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Table 8. Hematologic Toxicities
8.4 Aplastic Anemia
Workup/Evaluation
• History and physical examination (close attention to medications, exposure to
radiation, toxins, recent viral infections)
• CBC, smear, and reticulocyte count
• Viral studies including CMV, HHV6, EBV, parvovirus
• Nutritional assessments including B12, folate, iron, copper, ceruloplasmin, vitamin D
• Serum LDH, renal function
• Evaluation for infectious causes.
• Identify marrow hypo/aplasia
• BM biopsy and BM aspirate analysis
• Peripheral blood analysis including neutrophil count, proportion of
glycosylphosphatidylinositol (GPI) -negative cells by flow for PNH
• Flow cytometry to evaluate loss of GPI-anchored proteins
• Type and screen patient for transfusions and notify blood bank that all transfusions
need to be irradiated and filtered
G1: Mild: >0.5
polymorphonuclear cells
(PMNs) × 10/L hypocellular
marrow, with marrow
cellularity <25%, Peripheral
platelet count >20,000,
reticulocyte count >20,000
• Hold ICPi, provide growth factor support and close
clinical follow-up and laboratory evaluation.
• Supportive transfusions as per local guidelines.
G2: Moderate: Hypocellular
marrow <25% and tow of
the following ANC <500,
peripheral platelet <20,000
and Reticulocyte <20,000
• Hold ICPi and provide growth factor support and
close clinical laboratory evaluations daily.
• Hematolog y consult
• Administer Horse ATG + cyclosporine.
• Supportive transfusions as per local guidelines. All
blood products should be irradiated and filtered.
• HLA typing and evaluation for bone marrow
transplantation if patient is a candidate.
G3–4: Severe: ANC<200,
platelet count <20,000,
reticulocyte count of
<20,000, plus hypocellular
marrow <25%.
• As per G2
• Hold ICPi and monitor weekly for improvement.
If not resolved, discontinue treatment until adverse
event (AE) has reverted to G1.
• If no response, repeat immunosuppression with
Rabbit ATG plus cyclosporine, cyclophosphamide.
• For refractory patients consider eltrombopag plus
supportive care.
(cont'd)
