ALAS1 and porphyria: Any patient with an acute porphyria episode with worsening symptoms or lack of improvement within one to two days should receive hemin therapy.1,3,8 Prophylactic treatments for recurrent attacks include gonadotropin-releasing hormone agonists, IV hemin, and subcutaneous givosiran, which is a small interfering ribonucleic acid medication causing degradation of the delta-aminolevulinate synthase 1 enzyme.11 Our patient was advised to begin prophylactic hemin or givosiran therapy should she experience more than 4–6 attacks per year.