How quickly do you expect iron stores to decrease after starting iron chelators?

This is a complex answer to what seems like a simple question. It is not a standard rate of decline because each patient's situation is different. It is always about the balance of how much iron is going in vs. how much iron is being excreted. Essentially there are 4 variables that must be considered:

• the degree of iron overload one is starting out at - the higher the burden, the more time it will take to get to the ideal range, and the greater the likelihood of needing combination chelation
• the dose of the chelator, and whether using monotherapy or combination chelation,
• the patient's adherence to the chelation regimen - including the appropriateness of administration - DFX on an empty stomach, not with other medications, etc, and
• what the ingoing iron burden is - as in whether the patient is being transfused, and how aggressively. The greater the transfusion volumes, the longer it will take to achieve iron balance.

In general, the chelation should be optimized to a maximum dose of monotherapy if the burden is not very much above the target range (generally it is best to keep the liver iron concentration between 2 and 5 mg/g dry weight on MRI T2*), or combination therapy if the burden is much higher than this range. The chelators must be taken appropriately, and monitored closely for toxicity. This will bring the iron levels down faster. Would suggest repeating the MRI in 6 months to be sure it is coming down steadily, and this will also help decide if a second chelator needs to be added to a monotherapy regimen. Of course, the success of the chelation regimen is critically dependent on the patient's adherence. Finally, in some cases, it may be necessary to reduce the transfusion burden if possible, treat any autoantibody, consider a splenectomy if the spleen is very enlarged and hypersplenic, or consider an erythroid differentiation agent in transfusion-dependent beta thalassemia.