, while 80 did not meet inclusion criteria and 30 were excluded (Fig. 1). Drug administration was according to a predetermined schedule generated
from random numbers in a 1 : 1 : 1 manner based on a computer-generated randomization sequence maintained within
the investigational drug pharmacy with allocation concealment
by opaque sequentially numbered sealed envelope. A total of
180 patients were randomly assigned into three groups (60
patients in each group) receiving either DFO (Desferal, Novartis Pharma AG, Basel, Switzerland) infused subcutaneously in
a dose of 40 mg/kg/d (5 d/wk), DFP (Apotex, Toronto, ON,
Canada) 75 mg/kg/d, or DFX (Exjade; Novartis Pharma AG,
Basel, Switzerland) 25 mg/kg/d. To achieve an acceptable
treatment washout, previous chelation therapy was withdrawn
for 2 wk before randomization.
Patients in each of the three chelation groups were further
randomly divided into two subgroups according to vitamin
C supplementation. Thirty patients in each chelation group
received oral vitamin C in the morning in a dose of 100 mg
daily for 1 yr to clearly dene the therapeutic response.
Thus, the total number of patients receiving vitamin C was
90 representing group A, while group B included the other
90 patients who did not receive vitamin C (Fig. 1). Throughout the study, the patients consumed a low-iron diet (11
15 mg of iron/d) and standard vitamin C diet.

Baseline clinical assessment

All patients were initially subjected to detailed medical history

and thorough clinical examination stressing on spleen status,
transfusion history with calculation of transfusion index, chelation therapy, and evidence of renal and hepatic disease.

Sample collection and laboratory analysis

Peripheral blood samples were withdrawn in the pretransfusion phase and collected on ethylene diamine tetra acetic

319

Vitamin C as adjuvant to iron chelators in b-TM

Elalfy et al.

Figure 1 CONSORT flow diagram for the

enrolled patients with b-thalassemia major.
Dashed boxes constitute group A (n = 90) and
double lined boxes constitute group B (n = 90).

acid (EDTA) (1.2 mg/mL) for complete blood count (CBC)

and hemoglobin analysis. For chemical analysis, clotted samples were obtained and serum was separated by centrifugation for 15 min at 1000 g. For vitamin C assay, blood was
collected in heparinized tubes and separated at once and the
plasma stored at 70C.
CBC was done using Sysmex XT-1800i (Sysmex, Kobe
Japan). Hemoglobin analysis was performed using D-10
(Bio-Rad, Marnes La Coquette, France). Liver and kidney
function tests, serum iron, total iron binding capacity
(TIBC), and SF were done on Cobas Integra 800 (Roche
Diagnostics, Mannheim, Germany) with calculation of transferrin saturation (Tsat). Transfusion burden at baseline was
assessed using steady-state SF levels (with calculation of the
mean value of the last year prior to the study in order to
know the ferritin trend). Vitamin C was determined by the
colorimeteric method as redox reaction of ascorbate with
2,6-dichlorophenol indophenol in acid solution involving the
reduction in this dye to a colorless leucobase, while ascorbate is oxidized to dehydroascorbate (2224). Fifty control
samples from age- and sex-matched healthy volunteers were
enrolled during analysis of patients samples to determine
the reference range.
Radiological examination

Measurement of liver iron concentration (LIC) was performed by magnetic resonance imaging (MRI) R2*. It was
determined using a single 10-mm slice through the center of
the liver scanned at 12 different echo times (25, 26). For the
assessment of cardiac iron overload, a multislice multiecho
T2* approach was used (27, 28). Aggregate cardiac T2*

320

data are thus reported in terms of geometric mean values

calculated from the log-transformed T2* values.
Follow-up and endpoints

All patients were followed up on regular hospital/clinic visits with assessment of transfusion frequency and index,
hemoglobin level, vitamin C, serum iron prole, LIC, and
cardiac MRI T2* after therapy. Compliance to chelation
therapy was assessed by either pill or vial count; a cutoff
point below 70% of the prescribed dose was considered as
poor compliance to the regimen. The primary efcacy end
point was the change between treatment groups from baseline to 1 yr as regards SF, LIC, and cardiac MRI. Secondary
outcome measures were to determine the occurrence of any
adverse effects (Safety assessment).
Statistical analysis

Data analysis was performed using Statistical Program for

Social Science version 17 (SPSS Inc., Chicago, IL, USA).
Quantitative variables were described in the form of range,
mean and standard deviation (SD), or median and interquartile range (IQR; 75th and 25th percentiles). Qualitative variables were described as number and percent. To compare
quantitative parametric variables between the three groups,
analysis of variance (ANOVA) test with post hoc Bonferroni
analysis was used, while Students t-test was applied for
comparison between two groups. Comparison of nonparametric variables between three groups was carried out using
KruskalWallis test, while MannWhitney test was used for
comparison between two groups. Qualitative variables were

2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Vitamin C as adjuvant to iron chelators in b-TM

Elalfy et al.

compared using chi-square (v2) test or Fischers exact test

when frequencies were below ve. Correlation studies were
carried out using Spearmans rank correlation coefcient. A
P value < 0.05 was considered signicant in all analyses.
Results

Vitamin C levels were signicantly decreased in all the 180

enrolled patients with b-TM compared with controls
(3.8  1.7 mg/L vs. 9.4  2.1 mg/L; P < 0.001). Baseline
clinical, laboratory, and radiological variables were similarly
distributed among thalassemia major patients with and without vitamin C supplementation (Table 1) and also among
patients on the three used chelating agents (Table 2).
Upon comparing the studied variables at baseline and
post-vitamin C supplementation among group A patients
with b-TM (Table 1), transfusion index was signicantly
decreased after 1 yr of therapy (P = 0.041). Serum iron, SF,
Tsat, and LIC were signicantly lower after treatment than
baseline levels (P = 0.034, P = 0.033, P < 0.001 and
P = 0.006, respectively). Hemoglobin and vitamin C levels

were signicantly increased at the end of treatment

(P < 0.001). Cardiac MRI T2* was also increased post-vitamin C supplementation (P < 0.001). On the other hand, no
signicant difference was found between baseline and study
end as regards any of these variables among patients with
thalassemia major who did not receive vitamin C therapy
(group B) (Table 1).
Moreover, comparison between group A patients who
received vitamin C supplementation and group B (without
vitamin C) at study end revealed signicant improvement
among those who received vitamin C where transfusion
index, serum iron, SF, Tsat, and LIC were decreased, while
hemoglobin and Cardiac MRI T2* were increased (Table 1).
The same improvement was found when each chelation subgroup receiving vitamin C supplementation was compared
separately with the subgroup without vitamin C (data not
shown).
After vitamin C supplementation, DFO-treated patients
had signicantly lower transfusion index (P = 0.004), serum
iron (P < 0.001), SF (P < 0.001), Tsat (P < 0.001), and
LIC (P < 0.001), while hemoglobin (P < 0.001) and cardiac

Table 1 Laboratory and radiological data among thalassemia major patients with and without vitamin C supplementation
Group A (vitamin C)
Variable
Transfusion index (ml/kg/yr),
median (IQR)
% change
Hemoglobin (g/dL),
mean  SD
% change
Iron (lg/dL), mean  SD
% change
TIBC (lg/dL), mean  SD
% change
SF (lg/L)1, median (IQR)
% change
Transferrin saturation (%),
mean  SD
% change
Vitamin C (mg/L),
mean  SD
% change
LIC (mg/gm), mean  SD
% change
Cardiac T2* (msec),
mean  SD
% change

Baseline (n = 90)

Post-therapy
(n = 87)

Group B (no vitamin C)

P-value

Baseline
(n = 90)

P1

P2

P3

P4

Study end
(n = 88)

231.67  56.67
0

214.0  58.77
7.63

232.1  66.1
0

229.1  41.5
3.02

0.963

0.041

0.466

0.048

7.37  1.3
0
189.73  31.57
0
260.23  67.23
0
1710 (9582064)
0

8.20  1.1
11.26
177.93  42.03
6.22
271.37  41.07
4.28
1442 (6881878)
13.92

7.4  1.3
0
189.5  38.9
0
256.2  41.7
0
1690 (8471718)
0

7.5  1.5
1.35
176.6  37.2
6.81
258.5  38.2
0.9
1633 (7981961)
3.37

0.783

<0.001

0.633

0.043

0.96

0.034

0.056

0.032

0.63

0.181

0.7

0.06

0.815

0.033

0.885

0.041

0.095

<0.001

0.349

<0.001

0.207

<0.001

0.127

<0.001

0.846

0.006

0.352

0.016

0.698

<0.001

0.512

0.02

68.57  10.52
0
3.80  1.67
0
9.57  3.0
0
14.63  3.78
0

62.23  8.0
9.25
6.40  1.14
68.42
8.13  2.14
15.05
16.91  3.83
15.58

71.2  10.5
0
3.5  1.5
0
9.4  3.7
0
14.9  5.4
0

69.9  7.9
1.83
3.8  1.1
8.57
8.9  2.1
5.32
15.4  4.8
3.36

TIBC, total iron binding capacity; SF, serum ferritin; Tsat, transferrin saturation; LIC, liver iron concentration; MRI, magnetic resonance imaging;
IQR, interquartile range.
Data were expressed as mean  SD where Student t-test was used for comparisons or median (IQR) where MannWhitney test was used for
comparison. P1: baseline in group A vs. baseline in group B. P2: baseline vs. post-therapy in group A. P3: baseline vs. study end in group B. P4:
post-therapy in group A vs. group B.
1
Mean SF was calculated for each patient during the last year prior to the study.

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321

322
218.9  59.4
5.36
8.2  1.22
10.96
179.5  52.9
5.43
275.0  66.5
3.81
1314 (5342174)
17.10
68.5  8.6
0.72
6.3  1.1
+69.23
8.1  3.6
10.0
17.8  3.1
17.11

233.9  51.5
0
7.4  1.1
0
194.2  33.7
0
254.6  67.5
0
1750 (5732273)
0
65.7  9.9
0
3.7  1.7
0
10.2  3.2
0
14.9  4.6
0

219.6  55.6
6.11
7.8  1.0
6.76
182.7  50.3
5.92
269.2  49.1
5.73
1481 (8902151)
12.37
61.1  9.9
7.0
6.1  1.01
+72.97
8.5  1.85
16.67
17.0  5.1
14.09

Post-therapy (n = 30)

0.021
0.033
0.038

0.415
0.154
0.898

0.188

0.927

0.835

0.338

0.032

0.607

0.767

0.046

0.941

0.339

0.003

P2

0.961

P1

P-value

0.017

<0.001

<0.001

0.001

<0.001

0.63

<0.001

<0.001

0.004

P3

TIBC, total iron binding capacity; SF, serum ferritin; Tsat, transferrin saturation; LIC, liver iron concentration; MRI, magnetic resonance imaging; IQR, interquartile range; DFO, deferoxamine;
DFP, deferiprone; DFX, deferasirox.
Data were expressed as mean  SD where ANOVA with post hoc test was used for comparisons or median (IQR) where KruskalWallis and MannWhitney tests were used for comparison.
P1: baseline among the three chelation groups. P2: post-therapy among the three chelation groups. P3: baseline vs. post-therapy among DFO group.
1
Mean SF was calculated for each patient during the last year prior to the study.

231.3  58.3
0
7.3  2.8
0
189.8  38.1
0
264.9  65.6
0
1585 (6462190)
0
69  9.37
0
3.9  1.7
0
9.0  3.0
0
15.2  3.3
0

229.8  60.2
0
7.4  1.3
0
185.2  22.9
0
261.2  68.6
0
1605 (6172202)
0
71  12.3
0
3.8  1.6
0
9.5  2.8
0
13.8  3.43
0

Transfusion index (ml/kg/yr),

mean  SD
% change
Hemoglobin (g/dL), mean  SD
% change
Iron (lg/dL), mean  SD
% change
TIBC (lg/dL), mean  SD
% change
SF (lg/L)1, median (IQR)
% change
Tsat (%), mean  SD
% change
Vitamin C (mg/L), mean  SD
% change
LIC (mg/gm), mean  SD
% change
Cardiac T2* (msec), mean  SD
% change
203.5  61.3
11.44
8.5  1.0
14.86
171.6  22.9
7.34
269.9  70.6
3.33
1120 (8201578)
30.22
62.1  5.5
12.54
6.8  1.3
78.95
8.1  1.3
14.74
15.93  3.3
15.43

Baseline
(n = 30)

Post-therapy (n = 30)

Baseline
(n = 30)

Baseline
(n = 30)

Variable

Post-therapy (n = 27)

DFX

DFP

DFO

Table 2 Laboratory and radiological variables among patients with thalassemia major receiving different chelating agents at baseline and post-vitamin C supplementation

Vitamin C as adjuvant to iron chelators in b-TM

Elalfy et al.

2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Elalfy et al.

MRI T2* (P = 0.017) were increased compared with baseline levels (Fig. 2 and Table 2). Patients on DFP or DFX
showed non-signicant improvement in hematological variables. Cardiac MRI T2* was signicantly higher among
DFP-treated patients (P = 0.002), while LIC was signicantly decreased in patients receiving DFX after vitamin C
supplementation (P < 0.001) (Figs 2 and 3).
When the three thalassemia subgroups were compared
post-therapy, DFO-treated patients had the highest hemoglobin (P = 0.046) and vitamin C levels (P = 0.038) with
the lowest iron (P = 0.032), SF (P = 0.021) and Tsat
(P = 0.033) compared with the other two subgroups. The
percentage of change of hemoglobin was also higher,
while that of iron, SF, and Tsat was signicantly lower
among DFO-treated patients compared with patients receiving DFP or DFX. No signicant difference was found
between the three groups as regards LIC or cardiac MRI
T2* (Table 2).
Baseline vitamin C levels were negatively correlated with
transfusion index (r = 0.742, P < 0.001), SF (r = 0.674,
P < 0.001), and LIC (r = 0.772, P < 0.001). Five patients
in DFO subgroup did not continue till the end of study
because of poor compliance (three patients were on vitamin
C supplementation and two did not receive adjuvant vitamin
C). No serious adverse reactions related to iron chelators nor
to vitamin C administration have been reported.
Discussion

Although transfusion therapy is life saving in thalassemia,

obligatory iron loading accompanies such treatment, and
therefore, chelation therapy to remove and detoxify iron is
mandatory. Morbidity and mortality in thalassemia is linked
closely to the adequacy of chelation (29). We assessed
serum iron, TIBC, SF, Tsat, LIC, and cardiac MRI T2*. In
clinical practice, combinations of the different techniques
and serial measurements are utilized to assess iron burden
and to adjust chelation therapy (30). SF is the most common
indirect parameter used to assess body iron stores (31). Ferritin levels correlates with transfusion burden (32) and LIC
(33), and trends in ferritin levels are useful for following

Vitamin C as adjuvant to iron chelators in b-TM

iron load. Given that the liver is the major target organ for
iron accumulation following multiple transfusions, the LIC
is a good indicator of total iron burden (34, 35). Myocardial
iron deposition can be reproducibly quantied using myocardial T2*, and this is the most signicant variable for predicting the need for ventricular dysfunction treatment (28).
In this study, baseline clinicopathological and radiological
variables were non-signicant among patients receiving the
three iron-chelating agents. At baseline, vitamin C levels
were signicantly lower in all the studied patients compared
with controls. There was a negative correlation between
baseline vitamin C levels and transfusion index, SF, and
LIC. Several studies showed depletion of antioxidant vitamins including vitamin C in thalassemia (16, 36, 37). Depletion of vitamin C was found in patients with thalassemia
major, even with an adequate nutritional status. This suggests that low levels of vitamin C in patients with b-TM is
not due to nutritional deciency but may be due to consumption for the neutralization of lipid peroxidation which
occurs mainly due to iron overload and chronic transfusion
(38, 39).
After 1-yr follow-up, we observed decreased transfusion
index as well as laboratory and radiological improvement in
all patients with thalassemia major who received vitamin C.
This is because vitamin C supplementation directly scavenges oxygen free radicals and prevents the increase in lipid
peroxidation. Also indirectly, vitamin C upregulates the
activities of antioxidant enzymes (40, 41) and enhances the
rate of endogenous vitamin E regeneration (40, 42). Moreover, it would improve the availability of transfusional iron
to chelation by promoting irons redox cycling, increasing
its soluble ferrous form and promoting its release from reticuloendothelial cells (19, 43, 44). Thus, vitamin C increases
the efcacy of iron chelators.
Recently, Elalfy et al. (36) assessed the effects of combined vitamin therapy including vitamin C on oxidantantioxidant hepatic status and hemoglobin derivatives in b-TM
and found that the studied vitamins, reduced glutathione,
and hemoglobin levels were signicantly elevated and paralleled by progressive decline in malondialdehyde and ferritin
during therapy. The authors attributed the improvement of

Figure 2 Liver iron concentration (LIC) among

patients with b-thalassemia major on different
iron chelators at baseline and post-vitamin C
supplementation.

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Vitamin C as adjuvant to iron chelators in b-TM

Elalfy et al.

Figure 3 Cardiac MRI T2* among patients with

b-thalassemia major on different iron chelators
at baseline and post-vitamin C supplementation.

hepatic brosis on antioxidant therapy to the fact that

increased iron stores may stimulate hepatic brogenesis, by
leading to oxygen free radical injury and/or by inducing the
production of probrogenic cytokines such as tumor growth
factor (TGF-) (45, 46). Thus, combined vitamin therapy
improves the antioxidant/oxidant balance with subsequent
decrease in LIC and hepatic brosis. These results are in line
with that of the present study and could explain the mechanism of vitamin C action as a natural antioxidant for reducing reactive oxygen species (ROS) with subsequent
improvement in transfusion frequency, serum ferritin, and
hepatic brosis in patients with TM.
As regards the effect of vitamin C on the three studied
iron chelators, we found that patients receiving DFO had
signicant decrease in transfusion index and iron parameters
with elevated hemoglobin and cardiac MRI T2* compared
with baseline levels. Furthermore, vitamin C increased the
efcacy of DFO more than DFP and DFX. In line with our
results, it has been shown that ascorbate replacement in the
presence of DFO can markedly improve urinary iron elimination (18). The efcacy of DFO is well established. The
drug induces substantial iron excretion and can induce a net
negative iron balance (47) in chronically transfused patients
(30).
Furthermore, Xia et al. (48) performed a meta-analysis to
investigate the efcacy and safety of the three main chelators
for patients with TM, and in terms of the LIC measurement,
some studies (4951) showed that monotherapies of DFP
and DFO and associated DFP plus DFO therapy decreased
LIC signicantly. However, there were no signicant differences among these three types of treatments. A systemic
review (52) showed that DFO was more effective in reducing LIC level than DFP. This coincides with our ndings
where vitamin C increased the efcacy of DFO more than
DFP in reducing iron burden.
The signicant increase in cardiac MRI T2* among our
DFP-treated patients post-vitamin C supplementation could
be expected because DFP therapy, either as monotherapy or
in combination with DFO, has been shown to improve right
and left ventricular ejection fraction which may further contribute to improved cardiac function (5355). Emara et al.
(13) reported that treatment with DFP alone showed mild
swelling of cardiac muscle bers, while, on addition of vita-

324

min C, the cardiac tissue appeared ultrastructurally more or

less normal.
Although we showed that vitamin C potentiated the efcacy of DFO more than DFX in reducing iron burden, LIC
was signicantly decreased in patients receiving DFX. Iron
chelation therapy with DFO or with DFX was equally effective in decreasing iron burden and malondialdehyde (56). It
has been reported that similar efcacy of these two chelators
seems to be achievable depending on the dose and ratio of
DFX compared with DFO. Therefore, DFX could be offered
as an alternative to all patients with thalassemia who either
show intolerance to DFO or poor compliance. Ascorbate
deciency could potentially create a phenotype of relative
DFX refractoriness (57). Sarantos et al. (16) observed that
patients on DFX treatment for at least 1 yr had a negative
correlation between fasting vitamin C levels and LIC. These
observations suggest that ascorbate status should be probed
in any patient with unsatisfactory response to DFX or whose
SF and Tsat are not commensurate with their transfusional
iron burden (19).
In this study, no serious adverse reactions related to iron
chelators nor to vitamin C administration was reported.
However, it is worth to note that vitamin C supplements
should be administered carefully. When vitamin C is supplied in large amounts, a high serum level of reduced ascorbic acid converts the Fe3+ to catalytic Fe2+, and free
radicals are generated (58).
Study limitation

This study was limited by the xed dose of vitamin C in all

the studied patients with thalassemia major regardless of the
degree of vitamin C deciency; thus, ascorbate was not
increased entirely to reach normal levels.
In conclusion, vitamin C supplementation in a dose of
100 mg to patients with b-TM represents a potential therapeutic adjuvant agent increasing the efcacy of iron chelation therapy, decreasing transfusion frequency and elevating
hemoglobin levels. Vitamin C possibly potentiates the efcacy of DFO more than DFP and DFX in reducing iron burden in the moderately iron-overloaded vitamin C-decient
patients with b-TM. Vitamin C supplementation also
resulted in increased cardiac MRI T2* and decreased LIC in

2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Elalfy et al.

DFP- and DFX-treated patients, respectively, with no

adverse events and with safety outcome. Further studies
including higher doses of vitamin C depending on the
degree of vitamin C deciency with longer duration of follow-up are needed to verify vitamin C efcacy and safety in
patients with thalassemia major.
Conflict of interests

The authors declare that they have no conict of interests.

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