Aplastic Anemia Clinical Pathway — All Settings

Follow-up Care of Aplastic Anemia Patients

Most providers consider a “remission” to be patients who had a Complete Response (defined in table above) or a very good partial response, i.e. no clinical symptoms whatsoever from their cytopenias (such as a platelet count of 120,000)

1. Follow-up Care of Aplastic Anemia Patients after Initiation of ATG Immunosuppressive Therapy during First 12 Months

During First 12 Months Consider	To Include
Prophylaxis	Pneumocystis prophylaxis and antifungal prophylaxis should be initiated and continued as per CHOP’s Antimicrobial Stewardship Program Guidelines For duration: Refer to Antimicrobial Stewardship Guidelines
Cyclosporine Dose	When stopping Voriconazole or Posaconazole, Cyclosporine needs to be adjusted (increased). See Protocol for more details.
Recommended Peripheral Blood Laboratory Evaluation (Twice a week after discharge, wean as per physician discretion)	CBC w/ diff Retic count CMP Magnesium Cyclosporine level Type & screen, weekly for 12 weeks or until transfusion independent, with ANC stably > 500/µL off G-CSF *Taper lab schedule as per patient’s response after 12 weeks*
Bone Marrow Biopsy & Aspirate	To be performed at 12 weeks post-treatment initiation in all patients. Bone Marrow Aspirate Report and Biopsy review per hematopathology Cytogenetics: Karyotype and SNP Array T-cell receptor rearrangement Iron Stain
Transfusion Dependency	If patient remains transfusion dependent @ 8 week mark, patient should be discussed @ BMF conference to assess need for BMT evaluation
Vaccine Administration	No vaccines should be administered during the first 12 months, including influenza vaccine. See vaccine recommendation below.

2. One-year Evaluation and Wean of Immune Suppression

At one year	To Include
1. Bone Marrow Aspirate & Biopsy Evaluation	Bone Marrow Aspirate Report and Biopsy review Cytogenetics: Karyotype and SNP Array T-cell receptor rearrangement Iron Stain
2. Peripheral Blood Laboratory Evaluation	CBC w/ Diff Retic Count PNH RBC and WBC CMP BMT panel Thyroid function studies: TSH, Free T4
3. Cyclosporine Wean If Complete Remission Is Achieved (If partial remission only, discuss wean with BMF team).	A slow taper (~20-25% dose reduction every 3 months) with goal to wean off over a 1-year period

3. Long-term Follow-up of Aplastic Anemia Patients after Initiation of ATG Immunosuppressive Therapy

Complete Remission	Yearly clinic follow-up evaluations to include CBC w/Diff Retic Count PNH RBC and WBC CMP (only if previously abnormal) BMT panel (only if previously abnormal) Follow-up bone marrow biopsies beyond 1 year not indicated for patients in complete remission
Relapse or Partial Relapse	Discuss monitoring plan with BMF team.

4. Vaccine Recommendations for Aplastic Anemia Patients after Initiation of ATG Immunosuppressive Therapy

Inactivated vaccines may be given after immunosuppressive therapy has been discontinued for 6 months.
Live virus vaccines may be given after immunosuppressive therapy has been discontinued for 1 year.
Inactivated Influenza vaccine given I.M. should be used. The live intranasal formulation should not be used.

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.